Nursing Care Plan
Question
This a nursing care plan that needs to be done on a patient, it needs to be in a landscaped format,nanda approved nursing diagnoses, I need 3 nursing diagnoses, 5 interventions for each for each nursing diagnoses and 5 planning items for each diagnoses, I need a evaluation for each diagnoses, short term and long term goal for each diagnoses, and a medical diagnoses. I need a amazing care plan and done really quickly. I’ve added 2 pictures one paper of my patient and another is a sample of what it should look like, on top of the paper I would need a couple of sentences about the patient. I don’t need any references or anything like that.


Solution
Nursing
Care Plan
The patient presented at Ciara Maass
Medical Centre for Transitional with hyperkalemia, hypercalcemia, chronic
kidney disease stage 4, kidney injury, dyslipidemia, proteinuria and risk for
falls. The patient’s vitals on 2/22 at 1500hrs were as follows; Temperature-
97.0, Blood pressure- 121/61mmHg, Pulse-66 beats per minute and SpO2 of 95%. He
is currently actively under inpatient medications: Norvasc, amiodarone 200mg,
aspirin, atorvastatin, docusate, heparin 5,000units, metoprolol, multivitamin
pantoprazole, and pneumococcal 23-polyvalent vaccine. Also, the active PRN
medications include acetaminophen, melatonin, and polyethylene glycol 3350 17g.
Moreover, a laboratory test was done
and the results obtained are for the past 36 hours. However, the results showed
elevated levels of creatinine and BUN. Low glomerular filtration rate, red
blood cells, hemoglobin levels, hematocrit levels, lymphocytes were noted.
Eosinophils and monocytes were also elevated.
Below is a nursing care plan for this patient with
acute kidney injury medical diagnosis.
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. |



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