Question

You will develop a nursing care plan for a person with a nutritional concern. choose a patient condition type

Care plan for person with kidney disease

nursing diagnose

medical diagnose

Pt. INICIAL

Write up One priority nursing diagnosis.

Subjective data:  

Objective data:  

Measurable Goal:  

nursing interventions

Evaluation:  

#of intervention

Rationale

citation

Answer 1

1.Assessment

subjective data

*Patient verbalize that "I have difficulty in breathing"

*Objective data

Weight gain, edema.

Nursing diagnosis.

Excessive fluid volume related to decreased glomurlar filitration rate as manifested by presence of edema.

Goal-Patient attains a reduction in fluid retension as evidenced by stable intake output chart,stable body weight,reduction in edema.

Nursing interventions

*Assess the general condition of the patient

RATIONALE-To get a baseline data about the patient condition.

EVALUATION-Acquied a baseline data.

*Maintain intake output chart.

RATIONALE-To monitor kidney function and fluid retension.

EVALUATION-Monitored the kidney function and fluid retension aqurately.

*Encourage patient to limit the fluid intake.

RATIONALE-To prevent fluid overload.

EVALUATION-Patient limited the fluid intake.

*Administer diurectics as prescribed by the doctor.

RATIONALE-To reduce fluid retension.

EVALUATION-Patient attained a reduction in edema.

*Frequently change the position of the patient .

RATIONALE-To maintain skin integrity.

EVALUATION-Patient has a intact skin.

2.Assessment

Subjective data-Patient verbalize that" I have inadequate food intake and fatigue".

Objective data-Hemoglobin level less than 10 mg/dl.

Goal-Patient attains a normal lab values and reduction in fatigue.

Nursing diagnosis

Imbalanced nutrition less than body requirement related to restricted food as manifested by patient verbalization of fatigue and hemoglobin level less than 10mg/dl.

Nursing interventions.

*Assess the general condition of the patient.

RATIONALE-To attain a baseline data.

EVALUATION-Attained a baseline data about the patient.

*Provide a proper diet plan.

RATIONALE-To ensure adequate nutrition for the patient.

EVALUATION-Patient reported a relief from fatigue.

*Avoid sodium rich food.

RATIONALE-To prevent sodium retension.

EVALUATION-Normal sodium level,reduction in edema.

Provide best rest

RATIONALE-To reduce metabolic demand.

EVALUATION-Patient getting adequate bed rest and reduction in fatigue.

*Change the postion of the patient frequently

RATIONALE-To reduce the risk of pressure ulcers.

EVALUATION-Patient having a normal intact skin and no signs for ulcers.

*Administer IV fluids as prescribed by the doctor.

RATIONALE-To maintain hydration.

EVALUATION-Patient is hydrated adequately and no signs for dehydration.

3.Assessment

objective data -inadequate food intake,pulmonary edema.

Nursing diagnosis

Risk for infection related to inadequate food intake,pulmonary edema.

Goals-Reduce the risk of infection.

Interventions

*Assess the vital signs.

RATIONALE-To detect any infections.

EVALUATION-No deviation in vital signs.

*Send the samples regualrly for culture.

RATIONALE-To detect any infections.

EVALUATION-Normal culture report.

*Follow aseptic techniques before and aftter any procedures.

RATIONALE-To prevent the transmission of pathogens to patient.

EVALUATION-patient having no signs of infection.

*Encourage patient to maintain good personal hygiene.

RATIONALE-To prevent the growth of microoragnisms.

EVALUATION-Patient maintains good personal hygiene like regualr bathing and having no signs of infection.

REFERENCE-JOYCE M BLACK AND JANE HOKANSON HAWKS,TEXT BOOK OF MEDICAL SURGICAL NURSING,8TH EDICTION,ELSEVIER PUBLICATION.