RLE FORM 002

Cebu Normal University

College of Nursing Cebu City Mission-Vision: Care Using Knowledge and Compassion NURSING CARE PLAN
NCP Scoring System Nursing Dx 10 pts 2 pts Defining Characteristics Outcome 3 pts 1 pt Intervention Bibliography 3 pts 1 pt (at least 5 eferences)

Clients Name: __JBR________________________________________________________ Patient Care Classification: (Please Check) Age: 49 y.o._Sex: F__ Civil Status:_Married_ Religion: _Roman Catholic________________ __________ Wholly Compensatory: Pts. Therapeutic self-care is accomplished by Allergies: Food: __pt has no known food allergies__________________________________ nurse Drug: __no known drug allergies_________________________________________ ____/_____Partially Compensatory: Pts. Performs some self-care measures Diet: _________________________________________________________ __________ Supportive Educative Pts. Accomplishes self-care measures Date of Admission: _November 24, 2010______________________________________________ Clinical Division and Bed No: _Ward VI; Bed 14________________________________________ Diagnosis: __Chronic Renal Failure sec to probably CGN; Severe Anemia sec _______________Name of Physician: __Dr. ________________________________ ___________________________________________________________________________ Name of Student: ____ENOC, MIKKO CASTILLO______________________________

DEFINING CHARACTERISTICS

EXPECTED OUTCOME CRITERIA (Ideal)

INTERVENTION AND RATIONALE I: Identify the causes of the

BEHAVIORAL OUTCOME (Actual)

Nursing Diagnosis: Electrolyte imbalance (hyperkalemia) related to potassium retension and decrease renal excretion sec to CRF S: luya man ako pamati.as verbalized O:> received pt lying in bed, awake, conscious and coherent >w/ IV

LONG-TERM: After 2 days of nsg intervention the pts potassium level will be at the normal range SHORT-TERM: After 8 hours of nsg intervention the pt will demonstrate behaviors to monitor and correct deficits as appropriate

condition. R: affects the choice of intervention. S: Nursing Care Plan.4th ed I: Monitor respiratory depth and rate. Elevate the head of the bed and encourage DBE R: Patients may hypoventilate and retain CO2 leading to respiratory acidosis S: Nurses Pocket Guide.11th

#_________@____gtts/min infusing well to the___ arm >restlessness and irritability noted >diaphoresis noted >pale palpebral conjunctiva <dry oral mucous membranes LAB RESULTS: >K -5.69 >hct- .19mg/dl >Creatinine- 20.87mg/dl >BUN- 136.24 mg/dl

COLLABORATIVE I: assist w/ identification /treatment of underlying condition R: Refer to listing of predisposing/ contributing factors to determine treatment needs S: Nurses Pocket Guide.11th ed I: Provide fresh whole blood or washed RBC for transfusion R: FWB has less potassium than banked. S: Nursing Care Plan.4th ed

ed I:monitor fof heart rhythm/rate. Be aware of cardiac arrest occur. R: excess potassium depresses myocardial conduction S: Nurses Pocket Guide.11th ed I: Monitor urinary output R: In kidney failure, potassium is not excreted because of improper kidney excretion S: Nursing Care Plan.4th ed I: Assess level of consciousness, neuromuscular fxn, eg. Movement. Strength, sensation R: pt is usually awake and alert, but paresthesia, muscle weakness and flaccid paralysis may occur S: Nurses Pocket Guide.11th ed I: Encourage/assist w/ ROM exercises as tolerated R: improves muscular tone and reduces muscle cramps and pain. S: Nursing Care Plan.4th ed I: Recommend an increase in carbohydrates/fats/and foogs low in potassium eg. Canned fruits, apple juice R: Reduces exogenous sources of potassium and prevents catabolic tissue breakdown w/release of cellular potassium

BIBLIOGRAPHY >Brunner & Suddarth, MedicalSurgical Nursing, 10th ed. > Doenges, Marilyn E. et. al. 2004.Nurses Pocket Guide.11th ed., Philadelphia, FA Davis Company >Moyet, Lynda Juall.2006.Nursing Diagnosis: Application to Clinical Practice.Edition 11.Lippincott Williams and Wilkins >Wilkinson, et. al. Prentice Hall: Nursing Diagnosis Handbook.Singapore: Pearson 2008, p.451 > Doenges, Marilyn E. et. al. 2004.Nursing Care Plan.4th ed., Philadelphia, FA Davis Company Nurses Pocket Guide.11th ed Nursing Care Plan.4th ed

S: Nursing Care Plan.4th ed I: Encourage frequent rest periods; assist w/ care activities R: Gen weakness decreases activity intolerance S: Nursing Care Plan.4th ed

DEFINING CHARACTERISTICS >with limited ROM Laboratory: There are no laboratory results to support nursing diagnosis. Theoretical Basis: Self-care deficit: toileting is the impaired ability to perform or complete toileting activities for oneself. Because of pain caused by medical care procedures done to the patient, she is unable to do toileting activities without the help of her husband.

EXPECTED OUTCOME CRITERIA (Ideal) be able to increase level of own ability in toileting with caregivers assistance.

INTERVENTION AND RATIONALE desired goals to solve it. R>Enhances commitment to plan, optimizing outcomes, and supporting recovery and/or health promotion S>Doenges, 577 I>Practice and promote short-term goal setting and achievement R>To recognize that todays success is as important as any long-term goal S>Doenges, 577, 578 I>Provide privacy and equipment within every reach during personal care activities. R>To assist in dealing with the situation S>Doenges, 578 I>Assist the client to become aware of rights and responsibilities in health/healthcare. R>To promote wellness

BEHAVIORAL OUTCOME (Actual)

BIBLIOGRAPHY >Brunner & Suddarth, MedicalSurgical Nursing, 10th ed. > Doenges, Marilyn E. et. al. 2004.Nurses Pocket Guide.11th ed., Philadelphia, FA Davis Company >Moyet, Lynda Juall.2006.Nursing Diagnosis: Application to Clinical Practice.Edition 11.Lippincott Williams and Wilkins >Wilkinson, et. al. Prentice Hall: Nursing Diagnosis Handbook.Singapore: Pearson 2008, p.451 >http://www.medindia.net/patients/ Patientinfo/urinarystonedisease_ Treatment.htm