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Short Background: Chronic kidney disease (CKD) occurs when one suffers from gradual and usually permanent loss of kidney function over time. With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Glomerular Filtration Rate (GFR), the measure of the kidney's function, determines the severity or stage of the disease (whereas Stage 5 CKD is considered Renal Failure due to gradual loss of GFR, GFR < 15: needs dialysis). CKD often develops from 1Diabetes (stenosis/ischemic), 2Hypertension (microvascular damage), 3Glomerulonephritis (post-infection), or 4Nephrotoxicity (medications).
Assessment
Subjective: Patient is not able to verbalize.
Nursing Diagnosis
Ineffective Breathing Pattern r/t impending pulmonary congestion d/t impaired GFR and fluid retention or respiratory muscle weakness d/t physical stress.
Planning
Goal: Establish Spontaneous, nonLabored Breathing Short Term: After 4 hours of nursing interventions, patient will be able to reduce labored and difficult breathing and establish a respiratory rate of less than 30cpm. Long Term: After 5 days of nursing interventions, patient will be able to demonstrate nonlabored and spontaneous breathing.
Interventions
Collaborative: 1. Administer humid Oxygen (8-10Lpm) as ordered. 2. Assist in Manual Ventilation via ET Tube.
Rationale
Evaluation
1. To help patient get adequate oxygen despite of DOB. 2. To assist patient on respiration and to ensure adequate tidal volume.
Objective:
> Deep, fast, noisy breathing > RR 33cpm > Crackles heard on inspiration > SaO2 99% > BP 140/100mmhg > PR 80bpm > T 37.0 C > Diaphoretic, cold clammy skin > Unresponsive; may be due to fatigue/weakness. > Increased respiratory secretions.
Independent: 1. Monitor and record vital signs. 2. Assess for lung sounds.
1. To check and reassess vital function changes (Respiration). 2. To identify extent of fluid accumulation in the respiratory system. 3. To facilitate gravitational expansion of the lungs to decrease inspiratory effort. 4. To avoid stressors and let patient regain strength by manipulation of environment. 5. To facilitate airway clearance and reduce effort from DOB.
Assessment
Subjective: Patient is not able to verbalize.
Nursing Diagnosis
Fluid Volume Excess R/T decrease Glomerular filtration Rate and sodium retention.
Planning
Goal: Reduce Fluid Volume Excess, output more than input. Short Term: After 4 hours of nursing interventions, patient will be able to avoid recurrence of fluid excess Long Term: After 5 days of nursing intervention the patient will manifest stabilize fluid volume, I & O, normal VS, stable weight, and free from signs of edema.
Interventions
Collaborative: 1. Administer loop diuretics (Furosemide/Lasix) as ordered. 2. Assist in specimen extraction for serum analysis (Serum Electrolytes/ RBS or FBS) and urine analysis (BUN/Crea). 3. CBG Test as ordered. Independent: 1. Monitor and record vital signs 2. Auscultate breath sounds 3. Record occurrence of dyspnea
Rationale
Collaborative: 1. Diuretics reduce fluid volume by helping kidney excrete urine and sodium. 2. To prepare patient for possible lab orders.. 3. To determine the efficacy of DM regimen. Independent: 1. To check and reassess vital function changes (Circulation). 2. To determine extent of fluid excess. 3. To check possible respiratory complications (pulmonary congestion). 4.
Evaluation
Objective:
> Anuria > BP 140/100mahg > RR 27cpm > PR 80bpm > T 37.0 C > Peripheral Edema > Diaphoretic, cold clammy skin > Unresponsive; may be due to fatigue/weakness. > Increased respiratory secretions. > CBG 126mg/dL
6. Weigh client 7. Encourage quiet, restful atmosphere. Main Problem: (Priority 2) Fluid Volume Excess CELESTINO, JOHN CHRISTOPHER S. WUP SN13 senior block 04
Assessment
Subjective: Patient is not able to verbalize.
Nursing Diagnosis
Risk for Impaired Skin Integrity r/t edema and prolonged bed rest d/t
Planning
Goal: Prevent Risks on Developing Skin Breakdown. Short Term: After 4 hours of nursing interventions, patient will be able to remove potential threats that may lead to poor skin integrity. Long Term: After 5 days of nursing interventions, patient will be able to identify and avoid factors that lead to skin breakdown.
Interventions
Collaborative: 1. Ferrous Sulfate (Iron supplement) as ordered. 2. Update Lab Findings for CBC (RBC, Hgb, Hct). 3. CBG T.I.D. as ordered.
Rationale
Evaluation
Objective:
> Peripheral Edema > Prolonged bed rest > Pallor > Hgb > Diaphoretic, cold clammy skin > Unresponsive; may be due to fatigue/weakness. > CBG 126mg/dL
1. To help body regulate RBC in the absence/lacking of hormone erythropoietin. 2. To evaluate efficacy of treatment/prophylaxis for anemia regimen. 3. To determine hyperglycemia that makes blood viscous and induces the risk for infection.
Independent: 1. Assess skin appearance (color, texture, temperature). 2. Turn patient side to side every 2 hours if possible.
1. To determine edema or erythema that indicates possible bed sore. 2. To make pressure equal when lying to avoid unilateral skin tissue blood insufficiency. 3. To avoid skin irritation from crease. 4. To avoid risk for skin injury and infection.