End stage renal sickness (esrd nursing care plan

nursing care plan
nursing DX

1. NURSING PROCESS CARE PLAN




































INSTRUCTOR:
STUDENT NAME:
COURSE NAME:
ASSIGNMENT DATE:

2. Nursing Process Care Plan
Client Name: James Bean Culture/Ethnicity: African
American
Support System: wife and kids
Unit: Med Surg Room/Bed: 202 Religion: Baptist Occupation: Police officer
Age: 67 Sex: Male Language: English Current Work Status: Retired
Weight: 72.2 kg Height: 6’0 Marital Status: Married Highest Grade Completed: College
Primary Patient Complaint: SOB with chest pain/pressure on inspiration;
rated 10 on pain scale.
Patient Medical History: hypertension, type 1 diabetes, coronary artery disease, and
end stage renal disease
 Diagnostic Procedures (Not to include labs):
 Computed tomography scan
Renal or abdominal X-ray
Surgical Procedures: coronary artery bypass graft
Pathophysiology/Etiology (Theory): Define patient primary problem
and cause(s). In end-stage renal sickness (ESRD), the bloodstream to the kidneys might
be radically decreased because of all the harm to the purifying structures in the kidney (the
glomeruli). Urine output is diminished causing, dangerous substances develop in the blood.
The whole impact of this is "uremia," a complex biochemical disorder that outcomes from
this harmful development. Blood urea nitrogen and creatinine are two blood markers that
ascent in renal infection. Electrolyte levels can likewise wind up unsettled in renal disorder.
Diabetes is the most widely recognized reason for ESRD. Hypertension is the second most
basic reason for ESRD. Different issues that can cause kidney disappointment include:
Immune system sicknesses, for example, lupus and IgA nephropathy *Hereditary ailments
(illnesses you are conceived with, for example, polycystic kidney infection *Nephrotic
disorder *Urinary tract issues
Supporting Symptomatology: What patient data
supports your selection of Pathophysiology? History of
diabetes mellitus (DM) & Hypertension (HTN)
Vital Signs/Frequency: T: 36.8˚C; P: 88; R: 22; B/p: 160/96; Pain 10

Possible Complications
Health problems that can result from ESRD include: Anemia, bleeding from the stomach or intestines, bone, joint, and muscle pain, & damage to nerves of the legs and arms.

3. LAB RESULTS INTERPRETATION

LAB TEST PATIENT’S LAB RESULTS NORMAL RANGE
Blood urea nitrogen (BUN)


13.2mg/100ml


7- 20mg/100ml
Creatinine (cr) 3mg/100ml 0.7- 1.4mg/100ml
Urine specific gravity 1.030 1.010-1.025
A1c 8.1 < 7.0
Magnesium 3.5mEq/L 1.5-2.0mEq/L

4. DIAGNOSTIC RESULTS INTERPRETATION

PATIENT’S DIAGNOSTIC RESULTS PATIENT’S DIAGNOSTIC RESULTS NORMAL RANGE
 Computed tomography scan

 Reduced kidney size

Normal Size
Renal or abdominal X-ray Obstruction to renal structure No obstruction noted

5. ASSESSMENT
Subjective/
Objective
NURSING
DIAGNOSIS
#1
(Physical)
PLANNING/
OUTCOME
(Client Centered)
1 Short Term
1 Long Term
INTERVENTIONS
(Nurse Centered)
1 Monitoring, 1 Action
& 1 Teaching per Goal

RATIONALE FOR
INTERVENTIONS
1 per Intervention

EVALUATION
(Evaluate each
Goal)
Subjective Data:
 Pt c/o of SOB w ith
chest pain/pressure
on inspiration; rated
10 on pain scale.
Excess Fluid Volume R/T
decrease glomerular filtration
rate and sodium retention.
Patient w ill practices methods
to screen fluid status and
diminish repeat of liquid
abundance.
Explain to patient and family the
rationale for fluid restrictions

Including patients and their families is a vital
part of guaranteeing compliance w ith
disease management and increase the
likelihood of optimal patient outcomes.
PT w ill demonstrate appropriate
measure to monitor I&O.
Identify sources of fluid and limit
fluid as prescribe.



