NURSING CARE PLAN

Identified Problem: Acute Kidney Injury

Nursing Diagnosis: Fluid Volume Excess related to compromised regulatory mechanism as evidenced by pitting leg-to-foot edema and altered electrolytes

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent:  Accurate I&O is necessary for determining fluid replacement Short term:
His wife stated that the  In 8 hours of nursing  Record accurate intake and output needs and reducing risk of fluid overload. Goal met. Patient cooperates with
patient has been having interventions, patient will (I&O). Include “hidden” fluids,  Measures the kidney’s ability to concentrate urine. the monitoring of fluid status.
swelling of both legs in the demonstrate behavior to such as intravenous (IV) antibiotic  Daily body weight is best monitor of fluid status.
last four weeks which was monitor fluid status and additives, liquid medications, ice  Tachycardia and hypertension can occur because of (1)
temporarily relieved by leg reduce recurrence of chips, and frozen treats. failure of the kidneys to excrete urine, (2) excessive fluid
elevation at night. fluid excess  Monitor urine specific gravity. resuscitation during efforts to treat hypovolemia or
hypotension, and (3) changes in the renin-angiotensin
 Weigh daily at same time of day, system, which helps regulate long-term blood pressure and
on same scale, with same blood volume.
Objective: equipment and clothing.  Patient with CNS involvement may be dizzy and/or confused.
 2+ bilateral pitting leg-to-  Monitor heart rate, BP, and CVP.  Fluid management is usually calculated to replace output
foot edema from all sources as well as estimate insensible losses due to
Vital signs:  Use appropriate safety measures metabolism and diaphoresis. Long term:
BP: 160/90mmHg right Long term objectives: (raising side rails and restraints). Goals partially met.
 Catheterization excludes lower tract obstruction and provides
upper arm In 3 days of nursing means of accurate monitoring of urine output during acute  Vital signs:
Oral temperature: 37.4’C interventions, patient’s: phase Axillary temperature: 36.5’C
HR: 82 bpm  Vital signs within Dependent: Pulse rate: 86 bpm
 Given early in oliguric phase of ARF in an effort to convert to
RR: 18 breaths/minute patient’s normal range  Administer and restrict fluids, as RR: 20 bpm
diuretic phase, flush the tubular lumen of debris, reduce
Chest X-ray APL result:  Laboratory studies near indicated. BP: 135/85
hyperkalemia, and promote adequate urine volume.
Showed cardiomegaly, normal  Insert indwelling catheter, as  Some laboratory studies are near
 Given early in nephrotoxic ATN to reduce influx of calcium
enlarged pulmonary artery,  Free from signs of indicated. normal
into kidney cells, thereby helping to maintain cell integrity and
and interstitial edema edema  Administer medications as BUN: 25 mg/dL
improve GFR.
BUN: 85 mg/dL indicated. Creatinine: 1.5 mg/dL
Creatinine: 2.8 mg/dL  Assesses progression and management of renal
Diuretics: Furosemide (Lasix) 20 Hemoglobin: 9.5 g/dL
Serum sodium: 133 mEq/L dysfunction,failure.
mg IV push x 1 dose. Hematocrit: 28.4%
Serum potassium: 6.5  Hyponatremia may result from fluid overload (dilutional) or
 There’s still receding degree of
mEq/L Calcium channel blocker: kidney’s inability to conserve sodium.
edema on the left lower leg and
Hemoglobin: 8.6 g/dL Amlodipine 10 mg PO daily. Hold dose  Lack of renal excretion or selective retention of potassium by left foot at 1+
Hematocrit: 27.4% if SBP < 90 mmHg or DBP <50 mmHg the tubules leads to hyperkalemia, requiring prompt
 No noticeable swelling on the
and call MD. intervention.
right leg/right foot
 Decreased values may indicate hemodilution associated with
hypervolemia
Collaborative:  Increased cardiac size, prominent pulmonary vascular
markings, pleural effusion, and infiltrates indicate
 Monitor diagnostic studies
acuteresponses to fluid overload or chronic changes
Blood Urea Nitrogen, Creatinine, associated with renal failure and HF.
Serum sodium, Serum potassium,
Hemoglobin/Hematocrit, Chest X-
rays

