Cues Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Reason
Subjective: Ineffective For optimal Short Term: - Determine - to assess Short Term:
renal cell After the factors related to causative and  The client
Objective: perfusion functioning nurse’s shift, individual contributing was able to
- Blood pressure related to the kidney the client will be situation and factors demonstrate
168/92 glomerular note situation knowing the behavior to
excrete able to
malfunction that can affect all can be a guide correct health
as evidenced potentially body system for the situation.
- Urine output by Increased harmful -Demonstrate appropriate
low: 25ml/hour blood urea nitrogenou behaviors to treatment or  The client
(Oliguria) nitrogen s product- monitor and plan of care. was able to
(BUN) and Urea, correct the verbalize
- Specific gravity Creatinine Creatinine, deficit as understanding
was 1.010 Uric Acid indicated in his - Monitor intake, -Reduced regarding his
but condition observe changes intake or condition
-BUN 180 mg/dL in urine output. unrelenting ineffective renal
because of
and Record urine nausea may perfusion.
the loss of -Verbalize
specific gravity as consequence in
- Creatinine 1.3 kidney understanding necessary. lowered  The client
mg/dL excretory of the causative circulating achieved
functions factors and the volume, which decrease in BUN
- Bicarbonate there is purpose of negatively and creatinine
was 10mEq/L impaired given affects levels,
excretion interventions perfusion and
of organ function.  The client
- Both ankles and nitrogenou -The patient will Hydration achieved
one knee had status and renal decrease in
s waste have decreased
Grade 3+ pitating function are edema
product edema of 1+ or
edema and there revealed by within 48
was a large area causing in less within 48 specific gravity hours..
of sacral edema. increase in hours. measurements.
Laboratory Long Term:
result of -The patients  The client
BUN, BUN and - Inform client - to gain the attained
Creatinine, creatinine will regarding his trust of the normal and
Uric Acid be within current condition client and also within
Level. normal range and the possible range of Lab
encourage
plan of care to be Results .
. within 36 hours them to
implemented
cooperate with
Long Term: every
intervention
The client will that is a part of
display within the care plan.
range Lab Also discuss
Results. possible cause
and effect of
renal tissue
perfusion.

- Monitor BP, - Glomerular

ascertain Filtration Rate
patient's usual
may increase
range
 rennin and
Blood Pressure.

- Measure urine - this is to

output on assess renal
regular schedule perfusion and
and weigh daily function..

- The nurse will - Diuretics aids

assess the
in the excretion
patient’s
of excess body 
peripheral
edema every fluids.
shift. Take
diuretics as
prescribed.