Duro, Michael Vincent V.

Patient’s Name: John Edmer Timbang Chief Complaint: Periorbital Edema

BSN108/Group 32 Patient’s Age: 8 y/o Diagnosis: Acute Glumerulonephritis

Nursing Care Plan

Assessment Nursing Analysis Etiology Goals and Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Excess fluid Scientific: AGN Goal:

volume
- Client related to ↓ After 8 hours of
compromised Increased isotonic nursing intervention,
verbalized “hindi
ko masyado regulatory fluid retention. Impaired
the client will have
mechanism decreased/normal
umiihi”. filtration of
fluid volume.
as fluids
manifested
-Client’s father by AGN. ↓
Objectives:
verbalized “May Situational:
mga araw na
Retention of
hindi masyado Nursing interventions:
umiihi anak ko”. J.E.T. 8 y/o was fluids and
sodium A. The client will
admitted in the determine the 1. Note presence of • To determine A. Client
-Client’s father hospital due to ↓
underlying cause of medical cause of fluid determined
verbalized “Hindi excess fluids in the conditions/situatio cause of
periorbital edema, body ns that potentiate
excess and how to
excess fluid
naman manas correct it.
ung anak ko and mas diagnosed Excess fluid fluid excess. volume
volume
bago dalhin sa of having acute
ospital”. glumerulonephritis.
B. The client will
He is currently on know and observe 2. Measure • For changes that B. Client
Objective:
I.V. infusion of the effects of excess abdominal girth may indicate determined and
fluid volume. increasing fluid observed the
- (+) edema of D5W 500cc x retention/edema effects of fluid
hands and face KVO/microset. excess

-Blood pressure:
120/90 3. Observe skin and • For presence of
mucous dicubitus/ulceration
membranes s
-Looks bloated
4. Record I/O
C. The client will
accurately • Determine whether
have an improved therapeutic C. Client had an
fluid volume interventions’ improved fluid
effectively volume

• Decreases fluid
retained by the
5. Decreased intake body
of sodium

D. The client will

6. Elevate • Reduce tissue
edematous pressure and risk D. Client had
have decreased or
extremities, of skin breakdown decreased or
no complications
change position no
related to excess
frequently complications
fluid volume
related to
excess fluid
volume
Collaborative Interventions:

1. Administer • Aids in fluid

medications as excretion and
prescribed by the decreases fluid
physician volume