Unrecognized source of fluids may be
identified.
Assess for s/s of fluid volume
excess, keep accurate I&O and
daily w eights

It is important if the kidneys are not
functioning to measure the patient’s I&Os.
Notify the physician if there is a deficit
greater than 5-10%.

Objective Data:
 V/S:
T: 36.8˚C
P: 88
R: 22
B/p: 160/96
 Orthostatic Hypotension
 Atrial fibrillation
 JVD
 Pulmonary
Edema/Rales
 Edema
Patient w ill show balance out
fluid volume AEB balance I&O,
normal VS, stable w eight, and
free from signs of edema.
Review lab such as BUN,
Creatinine, Serum electrolyte.
To screen for fluid and electrolyte irregular
characteristics
The client w ill regains fluid and
electrolyte balance as evidence
by BP decreased, ideal body
w eight is maintained and no
neck vain distended or edema.


Monitor lung sounds and edema.
Measure for changes in
abdominal girth.
A backup of fluids in the lungs w ould cause
crackles and a backup systemically w ould
cause pitting edema in the legs. An
increase in AB girth may show increment in
fluid maintenance.
Weight daily and compare w eight
w ith admission or previous stated
w eight.
To screen for fluid retention and assess
level of abundance.

6. ASSESSMENT
Subjective/ Objective
NURSING
DIAGNOSIS
#2
(Physical)
PLANNING/
OUTCOME
(Client Centered)
1 Short Term
1 Long Term
INTERVENTIONS
(Nurse Centered)
1 Monitoring, 1 Action & 1
Teaching per Goal

RATIONALE FOR
INTERVENTIONS
1 per Intervention

EVALUATION
(Evaluate each
Goal)
Subjective Data:
Pt c/o of SOB w ith chest
pain/pressure on inspiration;
rated 10 on pain scale.
Acute pain ABE facial grimaces
and Pt c/o of SOB w ith chest
pain/pressure on inspiration;
rated 10 on pain scale.


Patient w ill report relief/control
of pain by end of shift.

Provided O2 @ 2 Lpm via nasal cannula as
ordered. Elevated the head of bed.

To provide an oxygen needed
by the body for compensation.
This position makes patient
comfortable & helps in
relieving client’s pain.
Pt w ill rate pain at 2 or
less on pain scale.
Instruct pt to report pain. Relief measures may be
instituted.
Provide analgesics as ordered, evaluating the
effectiveness and inspecting for any signs and
symptoms of adverse effects.
Effectiveness of pain
medications must be
evaluated individually
because it is absorbed and
metabolized differently by
patients. Analgesics may
cause mild to severe side
effects
Objective Data:
 V/S:
T: 36.8˚C
P: 88
R: 22
B/p: 160/96
 Orthostatic Hypotension
 Atrial fibrillation
 JVD
 SOB
 Pulmonary Edema/Rales
 Edema
 Facial grimaces
Pt w ill demonstrate use of
relaxation skills to relieve pain
by discharge.
Assess the patent’s anticipation for pain relief. Some patients may be
satisfied w hen pain is no
longer massive; others w ill
demand complete elimination
of pain. This influences the
perceptions of the
effectiveness of the treatment
of the treatment modality and
their eagerness to engage in
further treatments.
Pt w ill demonstrate
appropriate use of
relaxation skills to relieve
pain.
Encourage diversional activities such as TV and
socialization w ith others. Provide comfort
measures such as back rub, change position,
use of heat/ cold.
Provides diversionary
activities that help block the
perception of pain by the
brain. To provide non-
pharmacologic pain
management.
Explore method for alleviation/ control of pain.
Provide quite environment, calm activities and
adequate rest reinforce.
Timely intervention is more
likely to be successful in
alleviating pain. To
prevent fatigue and lessen
stimuli.

