Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Assessment
Subjective:
Patient is not
able to verbalize.

Objective:
> Deep, fast, noisy
breathing

Nursing
Diagnosis

Scientific Explanation
of the Problem

Planning

Interventions

Ineffective
Breathing Pattern
r/t impending
pulmonary
congestion d/t
impaired GFR and
fluid retention or
respiratory
muscle weakness
d/t physical stress.

Impaired GFR results into

fluid overload. With fluid
volume excess, venous
pressure is more likely to
cause both circulatory and
pulmonary congestion. The
patient may possibly
manifests fatigue,
dyspnea, tachypnea,
muscle weakness
(including diaphragm), or
sputum production that
are related to pulmonary
congestion. Physical stress
also impacts pulmonary
functioning.

Goal:
Establish Spontaneous, nonLabored Breathing

Collaborative:
1. Administer humid Oxygen
(8-10Lpm) as ordered.

Short Term:
After 4 hours of nursing
interventions, patient will be
able to reduce labored and
difficult breathing and
establish a respiratory rate
of less than 30cpm.

2. Assist in Manual
Ventilation via ET Tube.

> RR 33cpm
> Crackles heard
on inspiration
> SaO2 99%
> BP
140/100mmhg
> PR 80bpm
> T 37.0 C
> Diaphoretic, cold
clammy skin

Diabetic, there is a
possibility that sugar
crystallization has occurred
and leads to renal artery
stenosis or a microvascular
complication due to
viscosity.

> Unresponsive;
may be due to
fatigue/weakness.
> Increased
respiratory
secretions.

Long Term:
After 5 days of nursing
interventions, patient will be
able to demonstrate nonlabored and spontaneous
breathing.

Independent:
1. Monitor and record vital
signs.

Rationale

Evaluation

1. To help patient get

adequate oxygen despite
of DOB.
2. To assist patient on
respiration and to ensure
adequate tidal volume.

1. To check and reassess

vital function changes
(Respiration).

2. Assess for lung sounds.

2. To identify extent of
fluid accumulation in the
respiratory system.

3. Position on moderate high

back rest.

3. To facilitate
gravitational expansion of
the lungs to decrease
inspiratory effort.

4. Maintain calm and nonstimulating environment.

4. To avoid stressors and

let patient regain strength
by manipulation of
environment.

5. Suction secretions PRN.

5. To facilitate airway
clearance and reduce
effort from DOB.

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).
Priority Problem: (Priority 1) Ineffective Breathing Pattern
CELESTINO, JOHN CHRISTOPHER S.
WUP SN13
senior block 04

Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Assessment
Subjective:
Patient is not
able to verbalize.

Nursing
Diagnosis
Fluid Volume
Excess R/T
decrease
Glomerular
filtration Rate and
sodium retention.

Objective:
> Anuria
> BP 140/100mahg
> RR 27cpm
> PR 80bpm
> T 37.0 C
> Peripheral Edema
> Diaphoretic, cold
clammy skin
> Unresponsive;
may be due to
fatigue/weakness.
> Increased
respiratory
secretions.

Scientific Explanation
of the Problem
Renal disorder impairs
glomerular filtration that
resulted to fluid overload.
With fluid volume excess,
hydrostatic pressure is
higher than the usual
pushing excess fluids into
the interstitial spaces,
causes venous return,
leading the patient to have
edema, weight gain,
pulmonary congestion and
HPN at the same time due
to decrease GFR, nephron
hypertrophied leading to
decrease ability of the
kidney to concentrate
urine and impaired
excretion of fluid thus
leading to oliguria/anuria.
With associated DM, there
is a possibility that sugar
crystallization has occurred
and leads to renal artery
stenosis or a microvascular
complication due to
viscosity of blood.

Planning
Goal:
Reduce Fluid Volume
Excess, output more
than input.
Short Term:
After 4 hours of
nursing interventions,
patient will be able to
avoid recurrence of
fluid excess
Long Term:
After 5 days of
nursing intervention
the patient will
manifest stabilize fluid
volume, I & O, normal
VS, stable weight,
and free from signs of
edema.

