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).

Assessment Nursing Scientific Explanation of Planning Interventions Rationale Evaluation

Diagnosis the 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.
respiratory manifests fatigue, able to reduce labored and
Objective:
muscle weakness dyspnea, tachypnea, difficult breathing and
> Deep, fast, noisy
breathing d/t physical stress. muscle weakness establish a respiratory rate
(including diaphragm), or of less than 30cpm.
> RR 33cpm sputum production that
Independent:
are related to pulmonary Long Term: 1. To check and reassess
> Crackles heard 1. Monitor and record vital
congestion. Physical stress After 5 days of nursing vital function changes
on inspiration signs.
also impacts pulmonary interventions, patient will be (Respiration).
functioning. able to demonstrate non-
> SaO2 99%
labored and spontaneous 2. Assess for lung sounds. 2. To identify extent of
> BP Diabetic, there is a breathing. fluid accumulation in the
140/100mmhg possibility that sugar respiratory system.
crystallization has occurred
> PR 80bpm and leads to renal artery 3. To facilitate
3. Position on moderate high
stenosis or a microvascular gravitational expansion of
> T 37.0 C complication due to back rest.
the lungs to decrease
viscosity. inspiratory effort.
> Diaphoretic, cold
clammy skin
4. Maintain calm and non- 4. To avoid stressors and
> Unresponsive; stimulating environment. let patient regain strength
may be due to by manipulation of
fatigue/weakness. environment.
> Increased
respiratory 5. Suction secretions PRN. 5. To facilitate airway
secretions. clearance and reduce
effort from DOB.

CELESTINO, JOHN CHRISTOPHER S.

WUP SN’13 senior block 04
Patient’s Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy
Priority Problem: (Priority 1) Ineffective Breathing Pattern

Assessment Nursing Scientific Explanation of Planning Interventions Rationale Evaluation

Diagnosis 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
the interstitial spaces,
Objective:
causes venous return,
> Anuria
leading the patient to have
> BP 140/100mahg edema, weight gain,
pulmonary congestion and
> RR 27cpm HPN at the same time due
to decrease GFR, nephron
> PR 80bpm
hypertrophied leading to
decrease ability of the
> T 37.0 C
kidney to concentrate
> Peripheral Edema urine and impaired
excretion of fluid thus
> Diaphoretic, cold leading to oliguria/anuria.
clammy skin
With associated DM, there
> Unresponsive;
is a possibility that sugar
may be due to crystallization has occurred
fatigue/weakness.
and leads to renal artery
> Increased stenosis or a microvascular
respiratory complication due to
secretions. viscosity of blood.
> CBG 126mg/dL
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
serum analysis (Serum Electrolytes/ possible lab orders..
Short Term:
RBS or FBS) and urine analysis
After 4 hours of
(BUN/Crea).
nursing interventions,
3. CBG Test as ordered. 3. To determine the
patient will be able to
efficacy of DM regimen.
avoid recurrence of
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.

Main Problem: (Priority 2) Fluid Volume Excess

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

CELESTINO, JOHN CHRISTOPHER S.

WUP SN’13 senior block 04
Patient’s Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Assessment Nursing Scientific Explanation of Planning Interventions Rationale Evaluation

Diagnosis the 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
associated complications of able to remove potential anemia regimen.
Objective:
anemia, skin nutrition threats that may lead to
> Peripheral Edema
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
DM could cause high blood After 5 days of nursing induces the risk for
> Pallor sugar levels and leads to interventions, patient will be infection.
viscosity of blood that also able to identify and avoid
> Hgb impairs nutrition of skin or factors that lead to skin Independent:
reduction of blood cells to breakdown.
> Diaphoretic, cold 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