7. ASSESSMENT
Subjective/ Objective
NURSING
DIAGNOSIS
#3
(Psychosocial)
PLANNING/
OUTCOME
(Client Centered)
1 Short Term
1 Long Term
INTERVENTIONS
(Nurse Centered)
1 Monitoring, 1 Action & 1 Teaching
per Goal

RATIONALE FOR
INTERVENTIONS
1 per Intervention

EVALUATION
(Evaluate each
Goal)
Subjective Data:
 Pt c/o of SOB w ith chest
pain/pressure on
inspiration; rated 10 on
pain scale.
Disturbed thought process R/T
Physiological changes—
accumulation of surplus, such
as urea, ammonia; metabolic
acidosis; hypoxia; electrolyte
imbalances; calcifications in
the brain
Pt w ill identify w ays to
compensate for cognitive
impairment and memory
deficits w ith 2 days if admission
to unit.
Evaluate extent of impairment in thinking ability,
memory, and orientation. Note attention span.
Uremic syndrome’s effect can
begin w ith minor confusion or
irritability and progress to
altered personality, inability to
assimilate information or
participate in care. Aw areness
of changes provides
opportunity for evaluation and
Intervention.
Pt w ill successfully
identify w ays to
compensate for cognitive
impairment and memory.

Communicate information and guidelines in
simple, short sentences. Ask direct, yes or no
questions. Repeat elucidations as necessary.
May aid in reducing confusion
and increases possibility
that communications w ill be
understood and
remembered.
Promote adequate rest and uninterrupted
periods for sleep.
Sleep deprivation may further
impair cognitive abilities.
Objective Data:
 V/S:
T: 36.8˚C
P: 88
R: 22
B/p: 160/96
 Orthostatic Hypotension
 Atrial fibrillation
 JVD
 Pulmonary Edema/Rales
 Edema
Pt w ill regain or maintain
optimal level of mentation by
discharge.

Monitor laboratory studies, such as BUN/Cr,
serumelectrolytes, glucose level, and ABGs
(PO2, pH). Prepare for dialysis.
Correction of imbalances can
have profound effects on
cognition. Marked
deterioration of thought
processes may indicate
w orsening of azotemia and
general condition, requiring
prompt intervention to regain
homeostasis.
Pt w ill regain or maintain
optimal level of mentation
as evidence by pt being
able to express logical,
goal directed ideas w ith
the absence of delusions
as verbalized by the Pt.


Provide supplemental oxygen (O2) as indicated.
Avoid use of barbiturates and opiates.
Correction of hypoxia alone
can improve cognition.
Drugs normally detoxified in
the kidneys w ill have
increased half-life and
cumulative effects, worsening
confusion.
Ascertain from significant other (SO) client’s
usual level of mentation. Provide SO w ith
information about client’s status.
Provides comparison to
evaluate progression or
resolution of impairment.
Some improvement in
mentation may be expected
w ith restoration of more
normal levels of BUN,
electrolytes, and serum pH.

8. STUDENT NAME:
Medication #1: Sevelamer Classification of Medication: Electrolyte and water balance
agent; phosphate
Trade Name: Renagel Generic Name: Sevelamer
Dosage: 400mg, 403mg,
800mg
Dosage Forms: Tablet, capsule Routes: Po
Why is THIS patient SPECIFICALLY receiving this medication? Reduction of serum phosphorus in patients with
end-stage kidney disease. Polymer that binds intestinal phosphate; interacts with phosphate by way of ion-exchange and hydrogen
binding. Advantageously, does not contain aluminum or calcium acetate in treating hyperphosphatemia in end stage kidney failure.
Side effects/Adverse reactions: Body as a Whole: Headache, infection, pain. CV: Hypertension, hypotension,
thrombosis. GI: Diarrhea, dyspepsia, vomiting, nausea, constipation, flatulence. Respiratory: Increased cough.
Lab Values: phosphate levels.
CONTRAINDICATIONS: Hypophosphatemia; hypersensitivity to sevelamer HCl; bowel obstruction; pregnancy (category
C), lactation. Safety and efficacy in children <18 y are not established.

