Nursing Problems for Chronic Kidney Failure

Actual Nursing Problems

1. Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.

2. Ineffective Breathing Pattern r/t impending pulmonary congestion d/t impaired GFR and fluid retention or respiratory muscle weakness

d/t physical stress.

3. Imbalanced nutrition: less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous

membranes.

4. Ineffective renal tissue perfusion related to decreased hemoglobin concentration in the blood.

5. Impaired urinary elimination r/t diminished renal function.

6. Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure.

Potential Nursing Problems

1. Risk for impaired skin integrity r/t the accumulation of fluid in the interstitial space 2° imbalanced nutritional state
 NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician: Dr. V.
Age/Sex: 23/M Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2

CUES NURSING OUTCOME NURSING

RATIONALE RATIONALE EVALUATION
DIAGNOSIS CRITERIA INTERVENTION
SUBJECTIVE: Increased isotonic GENERAL: INDEPENDENT: GENERAL:
Excess fluid fluid retention 1. Establish rapport 1. To gain trust and cooperation.
“Nagparanghabok volume After 3 days of Goal Partially
run gid ako kapin related to Renal disorder nursing 2. Monitor and record vital 2. To obtain baseline data Met.
pa nagbahul run decreased impairs intervention, the signs.
gid busong ko”, as urine output, glomerular client will be able 3. Instructed to limit fluid 3. To monitor kidney function and fluid After 3 days of
verbalized by the dietary filtration that to manifest stabilize & Na intake. retention nursing
patient. excesses, and resulted to fluid fluid volume AEB interventions, the
retention of overload. With balance I & O, 4. Elevate edematous 4. This increases venous return and, in patient was able
OBJECTIVE: sodium and fluid volume normal VS, stable extremities. turn, decreases edema. to manifest
> Abdominal girth water excess, hydrostatic weight, and free stabilize fluid
= 96 cm pressure is higher from signs of 5. Record accurate intake 5. Accurate I&O is necessary for volume AEB
> Bipedal edema than the usual edema. and output (I&O). determining renal function and fluid balance I & O,
> capillary refill of pushing excess replacement needs and reducing risk of normal VS, stable
4 seconds fluids into the SPECIFIC: fluid overload. weight, and free
> Black nail beds interstitial spaces. from signs of
> Fatigue Since fluids are After 4 hours of 6. Assess for presence of 6. Pitting edema is manifested by a edema as
Weakness not reabsorbed at nursing edema by palpating over depression that remainsafter one’s evidenced by:
> CXR shows the venous end, intervention the tibia,ankles, feet, and finer is pressed over an edematous area >(-) DOB
pleural effusion fluid volume patient will be able sacrum. and then removed. >Total urine
> Fluid intake overloads the to: output within the
exceeds output. lymph system and shift = 210 cc.
Intake = 230 cc, stays in the 7. Assist patient in 7. To prevent pressure ulcers. >Total fluid
output = 120 cc. interstitial spaces repositioning every 2 hours intake = 190 cc.
leading the patient 8. For presence of crackles or
to have edema, 8. Auscultate breath congestion.
sounds.
 CUES NURSING OUTCOME
RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
weight gain, 9. Measure abdominal girth 9. May indicate increase in fluid SPECIFIC:
>V/S taken as pulmonary congestion > demonstrate for changes. retention.
follows: and HPN at the same behaviors to Goal Fully Met.
time due to decrease monitor fluid status 10. Evaluate mentation for 10. May indicate cerebral edema.
BP: 140/90 GFR, nephron and reduce confusion and personality
mmHg hyperthrophized recurrence of fluid changes. After 4 hours of
P: 98 bpm leading to decrease excess. nursing
R: 28 cpm ability of the kidney to 11. Weigh daily at same time 11. Daily body weight is best monitor intervention the
T: 37.3 °C concentrate urine and of day, on same scale, with of fluid status. patient was able
O2 Sat: 96 % impaired excretion of same equipment and to:
fluid thus leading to clothing.
oliguria/anuria. > demonstrate
12. Encourage quiet, restful 12. To conserve 
energy and lower behaviors to
Source: 
atmosphere. 
 tissue oxygen demand. 
 monitor fluid
status and
> Nursing diagnosis DEPENDENT: reduce
handbook (2006) 7th 13. Administer Furosemide 13. Furosemide, a loop diuretic, recurrence of
Ed. By Ackley, B.J., 40 mg. IV every 6 hours as inhibits water reabsorption in the fluid excess.
&Ladwig, G.B. ordered. nephron by blocking the sodium-
potassium-chloride cotransporter
>Brunner & Suddarth’ (NKCC2) in the thick ascending limb of
s textbook of Medical – the loop of Henle.
Surgical Nursing
(2010) 12nd Ed. by 14. Restrict sodium and fluid 14. To lessen fluid retention and
Smeltzer, Barre, intake if indicated. overload.
Hinkl& Cheever.
COLLABORATIVE:

