Nursing Care Plan

ASSESSMENT DATA

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

EVALUATION

OBJECTIVE DATA

High creatinine levels

Proteinuria

Low GFR

High BUN levels, edema, high blood pressure of 171/93mmHg.

Respiratory rate of 15b/minute and temperature of 35.2 degrees Celsius.

SUBJECTIVE DATA

The patient verbalizes reduced urine output,

Altered renal tissue perfusion related to glomerular malfunction as evidenced by high creatinine levels, proteinuria, low GFR and high BUN levels, high blood pressure, low temperature and respirations, and reduced urine output,

The patient will adopt behavior change to limit further complications.

The patient will demonstrate co-operation in the therapy plan recommended.

The patient will demonstrate vital signs within a normal range.

The patient will verbalize feelings regarding behavior and lifestyle change to promote wellness.

The patient will demonstrate overall health wellness to note improvement and coping.

1. Establish rapport with the patient to enhance co-operation and encourage him to openly communicate his feelings regarding treatment options provided to reduce anxiety and maximize his participation and autonomy.

2. Monitor vital signs and records to obtain baseline data and assess the patient’s general condition.

3. Provide a diet restriction to limit BUN and adequate calories intake to meet body requirements.

4. Administer medications as prescribed to limit complications.

 5. Identify the necessary lifestyle changes to incorporate in disease management.

SHORT TERM GOAL

After 2-3 hours, the patient cooperates in the recommended treatment plan.

LONG TERM GOAL

After 3 days, the patient demonstrates behavior and lifestyle changes to promote disease management and prevent complications.

OBJECTIVE DATA

Hyperkalemia

Hypercalcemia

Heart rate of 52b/minute.

SUBJECTIVE DATA

Inability to perform activities of daily living, general muscle weakness, muscle cramping.

Electrolyte imbalance related to chronic kidney disease as evidenced by hypercalcemia, hyperkalemia, heart rate of 52b/ min, inability to perform activities, general muscle weakness, and muscle cramping,

The patient will verbalize an understanding of dietary adjustments.

The patient will achieve a normal electrolytes level of potassium and calcium.

The patient will maintain a normal cardiac rhythm and rate.

The patient will maintain a normal neuromuscular function.

The patient will demonstrate compliance with medications to achieve normal electrolyte levels and prevent complications.

1. Monitor the client’s heart rhythm, and rate since excess potassium causes depression to myocardial conduction; hence cardiac arrest may occur.

2. Monitor respiratory depth and rate and encourage deep breathing exercises since the client may experience hypoventilation and carbon dioxide retention, causing respiratory acidosis.

3. Assess the patient’s consciousness level and neurologic and muscular function as muscular paresthesia and paralysis may occur.

4. Administer loop diuretic medications such as furosemide to promote renal clearance and excretion of potassium and assist the patient in performing daily activities to encourage him to have frequent rest periods.

5. Discontinue dietary potassium sources like beans, potatoes, bananas, fish, mushrooms, and avocadoes. Encourage low potassium food like whole grains, pineapple, carrots, and carbohydrate intake to reduce exogenous potassium sources.

SHORT TERM GOAL

After 6 hours of nursing interventions, the patient verbalizes an understanding of the dietary adjustments and re-establish appropriate dietary patterns.

LONG TERM GOAL

In 10 days of nursing interventions, the patient exhibits normal calcium and potassium laboratory levels.

OBJECTIVE DATA

Low hemoglobin, hematocrit, and RBC levels.

Risk of falls.

Weak peripheral pulses, pallor.

SUBJECTIVE DATA

The patient reports fatigue.

The patient verbalizes on difficulty of performing daily activities.

 Risk for activity intolerance related to an imbalance between the supply of oxygen and demand, as evidenced by low RBC, HGB, and hematocrit levels, fatigue and difficulty in performing daily chores.

The patient will demonstrate an ability to perform normal daily activities.

The patient will identify activity intolerance aggravating factors.

The patient will be able to verbalize and maximize techniques to conserve energy.

The patient will verbalize and identify ways to limit activity intolerance.

The patient will maintain pulse oximetry of 93%-99%.

1. Assess for signs of decreased oxygenation of tissues such as dizziness, dyspnea on exertion, palpitations and headache.

2. Blood transfusion (packed RBCs) to increase RBC circulation in blood and oxygen-carrying capacity.

3. Check patient’s

 Pulse oximetry and inform physician when it’s less than 92% and administer supplemental oxygen PRN.

4. Assess falling risks and enforce applicable measures.

5. Give iron and folate supplements and dietary supplements to restore hemoglobin and iron levels.

SHORT TERM GOAL

After 7hours of nursing intervention, the patient demonstrates increased activity intolerance in performing daily living activities.

After 4 hours of nursing interventions, the patient verbalizes an understanding of the need for iron supplements and dietary requirements to restore hemoglobin levels and the readiness to comply.

LONG TERM GOAL

After one month of nursing interventions, the patient exhibits a hemoglobin level of 11.0g/dl and increased RBC and hematocrit levels to normal.