Nursing Implications/Responsibilities:
Assessment & Drug Effects
 Lab tests: Obtain frequent serum phosphate levels.
Patient & Family Education
 Do not use capsules after printed expiration date.
 Take daily multivitamin supplement approved by physician.
 Do not breast feed while taking this drug.

STUDENT NAME:
Medication #2: Calcium carbonate Classification of Medication: FLUID AND ELECTROLYTIC
BALANCE AGENT; REPLACEMENT SOLUTION; ANTACID
Trade Name: Apo-Cal Generic Name: Calcium carbonate
Dosage: 125mg, 250mg,
650mg, 750mg,1.25g, 1.5g
Dosage Forms: Tablets Routes: Po
Why is THIS patient SPECIFICALLY receiving this medication? Control of hyperphosphatemia in chronic renal
failure. Rapid-acting antacid with high neutralizing capacity and relatively prolonged duration of action. Decreases gastric acidity,
thereby inhibiting proteolytic action of pepsin on gastric mucosa. Also increases lower esophageal sphincter tone. Although
classified as a nonsystemic antacid, a slight to moderate alkalosis usually develops with prolonged therapy. Acid rebound, which
may follow even low doses, is thought to be caused by release of gastrin triggered by action of calcium in small intestines.
Side effects/Adverse reactions: GI: Constipation or laxative effect, acid rebound, nausea,
eructation, flatulence, vomiting, fecal concretions. Metabolic: Hypercalcemia with alkalosis, metastatic calcinosis, hypercalciuria,
hypomagnesemia, hypophosphatemia (when phosphate intake is low). CNS: Mood and mental changes. Urogenital: Polyuria, renal
calculi.
Lab Values: serum calcium; urine calcium
CONTRAINDICATIONS: Hypercalcemia and hypercalciuria (e.g., hyperparathyroidism, vitamin D overdosage, decalcifying
tumors, bone metastases), calcium loss due to immobilization, severe renal disease, renal calculi, GI hemorrhage or obstruction,
dehydration, hypochloremic alkalosis, ventricular fibrillation, cardiac disease, pregnancy (category C).

9. Nursing Implications/Responsibilities:
Assessment & Drug Effects
 Note number and consistency of stools. If constipation is a problem, physician may prescribe alternate or combination
therapy with a magnesium antacid or advise patient to take a laxative or stool softener as necessary.
 Lab tests: Determine serum and urine calcium weekly in patients receiving prolonged therapy and in patients with renal
dysfunction.
 Record amelioration of symptoms of hypocalcemia (see Signs & Symptoms, Appendix F).
 Observe for S&S of hypercalcemia in patients receiving frequent or high doses, or who have impaired renal function (see
Appendix F).
Patient & Family Education
 Do not continue this medication beyond 1–2 wk, since it may cause acid rebound, which generally occurs after repeated use
for 1 or 2 wk and leads to chronic use. It is potentially dangerous to self-medicate. Do not take antacids longer than 2 wk
without medical supervision.
 Avoid taking calcium carbonate with cereals or other foods high in oxalates. Oxalates combine with calcium carbonate to
form insoluble, nonabsorbable compounds.
 Do not use calcium carbonate repeatedly with foods high in vitamin D (such as milk) or sodium bicarbonate, as it may cause
milk-alkali syndrome: hypercalcemia, distaste for food, headache, confusion, nausea, vomiting, abdominal pain, metabolic
alkalosis, hypercalciuria, polyuria, soft tissue calcification (calcinosis), hyperphosphatemia and renal insufficiency.
Predisposing factors include renal dysfunction, dehydration, electrolyte imbalance, and hypertension.
 Do not breast feed while taking this drug without consulting physician



