NCP - Poststreptococcal Glomerulonephritis
NCP - Poststreptococcal Glomerulonephritis
NCP - Poststreptococcal Glomerulonephritis
Plan
Group 1 and 4
Case Scenario
A case of 2 year old male brought
by his mother at the emergency room
due to dyspnea , puffy eyelids, flank
pain and tea-colored urine. Upon
assessment, patient was noted to
have scabies at both lower
extremities . The following are the
doctors order:
1. CBC, urinalysis, BUN, creatinine,
total protein AG ratio, chest x-ray
2. Strictly monitor intake and output
3. Weigh daily
Doctor: Dr. U.
General Objective:
To facilitate the maintenance of oxygen
supply to all body cells
Subjective Cues
As
Objective Cues
Pale
skin
Restlessness
Nasal Flaring
Temp. 37.9C (37.5 C)
RR: 72 cpm (32-60 cpm)
HR: 135 bpm (app. 80-110 bpm)
Weight: 11.5 lbs or 5 kg; increasing to 0.3
lbs/day (approx.11.7 lbs)
BP: 110/80 mmHg (105/55-70 mmHg)
Others:
Chest
NURSING
DIAGNOSIS
RATIONALE
SPECIFIC
GOAL
Altered breathing
pattern: Dyspnea
related to fluid
retention
secondary to Acute
Poststreptococcal
Glomerulonephritis
Within 4
days of
rendering
nursing care
the client will
display
normal
breathing
pattern
INTERVENTION
RATIONALE
INDEPENDENT
Assess the level of consciousness and skin tone.
Note
Auscultate
chest.
To avoid overexertion
Instruct
Note
INTERVENTION
COLLABORATIVE
Administer diuretic (furosemide)
IV/stock 40mg/2mL/0.3cc every
12 hours, as ordered.
Administer
RATIONALE
oxygen at lowest
concentration indicated and
prescribed repiratory medications.
For
management of underlying
pulmonary condition, respiratory
distress.
To verify maintenance/
improvement in O2 saturation
EVALUATION
After 4 days of rendering effective
nursing care, the client with altered
breathing pattern was able to restore
normal breathing by evidence of
absence of nasal flaring, no restlessness,
no pale skin with respiratory rate of 40
cpm, with the temperature of 37 C, and
heart rate of 90 bpm, with the BP of
100/70 mmHg. Chest x-ray shows
negativity of fluid retention in the lungs.