15. Review lab data like BUN, 15. To monitor kidney function
Creatinine, Serum
electrolyte.
 NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician:Dr. V.
Age/Sex: 34/F Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2

CUES NURSING OUTCOME

RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
SUBJECTIVE: GENERAL: INDEPENDENT: GENERAL:
“Wara ako Imbalanced Intake of nutrients 1. Assess general appearance and 1. To establish baseline data.
gana nutrition: insufficient to meet After 3 days of monitor vital signs. Goal Met.
magkaun”, as less than metabolic needs. nursing
verbalized by body intervention, the 2. Assess current eating patterns, 2. This allows for a more After 3 days of
the patient. requirements Due restricted foods client will be able including usual likes and dislikes, individualized plan based on nursing
related to and prescribed dietary to demonstrate and identify factors that impair food needs and preferences. interventions, the
OBJECTIVE: anorexia, regimen, an individual progressive weight intake. patient was able
> fatigue nausea, experiencing renal gain toward to demonstrate
>weakness vomiting, problem cannot desired goal. 3. Weigh the client daily at the 3. To monitor effectiveness of progressive
> Abdominal dietary maintain ideal body same time, same weighing scale, efforts and dietary plans. weight gain
girth = 96 cm restrictions, weight and sufficient and almost the same clothing; toward desired
> Black nail and altered nutrition. At the same SPECIFIC: and document results. goal.
beds oral mucous time patients may After 8 hours of
> (+) dry skin membranes experience anemia due nursing 4. Encourage folks to feed the 4. Small frequent feedings are
& lips to decrease intervention, the client with small quantifies of often effective in getting foods SPECIFIC:
> capillary erythropoietic factor client will be able food, served in an appetizing into clients who otherwise would Goal Fully Met.
refill of 4 that cause decrease in to: fashion at frequent intervals. not eat.
seconds production of RBC After 4 hours of
causing anemia and >demonstrate 5. Discouraged beverages that are 5. These may decrease appetite nursing
fatigue behaviors, lifestyle caffeinated or carbonated. and lead to early satiety and will intervention the
changes to regain make the client feel full easily. patient was able
and maintain to:
appropriate weight. 6. Encouraged range of motion 6. Metabolism and utilization of
exercise. nutrients are enhanced by
activity.
 CUES NURSING OUTCOME
RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
> consume 7. Facilitated proper position by 7. Aids in swallowing and
>V/S taken as Sources: adequate elevating HOB. reduces risk of aspiration >demonstrate
follows: nourishment. behaviors,
> Nursing diagnosis 8. Monitor state of oral cavity. 8. Good oral hygiene enhances lifestyle changes
BP: 140/90 handbook (2006) 7th Provide good oral hygiene before appetite. to regain and
mmHg Ed. By Ackley, B.J., > verbalize and after meals maintain
P: 98 bpm &Ladwig, G.B. understanding of appropriate
R: 28 cpm causative factors 9. Promote pleasant, relaxing 9. A pleasant environment helps weight.
T: 37.3 °C > Brunner & Suddarth’ when known and environment including promote intake. And It gives a
O2 Sat: 96 % s textbook of Medical – necessary socialization when possible. relaxed feeling and will not spoil
Surgical Nursing interventions. her appetite. >consume
(2010) 12nd Ed. by adequate
Smeltzer, Barre, Hinkle 10. Prevent or minimize 10. May have negative effect on nourishment.
& Cheever. unpleasant odors or sights. appetite and eating.

