Question

Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned. Dr. Brown

Write a Nursing Care Plan Assessment, Diagnosis, Goal, Implement, Evaluation

Answer 1

Nursing care plan of Chronic Renal failure -

1) Assessment-  

Subjective data- Patient says- " I can't perform my daily living activity "

Objective data -

• Intake-Output chart should be assessed
• Patient's weight should be assessed..because in the case of chronic renal failure there is a chance of weight loss
• The daily activity level of the patient should be assessed
• Emotional state of the patient should be assessed

2)  Diagnosis -

Risk for fluid and electrolyte imbalance related to impairment of kidney function as evidenced by altered level of electrolyte and weight loss.

3) Goal -

To maintain the normal proportion of electrolyte in the body

4) Implementation -

• Electrolyte level is assessed
• Vitals signs are checked
• High sodium diet is given to the patient
• Pottasium restricted diet is used frequently

5) Evaluation -

Electrolyte level is maintained to some extend..