NURSING CARE PLAN

Patient X / Room No. | 1
Identified Problem: Increased serum potassium level

Nursing Diagnosis: Electrolyte Imbalance: Hyperkalemia

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent: Independent: Short term:

Goal met.
Patient reported having After 8 hours of nursing 1. Monitor heart rate and rhythm. Be aware 1. Potassium excess depresses myocardial Axillary temperature: 36.5’C,
nausea, vomiting, and interventions, because cardiac arrest may occur. conduction. Bradycardia can progress to cardiac Radial pulse rate = 86 bpm
generalized muscle 2. Monitor respiratory rate and depth. Encourage fibrillation and arrest. RR = 20 breaths/min
weakness deep breathing and coughing exercise. Elevate 2. Clients may hypoventilate and retain carbon right upper arm BP: 135/85 mmHg
 the patient’s vital signs and
the head of the bed. dioxide resulting in respiratory acidosis. high fowler’s position,
serum potassium level will
be within the normal limits, 3. Encourage frequent rest periods; assist with Muscular weakness can affect respiratory
daily activities, as indicated. muscles and lead to respiratory complications. Serum potassium level: 4.9mEq/L
and
4. Teach and assist the client with range-of-motion 3. General muscle weakness decreases activity Patient is alert, oriented to person,
 the patient will have a time, place, and events.
decrease severity of (ROM) exercises, as tolerated. tolerance.
nausea and vomiting, 5. Identify and discontinue dietary sources of 4. Improves muscle tone and reduces muscle
Objective:
generalized muscle potassium, such as beans, dark leafy greens, cramps and pain.
weakness, and lethargy potatoes, squash, yogurt, fish, avocados, 5. Facilitates the reduction of potassium levels and
 Serum mushrooms, and bananas. helps prevent recurrence of hyperkalemia.
potassium level
of 5.5 mEq/L
Dependent: Dependent:
 Lethargic Long term:
 Vital signs are Long Term Objectives:
1. Administer medications, as indicated: - Promotes renal clearance and potassium
as follows: After 3 days of nursing interventions,
excretion.
 T: 36.9 C orally After 3 days of nursing the patient was free from
- Loop diuretics such as furosemide - Temporarily stops the gap measure that
 BP: 155/90 interventions, the patient will be complications resulting from
(Lasix). antagonizes toxic potassium depressant effects
mmHg free from complications electrolyte imbalance
- Calcium gluconate on the heart and stimulates cardiac contractility.
 HR: 88 bpm resulting from electrolyte
- IV glucose (D50) with insulin and - Short term emergency measure to move
 RR: 18 imbalance
sodium bicarbonate. potassium into the cell, thus reducing toxic
breaths/min - Sodium polystyrene sulfonate serum level.
(Kayexalate), given orally. - Resin removes potassium by exchanging
potassium for sodium or calcium in the GI tract.
Collaborative: Sorbitol enhances evacuation.

1. Monitor the electrolytes (serum potassium level),

BUN, creatinine, CBC with the laboratory technician. Collaborative:

2. Discuss with a nutritionist and/or dietician the 1. This can help monitor and evaluate the
necessary fluids and foods for a hyperkalemic patient treatment regimen and interventions.
considering the patient's age. 2. Facilitates the reduction of potassium levels and
may prevent recurrence of hyperkalemia.

