Funda CARE PLAN 1 Actual final PDF

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Download Funda CARE PLAN 1 Actual final PDF

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Selected Nursing Diagnosis: ACTUAL: Acute Renal Failure r/t electrolyte imbalance as evidenced by intake exceeding output Goal/Outcome Criteria: S.T.- Urine output that is yellow and clear within 24 hours L.T.- Maintain serum electrolytes (K, PO4, Na) within normal limits within three days

Assessment Data Cluster Subjective Symptoms: -Complains of left leg swollen, bruised, sensitive to touch. -Expressed difficulty breathing -Expressed being uncomfortable and bloated.

Objective Signs: -Abnormal breath sounds: crackles -Intake exceeds output -Altered electrolytes -HGB, HCT, PLT are low -BUN, Creatinine, INR are high

Nursing Interventions Assessment Interventions: 1) Assess client for history of risk factors of decreased renal perfusion, which indicates acute kidney failure 2) Assess for signs of dehydration

Therapeutic Interventions: 1) Continuously monitor for edema 2) Continuously monitor intake and output

Teaching Interventions:

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Rationale (Include Source) 1) If it is classified as prerenal, that means that the damage comes before the kidneys due to insufficient renal profusion (A&L 653). 2) Dehydration may cause decreased renal perfusion, resulting in renal failure (A&L 653). 1) Edema could be present due to increased fluid retention due to decreased renal function (A&L 652). 2) Oliguria is associated with acute renal failure. Urine output should be 0.5 ml/kg/hr (A&L 652).

Goal Evaluation Shift ended before S.T. and L.T goals could be met. The client did not urinate before shift ended. Laboratory reports were not received yet before shift ended.

1) Teach the related risk factors, signs and symptoms, and lifestyle changes that can improve renal function. 2) Teach client about all medications prescribed.

1) client education is vital to making lifestyle changes. Start with the base level of their understanding as the foundation for education (A&L 654). 2) Include the drug name, purpose, how to administer, and side effects (A&L 654).

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to planning care. Tenth edition. Maryland Heights, Missouri: Mosby Elsevier.

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