POKHARA UNIVERSITY

NOBEL COLLEGE
Sinamangal, Kathmandu

Nursing care plan on Chronic Kidney Disease

Submitted to: Submitted by:

Respected Madam Rubisha Basnet
Mrs. Roll no. 22
Bsc. Nursing 2nd year
Assessment Nursing Nursing Planning Implementation Rationale Evaluation
Diagnosis Goal

1. The -To assess the Vital signs It provides Goal was

Subjective Excess fluid fluid vital signs of were baseline fully met
data :- volume related to volume patient. monitored. i.e. data for as the fluid
decreased urine will be T= 99.8 monitorin volume
Patient output as maintai Degree g patient. was
verbalized, evidenced by ned to Fahrenheit maintained
“I have edema. normal P= 80 bpm to normal
swelling in as R=24br/m i.e.
my legs evidenc BP= 150/100 1600ml/
and face.” ed by mm of hg day within
increas 2 days as
Patient ed -To monitor Patient’s body Sudden evidenced
said, urine bodyweight weight was weight by
“ I have output regularly. taken gain may increased
decreased and regularly. be due to urine
urine decreas Body weight= fluid output and
output.” ed 52 kg retention. decreased
edema edema.
2. within -To monitor Monitored the It helps in
Objective 2 days. intake and intake and further
data :- output closely. output. planning
Intake per and
-Edema of day= 900 ml interventio
legs, face Output per n.
day=500 ml

-Increased -To assess for Assessed the Edema

blood the presence of presence of occurs due
pressure any edema. edema. to excess
i.e.150/100 (Edema over fluid in
mm of Hg face and legs) body.
-To instruct to Patient was It helps to
limit fluid instructed to reduce
intake to limit fluid edema and
prescribed intake. maintain
volume. Prescribed body
fluid intake weight.
per day= 1
liter

-To encourage Patient was It helps to

to limit sodium encouraged to decrease
intake. limit sodium fluid
intake. retention.

-To encourage Patient was It helps to

frequent oral encouraged to prevent
hygiene. perform dry mouth
frequent oral due to low
hygiene. sodium
intake.

-To provide Diuretic was It helps to

diuretics as given to excrete
prescribed. patient. (Inj. excess
Lasix 20 mg) fluid from
body.
 Assessment Nursing Nursing Planning Implementation Rationale Evaluation
Diagnosis Goal

1. To assess the Assessed the It

Subjective Activity Patient factors factors provides Goal was
data :- intolerance related will be contributing to contributing to baseline fully met
Patient to fatigue and able to activity activity data for as the
verbalize, dialysis procedure particip intolerance. intolerance. nursing patient was
“I cannot as evidenced by ate in (fatigue, interventio able to
perform inability to activitie dialysis n. participate
physical perform basic s within procedure) in
activity” activities. 3 days activities
as To assist the Assisted the patient to It as
2. evidenc patient with perform activities and promotes evidenced
Objective e by activities and hygiene. (hair care , nail exercise by
data :- increasi hygiene. care, etc. ) and increased
Patient ng hygiene of ability to
looks tired, ability patient. work
fatigued. to within 3
work. To encourage Encouraged to perform It promotes activity days.
to perform activity slowly with within limits and
activity slowly pause in between. adequate rest.
with rest and
pause in
between.

To encourage Encouraged to It improves

to participate in participate in planning participation as the
planning and and selecting desired activity can be
selecting activities. according to
desired patient’s interest.
activities.
To encourage Encouraged active range It maintains muscle
active range of of motion exercises. strength and
motion increases tolerance
exercises. level for more
activity.

To provide Provided emotional It provides strength

emotional support and positive and promotes
support and feedbacks. independence of
positive patient.
feedback.

To encourage Encouraged to gradually It will help to

to gradually increase the physical increase patient’s
increase the activities. ability.
physical
activities.

To provide Provided nutritious diet It provides calories

nutritious diet rich in vitamins, for energy to
to patient. minerals. perform activities.
Assessment Nursing Nursing Planning Implementation Rationale Evaluation
Diagnosis Goal

1. Disturbed body Patient To assess the Assessed changes It

Subjective image related to will have changes in in body appearance. provides Goal was
data:- changes in body improve appearance. (Edema of face and baseline fully met
Patient appearance as ment in legs) data for as the
said, “I evidenced by her body interventi patient
have verbalization of image on. had
swelling patient and within 3 improve
of face edema of face days of To encourage Encouraged the It enables ment in
and legs.” and legs. nursing the patient to patient to talk about to express her body
interventi talk about her her feelings. concerns image
Objective on as feelings. (Patient is worried and within 3
data:- evidence for changes in her feelings days of
-edema of d by body appearance.) of nursing
face and decreased patient. interventi
legs edema of on as
face and evidence
legs. To assist in Assisted in It serves d by
identifying identifying short as decreased
short term term goals. (To positive edema of
goals. limit fluid and reinforce face and
sodium intake to ment and legs.
reduce edema, etc.) increases
self-
esteem.

