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NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBEJECTIVE INTERVENTION RATIONALE EVALUATION


THE PROBLEM
Subjective: • Nephritis refers to Short term: Independent: • Display
inflammation of one • Increased • Record accurate • Low output (less appropriate
“Namamanas or both kidneys. It urinary output. intake and output than 400ml/24 hr) urinary output
ang binti ko” as can be caused by (I&O). is the first indicator with normal
infection, but is
verbalized by the • Minimize of acute renal specific gravity
most commonly
patient. presence of failure. and laboratory
caused by
autoimmune edema. • Monitor urine • To measure the status within
Objective: disorders that affect specific gravity. kidney’s ability to normal range.
• Oliguria. the major organs. • Achieve stable concentrate urine. • Absence of
For example, those weight and • Weigh daily at the • Daily body weight edema and
• Weight gain. with lupus are at a stable vital same time of the is best monitor of body weight
much higher risk for signs. day. fluid status. A returns to
T : 36.4 developing weight gain of normal.
P : 98 nephritis. In rare Long term: more than 0.5kg/ • Vital signs
cases nephritis can
R : 18
be genetically
• Prevents day suggest fluid within normal
BP: 130/80 complication retention. range.
inherited, though it
may not present in of the disease. • Monitor heart rate • Tachycardia and
childhood. As the and Bp. hypertension can
kidneys inflame, occur because of
they begin to failure of the
excrete needed kidney to excrete
protein from the urine.
body into the urine • Elevate edematous • To promote
stream. Nephritis body part. venous return.
also causes
additional problems
like water retention, Collaborative:
as the kidneys • Monitor serum • Hyponatremia may
cannot function sodium. result from fluid
properly to rid the overload or
body of water. kidney’s inability to
Water retention or conserve sodium.
edema, can further Hypernatremia
cause swelling of indicates total
the feet, ankles, body water
legs, and hands.
deficits.
• Monitor serum • Lack of renal
potassium. excretion and
selective retention
of potassium to
excrete excess
hydrogen ions lead
to hyperkalemia
requiring prompt
treatment.
• Administer diuretics. • To promote
adequate urine
volume.