Patients Data

Name of Patient: J.A.R. Age: 2 y/o

Diagnosis: Acute AGN
Physician: Dr. Q

NURSING CARE PLAN

General Objective: To facilitate the maintenance of regulatory mechanisms and functions.

Assessment Nursing Diagnosis Rationale Specific Objectives Nursing Intervention Rationale Evaluation

Subjective Cues: >Deficient fluid In AGN, kidneys Within 27 hours of 1. Assess the 1. Low urine output Due to strict
(As verbalized by volume r/t become large, rendering care, fluid characteristics, amount may be first monitoring of I&O and
the mother) decreased renal edematous, and volume will increase and frequency of the indicator of acute through encourage-
output secondary congested. All within normal range. urine output. failure. ment of increase fluid
Dutay lang ihi to AGN renal tissues, intake, there will be
niya dayon lasaw including the 2. Record accurate 2. Accurate I&O is an increase of the
nga pula ang glomeruli, intake and output. necessary for I&O, fluid and
color. tubules and determining fluid electrolytes are now
blood vessels are replacement needs stabilized.
Objective Cues: affected to and reducing risk for
*Tea colored urine varying degrees. fluid overload.
noted The urine may
*Urine output of appear cola- 3. Monitor urine 3. Measures the
less than 25 cc per colored because specific gravity kidneys ability to
hour in 24 hour of the RCBs and concentrate urine.
period protein plugs.
Glumerolo- 4. Weigh daily at same 4. Daily body weight
nephritis may be time of day, on same is best monitor of
mild with acute scale with same fluid status. A
renal failure and equipment and weight gain of more
oliguria. clothing than 0.5 kg /day
suggest fluid
retention.

5. Plan oral fluid 5. Helps avoid

replacement with periods without
client, within multiple fluid and reduce
restrictions. sense of deprivation
 and thirst.

6. Monitor laboratory 6. Assesses

and diagnostic studies, progression and
such as the following: management of
BUN, Creatinine and renal dysfunction,
CBC failure.