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.

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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 (O₂Sat)	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