To provide Provided hope It

hope according according to maintains
to expected expected outcome. positive
outcome. attitude.
To give Provided positive This can
positive reinforcement of help to
reinforcement progress. develop
of progress. positive
coping
behaviors

To support the Supported the This

patient to patient to identify helps to
identify ways ways to cope the build
to cope the problem. confidenc
problem. (Performing e of
diversional patient.
therapies,
communicating
about problems,
etc.)

To encourage Encouraged A good

interaction interaction with conversat
with friends friends and family. ion
and family. provides
ongoing
support.

To provide Provided positive It helps to

positive feedback for buildup
feedback for accomplishment i.e. confidenc
accomplishme decreased edema of e and for
nt. face and legs. healthier
life.
Assessment Nursing Nursing Planning Implementation Rationale Evalu-ation
Diagnosis Goal

Objective Risk for impaired Patient To assess the Assessed the To obtain Goal was fully
data:- skin integrity will not general general baseline met as the
related to develop condition of condition of data on patient didn’t
Dry skin, improper any patient. patient. present developed any
Rough personal hygiene. bedsore condition. bedsore within
skin within hospitalization.
texture hospital
ization. To make bed Bedmaking was Smooth,
neat and clean. done. clean bed
minimizes
source of
skin
irritation.

To provide back Back care was It helps to

care. provided once a maintain
day. skin
condition.

To maintain Maintained Skin

strict personal strict personal hygiene
hygiene and hygiene and prevents
skincare. skin care. skin
problems
and keeps
skin soft.
To anticipate Used preventive Healing
and use measures to takes time.
preventive prevent risk of So,it is
measures to skin better to
prevent risk of breakdown. apply
skin (Back care, Oil preventive
breakdown. massage) measures in
time.

To maintain Position was It improves

appropriate changed circulation
position by frequently to and muscle
changing semi-fowlers tone.
frequently. and sitting
position.

To encourage Encouraged the It helps to

the patient to patient to promote
perform range perform range comfort
of motion of motion and
exercises. exercises. improves
circulation.

To provide Provided It helps in

nutritious diet. nutritious diet. maintaining
(low sodium skin and
diet, vitamins prevent
rich diet) skin
breakdown.
To inspect skin Inspected the Skin
folds, bony skin folds, bony breakdown
prominences prominences occurs
routinely for routinely. No quickly
any redness or any redness and with
irritation. irritation of infection
skin. and there is
high risk in
bony areas
and
skinfolds.
Assessment Nursing Nursing Planning Implementatio Rationale Evaluation
Diagnosis Goal n

Objective Risk for After the To assess Assessed It provides

data:- situational low nursing patient’s patient’s data about The goal
self-esteem intervention and and family’s perception was fully
Patient related to change , patient’s family’s reaction to of patient met as
looks in body image. self-esteem responses illness. and family. after 6
sad, will and (They think hours of
worried, upgrade as reaction to the patient nursing
restless. evidenced illness. is suffering interventi
by cheerful from big on,
Patient facial uncurable patient’s
talks expression disease.) self
about of patient esteem
negative within 6 was
result of hours. To assess Assessed It identifies strength upgraded
disease relationship relationship and support of as
condition of patient of patient patient. evidence
. and other and other d by
family family cheerful
members. members. facial
(Healthy expressio
relationship) n.

To Maintained It helps the patient to

maintain caring and see herself as a
caring and respectful respected person.
respectful behavior
behavior with the
with the patient i.e.
patient. communicat
ing
properly,
 assisting in
her activity,
providing
care such as
back care,
hair care,
nail care,
etc. )

Provided It encourages
To provide emotional
emotional support to
support to patient by
patient. convincing
her and
showing
concern.

To Encouraged It encourages patient

encourage the patient to be opem-up which
the patient to discuss helps to deal with
to discuss concerns problems.
concerns about
about change in
change in lifestyle,
lifestyle, body
body appearance,
appearance etc.
, etc.
To Discouraged It will help to move
discourage the patient ahead in life with
the patient from self- positive vibes.
from self- blaming and
blaming negative
and thinking.
negative
thinking.