Interventions
Collaborative:
1. Administer loop diuretics
(Furosemide/Lasix) as ordered.
2. Assist in specimen extraction for
serum analysis (Serum Electrolytes/
RBS or FBS) and urine analysis
(BUN/Crea).
3. CBG Test as ordered.
Independent:
1. Monitor and record vital signs

Manifestation Problem: (Priority 3) Risk for Impaired Skin Integrity

CELESTINO, JOHN CHRISTOPHER S.
WUP SN13
senior block 04

Collaborative:
1. Diuretics reduce fluid
volume by helping kidney
excrete urine and sodium.
2. To prepare patient for
possible lab orders..
3. To determine the
efficacy of DM regimen.
Independent:
1. To check and reassess
vital function changes
(Circulation).
2. To determine extent of
fluid excess.
3. To check possible
respiratory complications
(pulmonary congestion).

2.

Auscultate breath sounds

3.

Record occurrence of dyspnea

4.

Review lab data like BUN,

Creatinine, Serum electrolyte.

4.

5.

Record I&O accurately and

calculate fluid volume balance

5. To determine fluid
retention and kidney
function (GFR).

6.

Weigh client

6. Increasing weight may

indicate fluid retention.

7.

Encourage quiet, restful

atmosphere.

7. To allow patient cope

with stressors naturally.

> CBG 126mg/dL

Main Problem: (Priority 2) Fluid Volume Excess

Rationale

To monitor kidney
function and fluid
retention (electrolyte
compensation).

Evaluation

Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Assessment
Subjective:
Patient is not
able to verbalize.

Nursing
Diagnosis

Scientific Explanation
of the Problem

Planning

Risk for Impaired

Skin Integrity r/t
edema and
prolonged bed rest
d/t

Due to fluid retention, fluid

accumulates and fluid
shifts from intracellular
compartment to
extracellular compartment
causing escape of fluid to
the tissues (edema). With
associated complications of
anemia, skin nutrition
would be crucial and may
have easily broken off.

Goal:
Prevent Risks on Developing
Skin Breakdown.

Objective:
> Peripheral Edema
> Prolonged bed
rest
> Pallor
> Hgb
> Diaphoretic, cold
clammy skin
> Unresponsive;
may be due to
fatigue/weakness.

DM could cause high blood

sugar levels and leads to
viscosity of blood that also
impairs nutrition of skin or
reduction of blood cells to
capillaries.

Short Term:
After 4 hours of nursing
interventions, patient will be
able to remove potential
threats that may lead to
poor skin integrity.
Long Term:
After 5 days of nursing
interventions, patient will be
able to identify and avoid
factors that lead to skin
breakdown.

Interventions
Collaborative:
1. Ferrous Sulfate (Iron
supplement) as ordered.
2. Update Lab Findings for
CBC (RBC, Hgb, Hct).

1. To help body regulate

RBC in the
absence/lacking of
hormone erythropoietin.
2. To evaluate efficacy of
treatment/prophylaxis for
anemia regimen.

3. CBG T.I.D. as ordered.

3. To determine
hyperglycemia that makes
blood viscous and induces
the risk for infection.

Independent:
1. Assess skin appearance
(color, texture,
temperature).

1. To determine edema or
erythema that indicates
possible bed sore.

2. Turn patient side to side

every 2 hours if possible.

> CBG 126mg/dL

3. Maintain crease-free bed

linen.
4. Maintain a clean,
therapeutic environment.

CELESTINO, JOHN CHRISTOPHER S.

WUP SN13
senior block 04

Rationale

2. To make pressure
equal when lying to avoid
unilateral skin tissue
blood insufficiency.
3. To avoid skin irritation
from crease.
4. To avoid risk for skin
injury and infection.

Evaluation