Chronic Renal Failure Nursing Care Plan
Chronic Renal Failure Nursing Care Plan
CASE STUDY SCENARIO #5
D.T. is an 84-year-old Middle Eastern male, who arrived into the ER with worsening shortness of breath, anxiety, forgetfulness, and difficulty urinating. Patient brought into the ER by his wife, and has a family who is very involve in his care. Patient is at times non-compliant with diet.
ORDER NOW FOR CUSTOMIZED SOLUTION PAPERS
Patient with multiple comorbidities including the following: Hypertension, presence of permanent pacemaker, CHF, COPD, Chronic kidney disease stage IIII, anxiety
Patient with a long surgical history as follows: pacemaker placement, open heart surgery, x 3 myocardial infarctions, vascular surgery in bilateral lower extremities, circumcision
Upon assessment, patient with crackles in bilateral lower lobes, +2 pitting edema in bilateral feet, and dyspnea upon exertion and lying flat.
Admitting Diagnosis: Acute VS chronic renal failure
H:5’9”
W: 250 lbs
FULL CODE
NKDA
Labs drawn and results as follows:
Sodium: 138
Potassium: 3.8
Magnesium: 1.9
WBC: 10
BUN: 34
Creatinine: 2.9
Troponin: 0.14
BNP: 8898
Vital signs as follows:
BP: 104/56
HR: 70
RR: 22
Temp: 97.9
Oxygen Saturation: 89% on room air
Orders as follows:
Bumex 1 mg/hr x 4 hours via IV piggyback
Foley catheter
Strict intake and output
Ativan 1 mg PO BID
Ativan 1 mg IV push Q8H PRN anxiety/insomnia
Oxygen 2 liter per minute via nasal cannula
Chest x-ray 1 view, STAT
| Student | Date | ||||
| Instructor | Course | ||||
| Patient Initial | Unit/ Room# | DOB | |||
| Code Status | Height/Weight | ||||
| Allergies | |||||
| Temp (C/F Site) | Pulse (Site) | Respiration | Pulse Ox (O2 Sat) | Blood Pressure | Pain Scale 1-10 |
| History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations |
Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations |
|
|
| Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
|
Past Medical & Surgical History,
Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations |
|
|
| Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations |
Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations |
|
|
| Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx) |
Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations |
| Contributing
Factors |
| Diagnostic
Label |
|
Related to |
|
As evidenced by |
| Signs and
Symptoms |
|
Priority Nursing Diagnosis
(at least 2) Written in three part statement
|
Planning
(outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis)
|
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal) |
Rationale Each must be
supported with Evidence Based Citations |
Evaluation
Goal Met, Partially Met, or Not Met & Explanation
|
MEDICATION LIST
| Medications (with APA citations | Class/Purpose | Route | Frequency | Dose (& range)
If out of range, why? |
Mechanism of action
Onset of action |
Common side effects | Nursing considerations
specific to this patient |