To talk Encouraged It helps to focus on

with the the patient positive side of life
patient to talk about and minimize
about her her future negative thinking.
future goals and
plans and plans. (She
goals. wants to be
independent
and start to
work after
she gets
well .)

To provide Provided It helps to buildup

positive positive confidence of patient.
hope to hope to
patient. patient. (She
will get
better within
some days.)
To focus Focused on It helps to uplift
on strengths of patient’s condition by
strengths of patient i.e. talking about her
patient. her abilities. abilities.

To Encouraged A good conversation

encourage the patient provides support.
the patient to talk with
to talk with friends and
friends and family.
family.
  Progress report:

Date Day Present General Medication Investigation Remark

complain condition
/vital sign
2076/ 1st Patient -Patient 1. Inj. Lasix 20mg Blood tests Intake and
2/18 complains general IV BD output was
of decreased health i.e. 6am and 6pm monitored.
urine condition (Intake=900
output. seems fair. 2. Tab Pantocid ml/day,
40mg Output=500
-The vital PO OD ml/day)
signs was i.e. 6am
monitored. Fluid intake
BP= 3. Tab Medomol was limited
150/100 500mg to prescribed
mm of Hg, PO SOS amount.
T=99.8 (1000ml/day
degree 4. Cap Flupen )
Fahrenheit, 500 mg
P= 80 bpm, PO QID Low
R= 24 b/m i.e. 6 am, 12md, sodium diet
and SPO2= 6pm, 12mn was given.
94% in
RA. 5. Inj. Ondem Diuretic
4 mg (Lasix 20
-Body IV SOS mg) was
weight was given.
taken.(52 6. Tab Amlod 5 mg
kg) PO OD i.e. 6am
Date Day Present General Medication Investigation Remark
complain condition
/vital signs
2076 2nd Patient Patient 1. Inj. Lasix 20mg No any
/2/19 complains general IV BD investigations Assisted
difficulty health i.e. 6am and patient with
to perform condition 6pm activity and
physical seems fair. hygiene
activity 2. Tab Pantocid such as nail
due to The vital 40mg PO OD care, hair
fatigue. signs was i.e. 6am care, etc.
monitored.
BP= 3. Tab Medomol Rest and
140/100 mm 500mg pause in
of Hg, T=99 PO SOS between
Degree exercise was
Fahrenheit, 4. Cap Flupen encouraged.
P= 80bpm, 500 mg
R= 22 b/m PO QID Active range
and SPO2= i.e. 6 am, of motion
92% in RA. 12md, 6pm, exercises
12mn was
encouraged.
5. Inj. Ondem
4 mg Patient was
IV SOS encouraged
to gradually
6. Tab Amlod 5 increase
mg PO OD i.e. activity.
6am
Date Day Present General Medication Investigation Remark
complain condition
/vital sign
2076 3rd No any Patient 1. Inj. Lasix 20mg No any Vital signs
/2/20 complains general IV BD investigations was
from health i.e. 6am and monitored.
patient condition 6pm Blood
side seems fair. pressure is
2. Tab Pantocid slightly
The vital 40mg high.
signs was PO OD
monitored i.e. 6am Low
.i.e. BP= sodium diet
140/90 mm 3. Tab Medomol was
of Hg, 500mg encouraged.
T=97 PO SOS
Degree Normal
Fahrenheit, 4. Cap Flupen bladder and
P= 72 bpm, 500 mg bowel habit
R= 20 b/m PO QID
and SPO2= i.e. 6 am,
90% in RA. 12md, 6pm,
12mn

5. Inj. Ondem
4 mg
IV SOS

6. Tab Amlod 5
mg PO OD i.e.
6am
 REFERENCES:
1. Suddarth, B. (2016). Medical- Surgical Nursing (13th ed., Vol. 1). New Delhi, India: Wolters
Kluwer. doi:920-930

2. Williams, L., & W. (2017). Lippincott Manual Of Nursing Practice(10th ed., 446-447). New
Delhi, India: Wolters Kluwer.

3. R., & C. (2016). Pathologic basis of disease(Vol. 2, 655-656). New Delhi, India: Elsevier.

5. https://www.scribd.com/doc/12445474/NCP-Risk-for-Impaired-skin-integrity-r-t-dry-skin-and-

behaviors-that-may-lead-to-skin-integrity-impairment-AEB-scratching-of-scabs.

6.https://www.google.com.np/search?q=risk+for+bleeding+nursing+interventions&source=lnms&sa

=X&ved=0ahUKEwjO7dj8qJbcAhUYeysKHTU5A-MQ_AUICSgA&biw=1517&bih=705&dpr=0.9