Our Lady of Guadalupe Colleges

COLLEGE OF NURSING
Mandaluyong City
NURSING CARE PLAN

NAME OF STUDENT: Erine Emmanuelle C. Hetrosa

NAME OF PATIENT:
CASE: Uremic Encephalopathy r/t acute renal failure s/t acute kidney infection
Assessment
Diagnosis
Inference
Planning
Intervention
Subjective
PC:
Acute Kidney
Goal: After
The student nurse
Nagkaroon
Metabolic
Infection from
interventions, the
will:
ako ng
Acidosis
unknown source
patient will have
seizures kaya
less severity of
ako dinala sa

complications of
ospital, as
metabolic acidosis
verbalized by
Activation of the
and no progress of
the patient.
inflammatory
the condition.
process
Objective
With right IJ

catheter
Rapid, shallow
Destruction of the
breathing
glomeruli of the
(+) pruritus
kidneys from the
1. Monitor for signs
(+) weight
infection and
and symptoms of
gain
inflammation
metabolic acidosis.
Grade 1
bilateral

pitting
edema
Decreased
Patient is

Rationale

Evaluation
After 3-4 months of
interventions, the client
will be have:

1. Knowledge of
1. S:Decreased or no
severity of signs
progress of symptoms
C:
and symptoms
[ ] eupneic
is key to
respirations
treatment
[ ] (-) headache,
changes in sensorium
[ ] (-) nausea and
vomiting

undergoing
hemodialysis

glomerular
filtration rate

Laboratories
647 creatinine
level
ABG level
indicate
metabolic
acidosis
Hyperkalemia
hyperphospha
temia

Impaired excretion
of waste products

2. Metabolic
acidosis can
2. Monitor for
manifest in
laboratory tests that
several
may indicate
laboratory
worsening of
values
metabolic acidosis

Buildup of toxic
wastes inside the
bloodstream

Uremia

3. Administer IVF
replacement as
ordered.

3. Dehydration
may result from
the urinary fluid
losses

2. S:Decrease in
laboratory values or
normalizing of values
C:
[ ] normal ABG values
[ ] normal blood pH
[ ] normal serum
potassium
[ ] normal serum
phosphate
[ ] normal serum
calcium
[ ] urine pH

Failure of excretion
of acid anions

Failure of excretion
of potassium

4. Administer sodium
bicarbonate as
ordered.

Hyperkalemia

Need for dialysis

5. Administer calcium

4. Sodium
bicarbonate acts
3. Normal ABG values
as alkalinizing
agent by
releasing
bicarbonate
ions, negating
the effect of
metabolic
acidosis.
4. Normal serum calcium
5. Calcium

carbonate as
ordered.

6. Administer renvela
as ordered.

7. Administer
antihypertensive
drugs as ordered

8. Prepare client for

hemodialysis
sessions

9. Monitor client's
condition pre- and
post-hemodialysis.

carbonate is
replacement for
calcium is
5. Normal serum
patients with
phosphate
hypocalcemia
6. Renvela reduces
phosphorus
6. Normal blood pressure
levels in the
body.
7. The kidneys are
major regulatory
organ of blood
pressure. ARF
causes
hypertension.
Antihypertensive
medications
7.
control effects
and
complications of
high blood
pressure.
8. Patient's kidneys
have impaired
potassium
excretion.
Dialysis is
needed to

S: Good response to
hemodialysis
C:
[ ] normal serum
potassium
[ ] no symptoms of
metabolic acidosis
[ ] no seizures
[ ] weight loss
[ ] normal creatinine
levels
[ ] normal BUN-crea
ration

excrete
potassium.
9. Measures the
effectiveness of
hemodialysis.