NCP DM
NCP DM
NCP DM
S> O: the
Excess
fluid Acute
To trust
gain Short term: and the patient shall have demonstrated behaviours to fluid and
patient of fluid in the known as acute After the body renal failure is nursing
manifest following:
the abrupt loss intervention the of kidney pt. demonstrate to behaviours falls monitor of the status reduce of to fluid and will Note presence of
Edema upper
on
medical To or that
conditions situations
glomerular
volume
failure
of
the
presence of fluid congestion to The shall stabilized patient have fluid as by I/O, within limits, weight free of
kidneys to filter Long term: large molecules. including with molecule those After 3-4 days of Advice larger nursing can intervention the
restrict sodium To prevent volume and fluid intake, as indicated. more evidence retention of balanced fluids VS normal I/O . stable
The patient may manifest the following: Jugular vein distention Positive hepatojugula r reflex
pass through the patient will have GFR leading proteinuria, thus stabilize to volume evidence fluid as
by Record accurately.
There is excess balance in intake fluid because of volume and output, VS of within protein stable pts limits, weight
fluids in the
and free of signs Assess which of edema. neuromuscular reflexes To evaluate for presence of electrolyte Weigh daily or imbalances
on
schedule, indicated.
Stress need for mobility frequent position changes and To prevent stasis and reduce risk of injury . Suggest interventions, such frequent care, gum/hard candy, use of lip balm as oral To of reduce discomfort fluid tissue
chewing
restrictions
Administer medications
Ineffective renal tissue perfusion r/t impaired renal function Cues Nursing diagnosis Scientific explanation Planning Interventions Rationale Expected outcome
S>O
Ineffective renal One of the risk Short term: tissue perfusion factor of patient
Establish rapport and assess general condition Determine factors to related individual
To gain trust Short term: and establish baseline data the patient shall have demonstrated To assess behaviours/ or lifestyle changes improve circulation. to causative contributing factors
patient r/t
impaired having
on
changes improve
extremities, face and neck Oliguria Hematuria Hct: 0.25 Ph: 6.6 SG: 1.025 Albumin 3+
mellitus it occurs circulation. when pancreas produces insufficient amounts of the hormone insulin and/or the bodys tissues become the
situation
provide
comparison current
findings.
Determine usual To
know
resistant
to
voiding pattern
of or
normal or even high insulin. causes blood The patient may manifest: (sugar) levels of Long term: This high After 3-4 days of Review glucose NI, the patient will levels demonstrate as Note mentation laboratory studies
Long term: To there know if the patient shall are have demonstrated increased perfusion To know if individually an appropriate. as
decrease or
renal individually
theres alteration
impaired function kidneys causing improper tissue perfusion. There and which causes is circulation also a Assess
impaired filtration
BP, To determine
of
for To or
evaluate
To condition
treat
underlying
Impaired urinary elimination r/t glumerular malfiltration Cues Nursing diagnosis Scientific explanation Planning Interventions Rationale Expected outcome
S>
Impaired urinary
There exceed
is Short term: fluid After 4 hours of of nursing intervention the patient will be of able to verbalize understanding of the condition.
Established rapport
Short term: the patient shall have verbalize understanding of the condition
O:
the
patient elimination r/t volume the glumerular malfiltration because decreased levels
manifest following:
Edema on upper extremities, face and neck Oliguria Hematuria Hct: 0.25 Ph: 6.6 SG: 1.025 Albumin 3+
Long term:
pressure. With After 3-4 days of Assess low levels, fluid nursing intervention is retained and the patient will be not excreted. able to participate measures to patients general condition To know what problem and
Loss of kidney in
functions as
and correct/compensate GFR for defects. Review for lab test changes in renal function
interventions to prioritize
decreases, the kidney cannot excrete The patient may nitrogenous product causing Urinary frequency/hesita ncy anuria impairment the in and
manifest:
factors
outcomes
and the
fluid intake
determine level of
hydration
Emphasize the need to adhere with the prescribed diet To prevent aggravation of disease condition
To promote wellness
Impaired skin integrity r/t facial edema and changes in skin pigmentation Cues Nursing diagnosis S>O impaired O:The manifests following: Rough dry skin Pruritus upper lower extremities and abdomen Edema the neck upper on face, and on on and patient integrity the facial skin Because of the Short term: r/t complication edema the of Establish rapport To gain trust and cooperation the patient shall have identified Establish baseline data individual risk Scientific explanation Planning interventions Rationale Expected outcome Short term:
underlying After 4r of NI, the patient will Assess general risk condition
condition which identify may result with individual the impairment factors that may
of the function of contribute to the Assess the kidneys thus disease leading condition, to condition. the Note presence edema With this condition
skin To
reveal condition
abnormality/ skin disruption To of causative/ Contributing factors. know Long term: the patient shall have demonstrated behaviours/
skin is stretched Long term: abnormally because of fluid After 2-3 days of retention. If the NI, the patient fluid will not be will demonstrate
skin integrity.
