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Name of the Client: W. R. Age: 55 Y.O.

Chief Complain: Vomiting Attending Physician: Dr. Jocson/Lavente


Medical Diagnosis: Uremic Gastropathy 2˚ to Chronic Kidney 2˚ to Urate Nephropathy Date of Admission: Sept. 25, 2010

Assessment Nursing Diagnosis Rationale Outcome Nursing Justification Evaluation


Intervention

Actual/Abnormal Risk for infection r/t Uremic After 5 days of nurse- Independent:
Cues: accumulation of Gastropathy client interaction, the 1. Require good 1. Prevents cross-
uremic waste client will be able to: handwashing contamination and
 BUN-30 mmol/L products 1. Understanding of protocol for all reduce risk for
(N=1.7- Accumulation of individual personnel and infection.
8.3mmol/L) uremic waste causative visitors.
 Creatinine- products factor/risk 2. Inspect oral 2. The oral cavity is an
645.9mmol/L (Uremia)in the factor(s). mucous excellent medium for
(N=53- Definition: At blood membranes. growth of organism
132.6mmol/L) increased risk for Provide good oral and is susceptible to
 Low levels of being invaded by 2. Identify hygiene. Use a ulceration and
Hgb-74 (N=130- pathogenic organisms Increase BUN and interventions to soft toothbrush, bleeding.
180) and Creatinine prevent/reduce risk sponge, or swabs
lymphocytes -7% of infection. for frequent
(N=25%-35%) mouth care.
 Altered level of Sources: 3. Provide 3. Reduces skin/tissue
consciousness Risk for infection 3. Demonstrate meticulous skin breakdown and
 Many bacteria on Doenges, Moorhouse, techniques, care. infection
U/A results Geissler-Mur,2004, lifestyle changes to 4. Monitor vital 4. Reflective of
 Temperature of Nurse’s Pocket Reference: promote safe signs especially inflammatory
37.6˚C Guide: Diagnoses, environment. temperature. process/ infection,
Interventions and http://www.kosmix. requiring evaluation
 Highest BP of th
Rationales, 9 ed. com/topic/Uremia/o and treatment.
180/100 mmHg
verview/adam20? 5. Encourage intake 5. This maintains
fdid=Adamv2_000 of protein- and optimal nutritional
508&section=Full_ calorie-rich foods. status.
Risk Cues/Related Article.html 6. Encourage 6. These measures
Factors: frequent turning reduce stasis of
and deep secretions in the
 Medical breathing. lungs and bronchial
diagnosis:Uremic tree. When
Gastropathy 2˚ to stasis occurs,
Chronic Kidney pathogens can cause
2˚ to Urate upper respiratory
Nephropathy infections, including
 Alcohol drinker pneumonia.
and smoker
 Reason for
admission: Collaborative:
vomiting 1. Obtain specimens 1. Verifies presence
for culture and of infection,
Strengths/Wellness: sensitivity, as identifies specific
indicated. pathogen and
 Strong family influences choice
support of
 Ambivert treatment.
personality 2. Administer 2. May be given
antibiotics as prophylactically
indicated. or to treat specific
infection.

Reference:
Doenges, Moorhouse,
Geissler-Mur,2004,
Nurse’s Pocket Guide:
Diagnoses, Interventions
and Rationales, 9th ed.

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