Nursing care Plan for Mr. Paschal O.

with Chronic Kidney Disease

Care Plan by: Oscass Jimmy Ruva 1800736651
Date: 11th March 2021
Laboratory Findings

Patient Values Range

BUN H 14.4 2.1-7.1
Na 136 136-145

K 5.11 3.5-5.1

chloride H 109 98-107

Bicarbonate L 21 23-29

)Glucose fasting H 7.4 3.9-5.8

Creatinine H 213 53-97

Urinalysis:
Protein +++
Sugar +
Keton +
pH 5.0
Vital signs
BP: 144/98 mm Hg
Weight: 105
Respiratory Rate: 20 BPM

Medications:
Captopril 25mg orally eight hourly;
Lasix intravascular 200mg twice daily;
Prednisolone 80 mg orally daily;
Cefixim 400mg orally daily;
Atorvastatin 40mg orally daily; and he is on daily
Fluid restrictions of 500mls every 24 hours
Nursing Concerns
 Sin integrity
 Nutrition
 Fluid volume
 Knowledge gaps

Problem: Fluid Volume Excess

Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
Subjective: (none) Fluid Volume Short Term: Weigh patient Information Short Term:
Excess R/T After 4-8 hours daily under the from the weight The patient
Objective: decrease of nursing same conditions: provides a demonstrated
Patient Glomerular interventions, time, clothing, baseline and behaviors to
manifested: filtration Rate patient will scale database for monitor fluid
 Edema and sodium demonstrate monitoring status and reduce
 Hypertension retention behaviors to changes. recurrence of
 Weight gain monitor fluid Record output fluid excess
status and reduce and intake Records of
recurrence of accurately using output
fluid excess a fluid balance determines Long Term:
chat intake. The patient
manifested
Long Term: Assess the lung stabilized fluid
After 3 days of sounds, volume As
nursing respiratory rates, This finding help Evidenced By
intervention the and effort, and to determine balance Intake &
patient will heart sound. fluid volume Output, normal
manifest stabilize Inspect for excess, needed VS, stable
fluid volume As jugular vein interventions, weight, and free
Evidenced By distention and effects of from signs of
balance Input & treatments. Fluid edema.
 Out, stable overload may
weight, and free cause pulmonary
from signs of edema.
edema. Administer
prescribed These drugs
diuretics and reduce blood
antihypertensive volume and
reduce cardiac
Advice patient workload
on the need for Dialysis reduces
dialysis uremic toxins,
corrects
electrolyte
imbalances, and
decreases fluid
overload

Nutrition: Less than required amounts

Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
Anorexia, Imbalance Short Term: Assess the These data Short Term:
anemia, fatigue, nutrition less Within three patients general provide baseline The patient shall
dietary restriction than body days of nursing nutritional status upon which to have
required related care; by taking compare demonstrated
to anorexia, Patient will: - weighing patients, intervention behaviors to
nausea, and Maintain good assess for anemia, success monitor fluid
dietary nutrition by body built, status and reduce
restrictions. consuming strength Provides a recurrence of
required database for fluid excess
amounts of Monitor and take nutritional
proteins and records of changes and
adhere to dietary patient’s dietary effects of Long Term:
restrictions intake intervention The patient shall
have manifested
This minimize stabilized fluid
nausea and volume As
Provide frequent anorexia and Evidenced By
small feedings promotes intake balance Intake
 of high calorie, and Output, stable
nutritious foods weight, and free
Involvement of from signs of
client promotes edema.
Encourage to be interests and
involved with control and
food choices choices of
preferences

This promotes
Explain nutrition clients
and a list of understanding of
nutritional needs the relationships
and acceptable between food
food choices intake and kidney
disease and
provides positive
approach to
dietary restriction

Skin integrity impairment

Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
Subjective: Risk for Short Term: Instruct client to These methods Short Term:
Patients states “I impaired skin Within three days bath with luke- reduce skin After three days
have itching skin integrity related of nursing warm or tepid drying and rinse of intervention,
after bath” to scratching intervention the water and use away any the client’s skin
Objective: secondary to skin will intact glycerin-based nitrogenous remains intact
Presence of pruritus and free from soap. Apply waste products without any
edema crystals cosmetics to the evidence of
Observation of skin twice daily crystals.
patient scratching
self Advice client to
keep nail short These measure
and to put on prevent trauma to
mittens or socks the skin and
maintains skin
integrity

Knowledge gaps
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
Subjective: Knowledge Short Term: Assess the patient Important for Short Term:
Patients states “I deficit related to Within one hour current planning of Within one hour
have itching skin misinterpretation of intervention, knowledge of the learning of intervention,
after bath” of information as patient will disease objectives to be patient verbalized
Objective: evidenced by verbalize discussed with understanding of
Presence of patient asking understanding of the patient the disease
edema questions about the disease process,
Observation of the disease, process, Fluid volume prognosis, and
patient patient prognosis, and Discuss the restriction is key potential
scratching self requesting for potential importance of to the complications
information, and complications fluid volume management of Patient
in accurate follow Patient will be restrictions chronic kidney understood
through of able to disease therapeutic needs
instructions understand Patient
regarding diet therapeutic needs Protein intake is appreciated and
and other Patient will regulated in demonstrated
interventions. appreciate and Discuss chronic kidney needs to change
demonstrate nutritional disease as its life style.
needs to change concerns with metabolites are
life style patient such as unable to be
regulating protein excreted and
intake accumulate as
toxins

Understanding of
the drugs a client
Discuss drug is taking gives
therapy such as them power and
diuretics, kind of control
antihypertensive and may promote
including their compliance.
mechanisms of
action and side
effects Written
information
Provide written reinforces
information with teaching and
visual aids to help visual aids
with memory or improves recalls
retention or recall of information
of learnt
information.