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    NCP&SOAPIE

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    Mica Omotsosirc
    The patient presented with edema of the face and lower extremities, decreased urine output, and lab results indicative of nephrotic syndrome; the diagnosis was excessive fluid volume related to fluid accumulation. The short term goal was to stabilize fluid volume within 8 hours through independent monitoring and intervention, with the long term goal of stabilizing fluid volume, balancing intake and output, and resolving edema signs within 3 days.

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    NCP&SOAPIE

    Uploaded by

    Mica Omotsosirc
    59 views4 pages
    The patient presented with edema of the face and lower extremities, decreased urine output, and lab results indicative of nephrotic syndrome; the diagnosis was excessive fluid volume related to fluid accumulation. The short term goal was to stabilize fluid volume within 8 hours through independent monitoring and intervention, with the long term goal of stabilizing fluid volume, balancing intake and output, and resolving edema signs within 3 days.

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    The patient presented with edema of the face and lower extremities, decreased urine output, and lab results indicative of nephrotic syndrome; the diagnosis was excessive fluid volume related to fluid accumulation. The short term goal was to stabilize fluid volume within 8 hours through independent monitoring and intervention, with the long term goal of stabilizing fluid volume, balancing intake and output, and resolving edema signs within 3 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    59 views4 pages

    NCP&SOAPIE

    Uploaded by

    Mica Omotsosirc
    The patient presented with edema of the face and lower extremities, decreased urine output, and lab results indicative of nephrotic syndrome; the diagnosis was excessive fluid volume related to fluid accumulation. The short term goal was to stabilize fluid volume within 8 hours through independent monitoring and intervention, with the long term goal of stabilizing fluid volume, balancing intake and output, and resolving edema signs within 3 days.

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    © All Rights Reserved
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    S “Madalang lang umihi yung anak ko at napansin ko na namamaga ang kanyang mukha at mga paa.

    ”
    verbalized by the mother of the patient.

    O - Presence of edema (periorbital ) , over the face and lower extremities


    - (+) proteinuria
    - Depressed C3 level 0638 g/L
    - hypoalbuminemia of 2.0 g/dL
    - -urine creatinine level of 620 mg/L
    - - APTT was prolonged- 47.7 sec

    A Excessive fluid volume related to fluid accumulation as evidenced by pitting edema to face in lower limbs and
    decreased urine output.
    P Short Term Goal:
    After 8 hours of nursing interventions the patient will stabilize fluid volume as evidence by: balanced I/O

    Long Term Goal:


    After 3 days of nursing interventions the patient will manifest stabilize fluid volume, balance I&O, stable
    weight and free from signs of edema.

    I Independent:
     Record accurate fluid intake and output of the patient
     Weigh daily at same time of the day, on same scale, with same equipment and clothing.
     Assess patient’s appetite
     Assess neuromuscular reflexes
     Assess skin, face, dependent areas of edema.
     Assess level of consciousness presence of restlessness
    Dependent:

     Restrict fluid and sodium intake as indicated


     Administer, prednisone, human albumin, furosemide, ceftriaxone

    Collaborative:
     Collaborate to dietician as needed

    E Short Term Goal:


    After 8 hours of nursing interventions the patient will stabilized fluid volume as evidenced by: balanced I/O

    Long Term Goal:


    After 3 days of nursing interventions the patient will manifest stabilized fluid volume, balance I&O, stable
    weight and already free from signs of edema.
    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
    Subjective: Excessive fluid Short Term Independent: Short Term
    “Madalang lang umihi volume related Goal: 1. Record 1. Accurate Goal:
    yung anak ko at napansin to fluid accurate fluid intake and
    ko na namamaga ang accumulation as After 8 hours of intake and output is After 8 hours of
    kanyang mukha at mga evidenced by nursing output of the nursing
    necessary for
    paa.” verbalized by the pitting edema to interventions patient interventions the
    the patient will determining patient will
    mother of the patient. face in lower
    limbs and stabilize fluid 2. Weigh daily at renal function stabilized fluid
    Objective: decreased urine volume as same time of and fluid volume as
    - Presence of output. evidence by: the day, on replacement evidenced by:
    edema balanced I/O same scale, needs and balanced I/O
    (periorbital ) , with same reducing risk
    over the face Long Term equipment and Long Term
    Goal: of fluid Goal:
    and lower clothing.
    extremities overload.
    - (+) proteinuria After 3 days of 3. Assess 2. Daily body After 3 days of
    - Depressed C3 nursing patient’s weight is the nursing
    level 0638 g/L interventions appetite best monitor interventions the
    the patient will of fluid status patient will
    - hypoalbuminemi
    manifest 4. Assess 3. To provide manifest
    a of 2.0 g/dL
    stabilize fluid neuromuscular further stabilized fluid
    - -urine creatinine
    volume, balance reflexes intervention volume, balance
    level of 620 mg/L
    I&O, stable 4. To determine I&O, stable
    - - APTT was 5. Assess skin,
    weight and free if the patient weight and
    prolonged- 47.7 is confused
    from signs of face, already free from
    sec and changes
    edema. dependent signs of edema.
    areas of in his
    personality.
    edema.
    5. Edema
    occurs
    6. Assess level
    primarily in
    of dependent
    consciousness tissues of the
    presence of body. It will
    restlessness serve as
    parameter the
    Dependent: severity of
    fluid excess.
    7. Restrict fluid 6. May reflect
    and sodium fluid shifts
    intake as and
    indicated electrolyte
    imbalances.
    8. Administer, 7. To prevent
    prednisone, worsening of
    human patient’s
    condition.
    albumin,
    8. To address
    furosemide, the patient's
    ceftriaxone condition and
    avoid certain
    Collaborative: complications
    9. To provide
    appropriate
    9. Collaborate to nutrition
    dietician as based in the
    needed patient’s
    condition

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