NURSING CARE PLAN

Identified Problem: Hypertension
Patient X / Room No. | 2
Nursing Diagnosis: Risk for Decreased Cardiac Output

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent: Independent:

1. Comparison of pressures provides a more Short term:
 Patient stated that For the next 8 hours of nursing 1. Monitor BP and HR. complete picture of vascular involvement or
care, the patient will be able to: scope of problem. Goal met. Patient’s BP is within
he has a 2. Observe ECG for changes in rhythm. 2. Changes in electromechanical function may
longstanding history 3. Auscultate heart sounds normal range (130/90 mmHg). There
of hypertension become evident in response to progressing was no irregularity in heart rhythm as
 maintain BP and 4. Assess color of skin, mucous membranes, renal failure and accumulation of toxins and
demonstrate stable cardiac observed in the patient’s ECG results.
and nail beds. Note capillary refill time. electrolyte imbalance.
rhythm and rate within 5. Note dependent and general edema. 3. S4 heart sound is common in severely
Objective: patient’s normal range Long term:
6. Provide calm, restful surroundings, minimize hypertensive patients because of the presence
 participate in activities that environmental activity and noise. Limit the of atrial hypertrophy
 BP 160/90mmHg will reduce BP and number of visitors and length of stay. Patient’s BP was maintained within
right upper arm activities that will prevent
4. 4) Pallor may reflect vasoconstriction or anemia. normal range. Adequate urine output,
7. Maintain activity restrictions (bedrest or chair Cyanosis is a late sign and is related to
 Chest X-ray APL stress rest); schedule periods of uninterrupted rest; peripheral pulse grading of +3 and
pulmonary congestion and/or cardiac failure. patient has increased activity
result: Showed assist patient with self-care activities as Development of S3 indicates ventricular tolerance, was able to ambulate at
cardiomegaly, needed. hypertrophy and impaired functioning. Presence the hospital hallway not getting tired
enlarged pulmonary 8. Instruct in relaxation techniques, guided of crackles, wheezes may indicate pulmonary quickly
artery, and interstitial Long Term Objectives: imagery, distractions. congestion secondary to developing or chronic
edema
heart failure.
 Emesis After 24 hours of nursing Dependent: 5. May indicate heart failure, renal or vascular
 pale mucous intervention, patient will be able impairment.
membranes, dry skin to: 1. Administer fluids, diuretics, inotropic drugs, 6. Helps lessen sympathetic stimulation; promotes
 2+ bilateral pitting antidysrhythmics, steroids, vasopressors, relaxation.
leg-to-foot edema; and/or dilators 7. To lessens physical stress and tension that
 demonstrate hemodynamic
 Patient appears tired stability and increase in 2. Implement dietary sodium, fat, and affect blood pressure and the course of
and drowsy activity tolerance cholesterol restrictions as indicated. hypertension.
8. Can reduce stressful stimuli, produce calming
Collaborative effect, thereby reducing BP.

1. Check laboratory data (cardiac markers, Dependent:

complete blood cell count, electrolytes, 1. To support systemic and cardiac circulation
ABGs, blood urea nitrogen and creatinine, 2. These restrictions can help manage fluid
cardiac enzymes, and cultures, such as retention and, with associated hypertensive
blood, wound or secretions). response, decrease myocardial workload.
2. Provide for diet restrictions , as indicated
Collaborative:
1. To identify contributing factors
2. to provide proper nourishment as well as to
prevent aggravation of disorder

NURSING CARE PLAN

Identified Problem: Pruritus
Patient X / Room No. | 3
Nursing Diagnosis: Risk for Infection

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objectives: Independent: Independent:

