Patient’s Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

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).

Priority Problem: (Priority 1) Ineffective Breathing Pattern

Assessment Nursing Diagnosis Scientific Explanation of the Planning Interventions Rationale Evaluation
Problem
Subjective: Ineffective Impaired GFR results into Goal: Collaborative:
Breathing Pattern fluid overload. With fluid Establish Spontaneous, non- 1. Administer humid Oxygen 1. To help patient get
Patient is not r/t impending volume excess, venous Labored Breathing (8-10Lpm) as ordered. adequate oxygen despite
able to verbalize. pulmonary pressure is more likely to of DOB.
congestion d/t cause both circulatory and Short Term: 2. Assist in Manual 2. To assist patient on
impaired GFR and pulmonary congestion. The After 4 hours of nursing Ventilation via ET Tube. respiration and to ensure
fluid retention or patient may possibly interventions, patient will be adequate tidal volume.
Objective: respiratory manifests fatigue, able to reduce labored and
> Deep, fast, noisy muscle weakness dyspnea, tachypnea, difficult breathing and
breathing d/t physical stress. muscle weakness establish a respiratory rate
of less than 30cpm. Independent:
(including diaphragm), or
> RR 33cpm 1. Monitor and record vital 1. To check and reassess
sputum production that
are related to pulmonary Long Term: signs. vital function changes
> Crackles heard
congestion. Physical stress After 5 days of nursing (Respiration).
on inspiration
also impacts pulmonary interventions, patient will be
> SaO2 99% functioning. able to demonstrate non- 2. Assess for lung sounds. 2. To identify extent of
labored and spontaneous fluid accumulation in the
> BP Diabetic, there is a breathing. respiratory system.
140/100mmhg
possibility that sugar
crystallization has occurred 3. Position on moderate high 3. To facilitate
> PR 80bpm back rest. gravitational expansion of
and leads to renal artery
stenosis or a microvascular the lungs to decrease
> T 37.0 C
complication due to inspiratory effort.
> Diaphoretic, cold viscosity.
clammy skin 4. Maintain calm and non- 4. To avoid stressors and
stimulating environment. let patient regain strength
> Unresponsive; by manipulation of
may be due to environment.
fatigue/weakness.
5. Suction secretions PRN. 5. To facilitate airway
> Increased
respiratory clearance and reduce
secretions. effort from DOB.

CELESTINO, JOHN CHRISTOPHER S.

WUP SN’13 senior block 04
Patient’s Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy
Main Problem: (Priority 2) Fluid Volume Excess

Assessment Nursing Diagnosis Scientific Explanation of the
Problem
Subjective: Fluid Volume Renal disorder impairs
Excess R/T glomerular filtration that
Patient is not decrease resulted to fluid overload.
able to verbalize. Glomerular With fluid volume excess,
filtration Rate and hydrostatic pressure is
sodium retention. higher than the usual
pushing excess fluids into
Objective: the interstitial spaces,
> Anuria causes venous return,
leading the patient to have
> BP 140/100mahg
edema, weight gain,
pulmonary congestion and
> RR 27cpm
HPN at the same time due
> PR 80bpm to decrease GFR, nephron
hypertrophied leading to
> T 37.0 C decrease ability of the
kidney to concentrate
> Peripheral Edema urine and impaired
excretion of fluid thus
> Diaphoretic, cold
leading to oliguria/anuria.
clammy skin
> Unresponsive; With associated DM, there
may be due to is a possibility that sugar
fatigue/weakness.
crystallization has occurred
and leads to renal artery
> Increased stenosis or a microvascular
respiratory
complication due to
secretions.
viscosity of blood.
> CBG 126mg/dL
Planning Interventions Rationale Evaluation
Goal: Collaborative: Collaborative:
Reduce Fluid Volume 1. Administer loop diuretics 1. Diuretics reduce fluid
Excess, output more (Furosemide/Lasix) as ordered. volume by helping kidney
than input. excrete urine and sodium.
2. Assist in specimen extraction for 2. To prepare patient for
Short Term: serum analysis (Serum Electrolytes/ possible lab orders..
After 4 hours of RBS or FBS) and urine analysis
nursing interventions, (BUN/Crea).
patient will be able to 3. CBG Test as ordered. 3. To determine the
avoid recurrence of efficacy of DM regimen.
fluid excess Independent: Independent:
1. Monitor and record vital signs 1. To check and reassess
vital function changes
Long Term: (Circulation).
After 5 days of 2. Auscultate breath sounds 2. To determine extent of
nursing intervention fluid excess.
the patient will 3. Record occurrence of dyspnea 3. To check possible
manifest stabilize fluid respiratory complications
volume, I & O, normal (pulmonary congestion).
VS, stable weight,
and free from signs of 4. Review lab data like BUN, 4. To monitor kidney
edema. Creatinine, Serum electrolyte. function and fluid
retention (electrolyte
compensation).
5. Record I&O accurately and
5. To determine fluid
calculate fluid volume balance retention and kidney
function (GFR).

6. Weigh client 6. Increasing weight may

indicate fluid retention.

7. Encourage quiet, restful 7. To allow patient cope

atmosphere. with stressors naturally.

CELESTINO, JOHN CHRISTOPHER S.

WUP SN’13 senior block 04
Patient’s Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy
Manifestation Problem: (Priority 3) Risk for Impaired Skin Integrity

Assessment Nursing Diagnosis Scientific Explanation of the Planning Interventions Rationale Evaluation
Problem
Subjective: Risk for Impaired Due to fluid retention, fluid Goal: Collaborative:
Skin Integrity r/t accumulates and fluid Prevent Risks on Developing 1. Ferrous Sulfate (Iron 1. To help body regulate
Patient is not edema and shifts from intracellular Skin Breakdown. supplement) as ordered. RBC in the
able to verbalize. prolonged bed rest compartment to absence/lacking of
d/t extracellular compartment Short Term: hormone erythropoietin.
causing escape of fluid to After 4 hours of nursing 2. Update Lab Findings for 2. To evaluate efficacy of
the tissues (edema). With interventions, patient will be CBC (RBC, Hgb, Hct). treatment/prophylaxis for
Objective: associated complications of able to remove potential anemia regimen.
> Peripheral Edema anemia, skin nutrition threats that may lead to
would be crucial and may poor skin integrity. 3. CBG T.I.D. as ordered. 3. To determine
> Prolonged bed
have easily broken off. hyperglycemia that
rest
Long Term: makes blood viscous and
> Pallor DM could cause high blood After 5 days of nursing induces the risk for
sugar levels and leads to interventions, patient will be infection.
> Hgb viscosity of blood that also able to identify and avoid
impairs nutrition of skin or factors that lead to skin Independent:
> Diaphoretic, cold reduction of blood cells to breakdown. 1. Assess skin appearance 1. To determine edema or
clammy skin capillaries. (color, texture, erythema that indicates
temperature). possible bed sore.
> Unresponsive;
may be due to
fatigue/weakness. 2. Turn patient side to side 2. To make pressure
every 2 hours if possible. equal when lying to avoid
> CBG 126mg/dL unilateral skin tissue
blood insufficiency.

3. Maintain crease-free bed 3. To avoid skin irritation

linen. from crease.

4. Maintain a clean, 4. To avoid risk for skin

therapeutic environment. injury and infection.

CELESTINO, JOHN CHRISTOPHER S.

WUP SN’13 senior block 04