11. Taught about foods what & 11. To make him aware about his >verbalize
not what to eat (↓protein, Na & diet that is needed for his understanding of
nourishment. causative factors
fluid restriction, ↑ fats & when known and
carbohydrates = calories). necessary
interventions.
DEPENDENT:
Aminovita Capsule works by
Administer aminoVita 1 cap. 3x a providing nutritional
day as ordered. requirements of the body to
maintain physiological balance;
promoting protein synthesis and
wound healing.

COLLABORATIVE:
To set nutritional goals when
Collaborate to interdisciplinary client has specific dietary needs.
team including the dietician and
nutritional support team.
 NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician: Dr. V.
Age/Sex: 34/F Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2

CUES NURSING OUTCOME

RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
Ineffective Decreased in the GENERAL: INDEPENDENT: GENERAL:
OBJECTIVE: renal tissue oxygen resulting 1. Establish rapport 1. To gain trust and cooperation.
perfusion in the failure to After 3 days of 2. Monitor and record VS 2. To have a baseline data Goal Met.
> Pale conjunctiva related to nourish the nursing
> Restlessness decreased tissues at the intervention, the 3. Assess patient general 3. To have baseline data and note After 3 days of
> Body weakness hemoglobin capillary level. client will show condition any abnormal findings. nursing
>Serum Creatinine = concentration signs of increased interventions, the
↑ 394.1 umol/L in the blood. Chronic renal perfusion such as 4. Encourage quiet and restful 4. To conserve energy and lower patient was able
> BUN = ↑ 27. 72 disease is a absence of edema. atmosphere tissue oxygen demands. to show signs of
mmol/L progressive loss increased
> Serum potassium in renal function SPECIFIC: 5. Encourage early ambulation 5. To enhance venous return perfusion such as
= ↑ 6.05 mmol/L over a period of once tolerated absence of
months or years. After 8 hours of edema.
> Hematology: Because of this nursing 6. Discourage sitting/standing 6. To improve and facilitates good
disease the blood intervention the for long periods, wearing circulation
- Hct =↓0.208 vol.(fr) constrictive clothing, crossing
vessels, the patient will have SPECIFIC:
- Hgb = ↓ 72 g/L kidney cannot normal vital legs Goal Fully Met.
adequately signs.
- RBC =↓2.3 x1012/L
produce 7. Check for calf tenderness 7. May indicate thrombus formation After 4 hours of
erythropoietin nursing
that leads to 8. Elevate the head of the bed, 8. To increase gravitational blood intervention the
decrease in Hgb 30-45 degrees especially at flow. patient was able
and Hct count, night to have normal
thus resulting to 9. To conserve energy vital signs as
anemia. 9. Instruct to avoid strenuous
activities
 CUES NURSING OUTCOME
RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
Because of this, the 10. Restrict sodium, fluid and fat 10. To decrease excess fluid volume evidenced by:
patient manifested intake as indicated
>V/S taken as pale palpebral RR= 20
follows: conjunctiva and 11. Instruct patient’s SO about 11. To help increase Hgb count. BP= 120/80
paleness. Then the food rich in iron, P= 98
BP: 160/90 oxygen being supplied O2 Sat= 96
12. To maintain hydration
mmHg in the body is not 12. Regulate IVF as ordered T= 36.4
P: 115 bpm enough due to
R: 26 cpm decrease production of 13. Promote adequate bed rest 13. To provide adequate wellness.
T: 37 °C RBC by the kidney that
O2 Sat: 93 % are responsible for the
oxygenation of tissues
thus leading to
DEPENDENT:
ineffective tissue
perfusion.
Administered oxygen as Oxygen therapy helps decrease
ordered. dyspnea through reduction in the
Source:
Nursing diagnosis central drive mediated via
handbook (2006) 7th peripheral chemoreceptors in the
Ed. By Ackley, B.J., carotid body.
&Ladwig, G.B.

