CUES DATA NURSING DESIRED OUTCOMES/ NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS GOALS
Subjective Risk for decreased After 4 hours of nursing 1. Establish rapport 1. Promote After 4 hours of nursing
data: cardiac output interventions, the and introduce self cooperation, build intervention, the goal
“Gamay ra related to fluid patient will 2. Auscultate heart trust and ease was met as evidenced
ahung maihi”, imbalances  Display and lung sounds. anxiety by the patient;
as verbalized secondary to hemodynamic Evaluate 2. S3 and S4 heart  Displayed
by the client polycystic kidney stability presence of sounds with muffled hemodynamic
disease  Participate in peripheral tones, tachycardia, stability
Objective treatment edema, vascular irregular heart rate,  Participated in
data: regimen within congestion and tachypnea, dyspnea, treatment
- dry skin Scientific basis: level of ability reports of crackles, regimen within
- bipedal CKD causes a or situation dyspnea. wheezes,edema and level of ability
minimal systemic, chronic 3. Assess presence jugular distension or situation
edema proinflammatory and degree suggest HF.
- abdominal state contributing to of hypertension: 3. Significant hypertensi
girth of 87cm vascular and monitor BP; note on can occur because
- weight gain myocardial postural of disturbances in the
- high remodeling changes (sitting, renin-angiotensin-
creatinine processes resulting lying, standing). aldosterone system
level of in atherosclerotic 4. Investigate (caused by renal
8.83mg/dl lesions, vascular reports of chest dysfunction).
- low calcification, and pain, noting Although
potassium vascular senescence location, hypertension is
level of as well as radiation, severity common,
3.45mmol/l myocardial fibrosis (0–10 scale), and orthostatic hypotensi
and calcification of whether or not it on may occur
v/s taken cardiac valves. In is intensified by because of
T: 36.4 C this respect, CKD deep inspiration intravascular fluid
P: 85 bpm mimics an and supine positi deficit, response to
R: 20 cpm accelerated aging of on. effects of
BP: 110/80 the cardiovascular 5. Evaluate heart antihypertensive
mmhg system.  sounds (note medications, or
SPO2: 98% friction rub), BP, uremic pericardial
Source: peripheral pulses, tamponade.
Jankowski, J., capillary refill, 4. Although
Floege, J., Fliser, D., vascular hypertension and
Böhm, M., & Marx, congestion, chronic HF may cause
N. (2021, March 16). temperature, and MI, approximately
Cardiovascular sensorium or half of CRF patients
disease in chronic mentation. on dialysis develop
kidney disease: 6. Assess activity pericarditis,
Pathophysiological level, response to potentiating risk of
insights and activity. pericardial effusion
therapeutic options. 7. Monitor or tamponade.
Circulation. electrolytes (pota 5. Presence of
Retrieved October ssium, sodium, sudden hypotension,
31, 2022, from calcium, paradoxic pulse,
https://www.ncbi.nl magnesium), BUN narrow pulse
m.nih.gov/pmc/artic and Cr pressure, diminished
les/PMC7969169/ 8. Monitor chest x- or absent peripheral
rays results pulses, marked
9. Administer jugular distension,
antihypertensive pallor, and a rapid
drugs such mental deterioration
as prazosin (Mini indicate tamponade,
press), captopril ( which is a medical
Capoten), clonidi emergency.
ne (Catapres), 6. Weakness can be
hydralazine attributed to HF
 (Apresoline) as and anemia.
ordered 7. Imbalances can alter
10. Prepare for electrical conduction
dialysis. and cardiac function.
11. Assist with 8. Useful in identifying
pericardiocentesi developing cardiac
s as indicated. failure or soft-tissue
calcification.
9. Reduces systemic
vascular resistance
and renin release to
decrease myocardial
workload and aid in
prevention of HF and
MI.
10. Reduction of uremic
toxins and correction
of electrolyte
imbalances and fluid
overload may limit
and prevent cardiac
manifestations,
including
hypertension and
pericardial effusion.
11. Accumulation of fluid
within pericardial sac
can compromise
cardiac filling and
myocardial
 contractility,
impairing cardiac
output and
potentiating risk of
cardiac arrest.

Sources:

Jankowski, J., Floege, J., Fliser, D., Böhm, M., & Marx, N. (2021, March 16). Cardiovascular disease in chronic kidney disease: Pathophysiological
insights and therapeutic options. Circulation. Retrieved October 31, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969169/

Vera, M. (2022, March 18). 17 chronic renal failure nursing care plans. Nurseslabs. Retrieved November 1, 2022, from
https://nurseslabs.com/6-chronic-renal-failure-nursing-care-plans/