Acute Glomerulonephritis _agn_ Nursing Care Plan 204q5a

Nursing Diagnosis Fluid volume excess Possible Etiologies: decreased glomerular filtration rate

Objectives Short term goal: Client will have an increased urine output of 70-80 ml for the next 6 hours.

Nursing Interventions Assessment: 1. Obtain complete physical assessment. 2. Monitor daily weight.

Disease Process: AGN Long term goal: Defining characteristics: Subjective Data: “I felt mutated with this enlarged arms and feet since if suffered from this illness,” as verbalized by the patient. Objective Data: +3 edema on both foot +2 edema on both hands (+) periorbital edema (+) proteinuria 30 ml urine output for the last 8 hours Vital signs: BP—140/90 PR—120 bpm

Client will have a sustained minimum urine output of 20 ml per hour and manifest lesser edema (+) 1.

3. Monitor fluid intake and output every 4 hours. 4. Monitor BP and PR every hour.

5. Assess for adventitious breath sounds. 6. Monitor laboratory values especially for the protein level in the urine. Treatment: 1. Maintain dietary restrictions during acute phase. a. sodium

Rationale

1. To have baseline data on the progress of fluid elimination through physical appearance. 2. To have a measurable on the fluid elimination. 3. To know progressing condition via glumerular filtration. 4. To know progression of hypertension and basis for further nursing intervention or referral. 5. To know for possible progression in the lungs. 6. To know the extent of protein loss which led to edema.

1.

a. to help prevent fluid retention

via absorption. b. protein 2. Maintain fluid restriction

3. Elevate extremities with pillows when at rest or at lying position. 4. ister diuretics as ordered. 5.ister antibiotics as ordered. 6. ister anti

b. it helps prevent fast elevation of BUN level. 2. Helps prevent further fluid accumulation while there is decreased glumerular filtration. 3. Helps fluid excretion via gravity. 4. Helps excrete excess fluids through pharmacological reaction. 5. Fights infection and progression of scarring. 6. Controls hypertension as

Evaluation Client had a total urine output of 72 ml 4 hours after the implementation of the nursing interventions. Client had edema of (+) 1 the second day of nursing intervention. Patient also had an average of 24 ml of urine output for the last 10 hours.

hypertensive drugs as ordered. Educative: 1. Encourage ambulation and non strenuous exercises. 2. Teach on the importance of elevating extremities when at rest. 3. Encouraged to maintain clean and moist skin. 4. Encouraged to stick on dietary and fluid restrictions.

caused by excessive fluid.

1. Helps increase blood and fluid circulation. 2. Reinforces awareness on its effect on fluid excretion. 3. Helps prevent skin breakdown and further infection arising from the skin. 4. For client cooperation even in the absence of any medical practitioner.