extremities
excreted,
to skin
Provide The patient may manifest: Pain Numbness on the affected Impaired circulation Impaired pigmentation Emphasize importance of adequate nutrition area Frequently change patients position meticulous skin care
To and
promote
To general
maintain good
Encourage exercise
To
enhance
circulation
decrease
irritable itching
To edema
decrease
Risk for injury r/t abnormal blood profile secondary to disease condition Cues Nursing diagnosis Scientific explanation Planning interventions Rationale Expected outcome
for The damage or SHORT TERM: r/t inflammation due After 3 hours of to the nursing of intervention the will
Monitor signs
vital To for
provide
baseline comparison
data
SHORT TERM:
decreased in secondary to the haemoglobin pale palpebral conjunctiva pale beds hgb count of 78 nail
assess or fatigue
factors To of
provide individual
factors
signs
appropriate interventions
decreasing blood factors supply kidney suppresses to the contribute which possibility or injury.
responses.
is
to
Elevate
To
maintain
risk
factors
and
airway
protect injury
self
from and in
and
deep-breathing To rest limit to clients To safety loss prevent demand oxygen limit a of
protect self from and Provide adequate and activities within tolerance
the body causing improvement in anemia, causes which laboratory fatigue values.
consumption
Promote measure
Provide oxygen
To oxygen
increase supply
supplement as prescribed
in the body
treat
that
Ineffective Airway clearance related to retained secretions in the trachea-bronchial tree AEB rales upon auscultation Nursing diagnosis Scientific explanation Expected outcome
Cues
planning
interventions
rationale
The patient develop pulmonary congestion due to retention of fluid in the body, in diabetes mellitus fluid retention happen because with the abscence of glucose, the body will then metabolize protein in replacement of glucose that cant be metabolize for
Short Term: After 4 hours of nurse-patient interaction, the patients will demonstrate ways in improving airway patency.
Monitor
and To obtain baseline data Tachypnea, of asymmetric movement because discomfort moving
record vital signs Assess rate/depth respirations and chest movement. Monitor for signs of failure cyanosis severe tachypnea) respiratory (e.g. and
respirations tree AEB pale palpebral conjuntiva pale lips nasal secretions productive rales upon auscultation
cough
energy production leading to protein wasting resulting to decrease colloid-oncotic pulling force in the intravascular
fields, areas
noting of
occurs
in
consolidated fluid.
the pt. may manifests: rapid and shallow breathing cyanosis DOB SOB retractions
spaces. Thus, more fluid stays in the third space resulting to edema. This edema may occur at any part of the body like the lungs. This may lead to pulmonary congestion. The body is unable to clear the airway due to secretions.
wheezes) Elevate head of keeping bed, position frequently change elevated diaphragm, promoting expansion, aeration segments, mobilization expectoration of lung and and of chest head lowers
This fluid in the lungs may affect the oxygen and carbon dioxide diffusion in the alveoli. The function of the alveolar-capillary membrane becomes altered resulting to an impairment in the exchange of gases, which are oxygen and carbon dioxide
Assist client with Deep frequent breathing exercises. Demonstrate chest effective coughing while in upright position and deepfacilitates maximum
breathing
of
Suction indicated
other respiratory
Aids reduction
in
the of