STUDENT NAME:
Medication #3: N-Acetylcysteine Classification of Medication: Skin and mucous membrane
agent; mucolytic; antidote
Trade Name: N-Acetylcysteine Generic Name: Acetylcysteine
Dosage: 10%, 20%; 20% Dosage Forms: solution Routes: Inhalation; Po; IV
Why is THIS patient SPECIFICALLY receiving this medication? Adjuvant therapy in patients with abnormal,
viscid, or inspissated mucous secretions in acute and chronic bronchopulmonary diseases, and in pulmonary complications of cystic
fibrosis and surgery, tracheostomy, and atelectasis. Also used in diagnostic bronchial studies and as an antidote for acute
acetaminophen poisoning. Acetylcysteine probably acts by disrupting disulfide linkages of mucoproteins in purulent and
nonpurulent secretions.
Side effects/Adverse reactions: CNS: Dizziness, drowsiness. GI: Nausea, vomiting, stomatitis, hepatotoxicity
(urticaria). Respiratory: Bronchospasm, rhinorrhea, burning sensation in upper respiratory passages, epistaxis.
Lab Values: ABGs; pulmonary functions
CONTRAINDICATIONS: Hypersensitivity to acetylcysteine; patients at risk of gastric hemorrhage.
Nursing Implications/Responsibilities:
Assessment & Drug Effects
 During IV infusion, carefully monitor for fluid overload and signs of hyponatremia (i.e., changes in mental status).
 Monitor for S&S of aspiration of excess secretions, and for bronchospasm (unpredictable); withhold drug and notify
physician immediately if either occurs.
 Lab tests: Monitor ABGs, pulmonary functions and pulse oximetry as indicated.
 Have suction apparatus immediately available. Increased volume of respiratory tract fluid may be liberated; suction or
endotracheal aspiration may be necessary to establish and maintain an open airway. Older adults and debilitated patients
are particularly at risk.
 Nausea and vomiting may occur, particularly when face mask is used, due to unpleasant odor of drug and excess volume of
liquefied bronchial secretions.

10. Patient & Family Education
 Report difficulty with clearing the airway or any other respiratory distress.
 Report nausea, as an antiemetic may be indicated.
 Note: Unpleasant odor of inhaled drug becomes less noticeable with continued use.
 Do not breast feed while taking this drug without consulting physician.

