Name of Student: Dullan,Garnado,Irisari

Section: BSN 3F Date: 08-24-10

Name of Patient: D.M Age: 75 Sex: M Status: Widow Medical Diagnosis: CKD secondary to hypertensive nephrosclerosis

NURSING CARE PLAN

Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Intervention Justification Evaluation

Actual Cues: Imbalanced Nutrition: Less After 5 days of Nursing After 5days of nursing
than Body Requirements Intervention, the client will • Discuss with • Factors such intervention the client
related to loss of taste or be able to: the client as was be able to:
• Sudden weight loss smell and unpalpable diet as possible causes pain,fatigue,
• Poor muscle tone evidenced by sudden weight of decreased analgesic use
• Pale mucous loss. • Demonstrate appetite. and
membranes progressive weight immobility
gain toward goal. can contribute
to anorexia.
Risk
Identifying a
• Age
• Verbalize possible cause
Definition: intake of understanding of enables
Strengths nutrients insufficient to meet interventions
causative factors
• Strong belief in God metabolic needs. when known and to eliminate or
necessary minimize it.
• Positive outlook in interventions.
life • Encourage and • Poor oral
• Demonstrate help the client hygiene leads
• Good emotional and behaviors, lifestyle to maintain to bad odor
family support changes to maintain good oral and taste,
or regain hygiene. which can
appropriate weight. diminish
appetite.
 Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Intervention Justification Evaluation

Actual Cues: Imbalanced Nutrition: Less After 5 days of Nursing After 5days of nursing
than Body Requirements Intervention, the client will • Discuss with • Factors such intervention the client
related to loss of taste or Renal tissue loses function be able to: the client as was be able to:
• Sudden weight loss smell and unpalpable diet as  possible causes pain,fatigue,
• Poor muscle tone evidenced by sudden weight Interferes with the of decreased analgesic use
• Pale mucous loss. kidney’s ability to • Demonstrate appetite. and • Goal met.
maintain fluid and progressive weight immobility Client client
membranes was able to
electrolyte homeostasis gain toward goal. can contribute
 to anorexia. demonstrate
Risk progressive
Decline in ability to Identifying a
• Age weight gain
concentrate urine • Verbalize possible cause
toward goal’
Definition: intake of  understanding of enables
Strengths nutrients insufficient to meet interventions
Decrease in ability to causative factors • Goal met.
• Strong belief in God metabolic needs. when known and to eliminate or
exude phosphate,acid & K Client was able
 necessary minimize it. to verbalize
• Positive outlook in interventions. understanding
Imbalanced Nutrition
life • Encourage and • Poor oral of causative
• Demonstrate help the client hygiene leads factors.
• Good emotional and behaviors, lifestyle to maintain to bad odor
family support changes to maintain good oral and taste,
or regain hygiene. which can • Goal met. Client
was able to
appropriate weight. diminish demonstrate
appetite. behaviors to
maintain
appropriate weight.

.
• Determine • To assess
psychologica body image
l factors or and
perform congruency
psychologica with reality.
l
assessment
as indicated.
..
 Name of Student: Dullan,Garnado,Irisari

Section: BSN 3F Date: 08-24-10

Name of Patient: D.M Age: 75 Sex: M Status: Widow Medical Diagnosis: CKD secondary to hypertensive nephrosclerosis

NURSING CARE PLAN

Assessment Nursing Diagnosis Rationale Desired Outcome Nursing Intervention Justification Evaluation

Actual Cues: Risk for powerlessness After 5 days of Nursing After 5days of nursing
related to feeling of loss of Renal tissue loses function Intervention, the client will • Determine • To plan intervention the client
control and lifestyle  be able to: client’s usual effective was be able to:
• Decreased restrictions as evidenced by Interferes with the response to interventions,
mobility decreased physical strength kidney’s ability to problems. nurse must
• Decreased physical maintain fluid and • Verbalize positive determine if • Goal met.
strength electrolyte homeostasis self-appraisal in client usually Client was
 current situation seeks to able to
• Body weakness
Decline in ability to change his verbalize
concentrate urine own behaviors positive self-
Risk Definition: At risk for to control appraisal in

• Age perceived lack of control problems or if his current
Decrease in ability to
over a situation and/or one’s exude phosphate,acid & K he expects situation.
Strengths ability to significantly affect • Make choices other or • Goal met.

• Strong belief in God an outcome related to and be external Client was
Decreased physical
strength involved in care. factors able to be
• Positive outlook in • Help client to • Clients with involved in

life identify chronic illness care and make
Risk for powerlessness
personal needs choices.
• Good emotional and • Acknowledge strengths and assistance to • Goal met.
family support reality that some assets. not see Client was
areas are beyond themselves as able to
individual’s control. helpless acknowledge
victims. reality that
*Nursing Diagnoses and some areas are
Collaborative Problems beyond his
Edition 4 control.