Medical – Surgical
Nursing (2008) 4th Ed.
By LeMone, P. & Burke,
K.
 NURSING CARE PLAN
Name of Patient: L.R. C. M. Ward/Bed Number: 3010 - 1 Attending Physician: Dr. V.
Age/Sex: 34/F Impression/Diagnosis: Breast CA Stage 2 w/ pulmonary & Brain metastasis; CAP HR w/o Hypoxemia; DM Type 2

CUES NURSING OUTCOME

RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
SUBJECTIVE: Decreased in the GENERAL: INDEPENDENT: GENERAL:
Ineffective oxygen resulting 1. Establish rapport 1. To gain trust and cooperation.
“Nabudlayan ako Breathing Pattern in the failure to After 3 days of Goal Met.
magginhawa”, as r/t impending nourish the nursing 2. Monitor and record VS 2. To check and reassess vital
verbalized by the pulmonary tissues at the intervention, the function changes (Respiration) and After 3 days of
patient. congestion d/t capillary level. client will be able to have a baseline data. nursing
impaired GFR and to demonstrate interventions, the
OBJECTIVE: fluid retention or Impaired GFR non-labored and 3. Assess for lung sounds. 3. To identify extent of fluid patient was able
respiratory results into fluid spontaneous accumulation in the respiratory to demonstrate
> Crackles muscle weakness overload. With breathing and system. non-labored and
> Deep and fast d/t physical fluid volume establish normal spontaneous
breathing stress. excess, venous vital signs. 4. Position on moderate high 4. To facilitate gravitational breathing as
> Chest PA result pressure is more backrest. expansion of the lungs to decrease evidenced by:
of Left Pleural likely to cause SPECIFIC: inspiratory effort.
Effusion both circulatory BP: 130/80
> Cold clammy and pulmonary After 8 hours of 5. Maintain calm and non- 5. To avoid stressors and let patient mmHg
skin congestion. The nursing stimulating environment. regain strength by manipulation of P: 88 bpm
patient may intervention the environment. R: 24 cpm
possibly patient will be T: 36.8 °C
manifests fatigue, able to reduce 6. Record I&O accurately and 6. To determine fluid retention and O2 Sat: 96 %
dyspnea, labored and calculate fluid volume balance kidney function (GFR).
tachypnea, difficult breathing
muscle weakness and establish a
(including respiratory rate
diaphragm), or of less than 30
sputum cpm.
 CUES NURSING OUTCOME NURSING
RATIONALE RATIONALE EVALUATION
DIAGNOSIS CRITERIA INTERVENTION
production that are 10. Restrict sodium, fluid 10. To decrease excess fluid volume SPECIFIC:
>V/S taken as related to pulmonary and fat intake as indicated Goal Fully Met.
follows: congestion. Physical
stress also impacts 11. Instruct patient’s SO 11. To help increase Hgb count. After 8 hours of
BP: 140/90 pulmonary about food rich in iron, nursing
mmHg functioning. intervention the
P: 108 bpm 12. Regulate IVF as 12. To maintain hydration patient was able
R: 36 cpm ordered to reduce labored
T: 37. 4 °C and difficult
O2 Sat: 93 % 13. Promote adequate bed 13. To provide adequate wellness. breathing and
rest establish a
Source: respiratory rate
Nursing diagnosis of less than 30
handbook (2006) 7th DEPENDENT: cpm. as
Ed. By Ackley, B.J., evidenced by the
&Ladwig, G.B. 14. Administered oxygen 14. To help patient get adequate oxygen RR of 25 cpm.
as ordered. despite of DOB. Oxygen therapy helps
decrease dyspnea through reduction in
Medical – Surgical the central drive mediated via
Nursing (2008) 4th Ed. peripheral chemoreceptors in the
By LeMone, P. & Burke, carotid body.
K.
14. Administer 14. Ipratropium and albuterol
Ipratropium Br + combination reduces bronchospasm
salbutamol sulfate through both anticholinergic and
(Duavent) 1 neb every 8 sympathomimetic mechanisms.
hours as ordered.