Ncp- Case Pre
6
SAN SEBASTIAN COLLEGE - RECOLETOS DE CAVITE INC. COLLEGE OF NURSING Sta. Cruz, Cavite City NURSING CARE PLAN Name: Kevin Kier Barias Age: 16 years old Sex: Male Civil Status: Single Home Address: Brgy. 3526 San Francisco, General Trias, Cavite Date Admitted: June 18, 2011 Admitting Diagnosis: Acute Glomerulonephritis Final Diagnosis: Acute Glomerulonephritis Assessment Nursing Diagnosis Background Knowledge Expected Outcome Interventi on Rationale Evaluation Subjective: “ namamaga po ang muka ko .” As verbalized by the client. Objective: Excess fluid volume related to failure of regulatory mechanism. Unhealthy life style Invasion of streptoccocus inflammation of glomerular Short term goal: -After 8 hours of nursing interventions the patient will be free from edema. Long term goal: -After 2 days of nursing intervention the patient will stabilized fluid volume Pdx: -monitored vital signs. -monitor input and output. -for base line data. - for baseline data - Goals met. After 8 hours of nursing intervention the patient became free from edema.
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Transcript of Ncp- Case Pre
Name: Kevin Kier Barias Age: 16 years old Sex: Male Civil Status: Single Home Address: Brgy. 3526 San Francisco, General Trias, Cavite Date Admitted: June 18, 2011Admitting Diagnosis: Acute Glomerulonephritis Final Diagnosis: Acute Glomerulonephritis
Assessment Nursing Diagnosis
Background Knowledge
Expected Outcome
Intervention Rationale Evaluation
Subjective: “ namamaga po ang muka ko .” As verbalized by the client.
Objective:- Restlessness- Puffy face- Input: 520- Output: 200
Excess fluid volume related to failure of
regulatory mechanism.
Unhealthy life style
Invasion of streptoccocus
inflammation of glomerular membrane
inhibiting filtration
Edema
Short term goal:-After 8 hours of nursing interventions the patient will be free from edema.
Long term goal:-After 2 days of nursing intervention the patient will stabilized fluid volume as evidenced by balanced input and output.
Pdx:
-monitored vital signs.
-monitor input and output.
Prx:
- asked patient to limit fluid intake.
- assisted patient to cope with the discomforts resulting from fluid limiting.
-for base line data.
- for baseline data
- Fluid restriction will determine on basis of urine output and response to therapy.
-increasing patient comfort promotes compliance with dietary restrictions.
- Goals met.After 8 hours of nursing intervention the patient became free from edema.
- Goals not met.After 2 days of nursing intervention the patient does not stabilize fluid volume.
SAN SEBASTIAN COLLEGE - RECOLETOS DE CAVITE INC.
COLLEGE OF NURSINGSta. Cruz, Cavite City
NURSING CARE PLAN
- Identified potential sources of fluid such as medication orally and intravenously and fluids used to take.
Ped:
- encouraged frequent oral hygiene
-review sign and symptoms of acute glomerulonephritis.
-provide quiet environment.
- Unrecognized sources of excess fluids may be identified.
- Oral hygiene minimizes dryness of oral mucous membranes.
-indicates need for prompt intervention.
-to have enough rest.
Prepared by: Group 1 BSN4A Submitted to: Ms. Mary Jochen SalvadorDate Submitted: June 29, 2011
SAN SEBASTIAN COLLEGE - RECOLETOS DE CAVITE INC.
COLLEGE OF NURSINGSta. Cruz, Cavite City
NURSING CARE PLAN
Name: Kevin Kier Barias Age: 16 years old Sex: Male Civil Status: Single Home Address: Brgy. 3526 San Francisco, General Trias, Cavite Date Admitted: June 18, 2011Admitting Diagnosis: Acute Glomerulonephritis Final Diagnosis: Acute Glomerulonephritis
Assessment Nursing Diagnosis
Background Knowledge
Expected Outcome
Intervention Rationale Evaluation
Subjective: “ Nauuhaw po ako.” As verbalized by the client.
Objective:- Restlessness- Dry lips- Input: 520- Output: 200
Imbalanced
nutrition less than body requirements related to dietary
restrictions.
Inflammation of glomerular membrane
inhibiting filtration
limited fluid intake
Imbalanced nutrition
Short term goal:-After 8 hours of nursing interventions the patient will verbalize understanding of individual fluid restrictions.
Long term goal:-After 1 day of nursing intervention the patient will only have 1,600ml fluid intake as prescribed by the physician.
Pdx:
-monitored vital signs.
-monitor input and output.
Prx:
- assessed patient’s nutritional dietary patterns such as diet history and food preferences.
- assisted patient to cope with the discomforts resulting from fluid limiting intake.
- encouraged
-for base line data.
- for baseline data
- Past and present dietary patterns are considered in planning meals.
-increasing patient comfort promotes compliance with dietary restrictions.
- Oral hygiene minimizes dryness
- Goals met.After 8 hours of nursing intervention the patient verbalized understanding of limitation in fluid intake.
- Goals partially met.
frequent oral hygiene
-noted age, body build, activity and rest level.
Ped:
- explained to patient and family the rationale for fluid limiting.
-review sign and symptoms of acute glomerulonephritis.
-provide quiet environment.
of oral mucous membranes.
-helps determine nutritional needs.
- Understanding promotes patient and family cooperation with fluid limiting.
-indicates need for prompt intervention.
-to have enough rest.
Prepared by: Group 1 BSN4A Submitted to: Ms. Mary Jochen SalvadorDate Submitted: June 29, 2011
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