STUDENT NAME:
Medication #4: sodium bicarb Classification of Medication: GASTROINTESTINAL
AGENT; ANTACID; FLUID AND ELECTROLYTE BALANCE AGENT
Trade Name: Sodium Bicarbonate Generic Name: Sodium Bicarbonate
Dosage: 325 mg, 520
mg, 650 mg; 4.2%, 5%,
7.5%, 8.4%
Dosage Forms: Tablet; solution Routes: PO, IV, TOPICAL
Why is THIS patient SPECIFICALLY receiving this medication? Systemic alkalinizer to correct metabolic
acidosis. Short-acting, potent systemic antacid. Rapidly neutralizes gastric acid to form sodium chloride, carbon dioxide, and
water. After absorption of sodium bicarbonate, plasma alkali reserve is increased and excess sodium and bicarbonate ions are
excreted in urine, thus rendering urine less acid. Not suitable for treatment of peptic ulcer because it is short-acting, high in
sodium, and may cause gastric distention, systemic alkalosis, and possibly acid-rebound.
Side effects/Adverse reactions: GI: Belching, gastric distention, flatulence. Metabolic: Metabolic alkalosis; electrolyte
imbalance: sodium overload (pulmonary edema), hypocalcemia (tetany), hypokalemia, milk-alkali syndrome,
dehydration. Other: Rapid IV in neonates (Hypernatremia, reduction in CSF pressure, intracranial hemorrhage). Skin: Severe tissue
damage following extravasation of IV solution. Urogenital: Renal calculi or crystals, impaired kidney function.
Lab Values: ABGs; Electrolytes
CONTRAINDICATIONS: Prolonged therapy with sodium bicarbonate; patients losing chloride (as from vomiting, GI
suction, diuresis); heart disease, hypertension; renal insufficiency; peptic ulcer; pregnancy (category C).
Nursing Implications/Responsibilities:
Assessment & Drug Effects
 Be aware that long-term use of oral preparation with milk or calcium can cause milk-alkali syndrome: Anorexia, nausea,
vomiting, headache, mental confusion, hypercalcemia, hypophosphatemia, soft tissue calcification, renal and ureteral
calculi, renal insufficiency, metabolic alkalosis.
 Lab tests: Urinary alkalinization: Monitor urinary pH as a guide to dosage (pH testing with nitrazine paper may be done at
intervals throughout the day and dosage adjustments made accordingly).
 Lab tests: Metabolic acidosis: Monitor patient closely by observations of clinical condition; measurements of acid-base
status (blood pH, Po2, Pco2, HCO3
–
, and other electrolytes, are usually made several times daily during acute period).
Observe for signs of alkalosis (over treatment)
 Observe for and report S&S of improvement or reversal of metabolic acidosis.
Patient & Family Education
 Do not use sodium bicarbonate as antacid. A nonabsorbable OTC alternative for repeated use is safer.
 Do not take antacids longer than 2 wk except under advice and supervision of a physician. Self-medication with routine
doses of sodium bicarbonate or soda mints may cause sodium retention and alkalosis, especially when kidney function is
impaired.
 Be aware that commonly used OTC antacid products contain sodium bicarbonate: Alka-Seltzer, Bromo-Seltzer, Gaviscon.
 Do not breast feed while taking this drug without consulting physician.

11. a. The patient is ordered to have daily dialysis. What is the rationale for this order?
During the recuperating phase after surgery the metabolic rate increase, causing a surge of squanders in the blood stream.
Squanders collect in the patient with renal failure and the patient creates manifestations of uremia more rapidly and needs
daily dialysis to dispose of the surge of squanders.
b. The patient is going to hemodialysis at 9 AM on an odd day. Which medication or medications should the nurse hold
before sending the patient?
Beta-blocker antihypertensive such as Carvedilol (Coreg) should be held prior to going to hemodialysis.
c. What related nursing management considerations should be made for this patient?
Nursing management consideration includes:

 Maintain strict aseptic technique when handling any invasive lines or when performing dressing changes because the
affected role is at increased risk to develop an infection.
 Assess and report signs of contagion at incisions, including fever, redness, edema, or purulent drainage.
 Provide the patient with the opportunity to vent touch and response to treatment.
 Placing a sign over the left half of the bed that expresses "No BP or venipuncture in the left arm."
 Assess AV fistula at regular intervals for patency and for indications of disease and report any issues to the doctor.
Review the arm to guarantee that there is no gems or any constrictive apparel on the arm.
 Assess VS, as requested, and report hypotension quickly (get requests to help build the circulatory strain so the AV
fistula does not cluster off).
 When regulating IV liquids dependably utilize a volumetric implantation pump and ensure that the liquid does not
contain potassium. (IV liquid, for example, lactated Ringer's, has potassium in the blend.) Assess drugs to guarantee
that the medicines don't contain magnesium also. Evaluate lungs for crackles, which is an indication of liquid over-
burden.

12. Nursing Process Care Plan
References



1.


2.


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1.



https://nurseslabs.com/nursing-care-plans/

2.



Retrieved from http://www.robholland.com/Nursing/Drug_Guide/

3.


Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans: Guidelines for individualizing client care
across the life span. Philadelphia: F.A. Davis Co.