1. Excoriations from scratching may become Short term:
 The pruritus on his After 8 hours of nursing care, 1. Assess skin integrity secondarily infected.
legs was going on the patient will be able to: 2. Fever with increased pulse and respiration
for four weeks now. 2. Monitor vital signs is typical of increased metabolic rate
 Reports itchiness in  Report lessened irritating resulting from inflammatory process and
the lesions noted on sensation of itchiness. 3. Assess for signs of infection can be a sign of infection.
both legs, 3. Patient is at highest risk for developing skin
 Practice appropriate
infections caused by staphylococcus
hygiene methods 4. Encourage the patient to use appropriate
Objective: aureus. With severe infections, the patient
hygiene methods.
may have an elevated temperature.
4. Keeping the skin clean, dry, and well
 BP 160/90mmHg 5. Trim fingernails lubricated reduces skin trauma and risk of
right upper arm Long Term Objectives: infection.
 Chest X-ray APL Dependent: 5. Trimming fingernails prevents skin
result: Showed After 24 hours of nursing scratches that might serve as an entrance
cardiomegaly, intervention 1. Administer oral antibiotics as indicated. for infections Long term:
enlarged pulmonary 2. Apply topical antibiotics.
artery, and interstitial Dependent:
edema  the patient will be able to
verbalized absence of 1. Oral antibiotics may be more effective in
 Emesis treating infections on the skin.
irritation and itchiness; Collaborative:
 pale mucous 2. Topical antibiotics may be used to treat
 the patient is free from any
membranes, dry skin infections that occur with dermatitis.
signs of infection 1. Obtain specimen for culture and sensitivity
 2+ bilateral pitting Collaborative:
and administer appropriate antibiotics as
leg-to-foot edema; 1. Verification of infection and identification of
indicated.
 Patient appears tired specific organism aids in choice of the most
and drowsy effective treatment.

NURSING CARE PLAN

Identified Problem: Nausea and vomiting
Patient X / Room No. | 4
Nursing Diagnosis: Risk for imbalanced nutrition: less than body requirements

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short Term Objectives: Independent: Independent:

Patient stated that he After 8 hours of nursing 1. Assess and document dietary intake 1. Aids in identifying deficiencies and dietary Short term:
had 4 episodes of interventions, patient is 2. Provide frequent small feedings needs. General physical condition, uremic
nausea and vomiting at alleviated from episodes of 3. Provide list for permitted food and fluids and symptoms (nausea, anorexia), and multiple
home which consisted nausea and emesis. encourage involvement in menu choice. dietary restrictions affect food intake.
mainly of food he 4. Offer frequent mouth care with diluted acetic 2. Minimizes anorexia and nausea associated
ingested at dinner time Long Term Objectives: acid solution. Give gums, hard candy and with uremic state and/or diminished
last night. His nausea After 72 hours of nursing breath mints between meals. peristalsis.
and vomiting has been interventions, patient is relieved 5. Weigh daily 3. Provides patient with a measure of control Long term:
going on for 8 hours prior from episodes of nausea and 6. Monitor BUN, albumin, potassium, sodium, within dietary restrictions. Food from home
to arrival. emesis, and weight is and transferrin. may enhance appetite.
maintained 4. Mucous membranes may become dry and
Objective: Dependent: cracked. Mouth care soothes, lubricates,
Height: 5’6” Weight: 85 1. physician ‘s order for laboratory test: and helps freshen mouth taste, which is
kg via bed scale albumin, BUN, transferrin, sodium and often unpleasant because of uremia and
Temperature: 37.4’C oral potassium. restricted oral intake. Rinsing with acetic
PR: 88 bpm radial BP: 2. Consult with the dietician support team. acid helps neutralize ammonia formed by
185/110 mmHg left arm 3. Restrict potassium, sodium, and conversion of urea.
RR: 24 breaths/minute phosphorus intake as indicated. 5. The fasting or catabolic patient normally
SpO2: 92% room air loses 0.2–0.5 kg/day. Changes in excess of
0.5 kg may reflect shifts in fluid balance.
6. Indicators of nutritional needs, restrictions,
and necessity for and effectiveness of
therapy.

Dependent:
1. Indicators of nutritional needs, restrictions,
and necessity for and effectiveness of
therapy
2. Determines individual calorie and nutrient
needs within the restrictions, and identifies
most effective route and product (oral
supplements, enteral or parenteral
nutrition)..
3. Restriction of these electrolytes may be
needed to prevent further renal damage,
especially if dialysis is not part of treatment,
and/or during recovery phase of ARF.

Patient X / Room No. | 5