Patient Care Plan

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Patient Care Plan

Student: Michelle Brook| Patient Initials: R.PAge: 85 m/ f Female| Admitting DiagnosisAcute/Chronic Kidney Failure| Nanda Dx and Statement:| Goals:Short Term/Long Term| Nursing Interventions| Rationales| Evaluation:Goals met?| Risk for excess fluid volume related to inability of kidneys to excrete fluid and excessive fluid intake as evidenced by edema, hypertension and shortness of breathSubjectiveR.P said “ouch” when touching areas with edema (feet and legs)ObjectiveLegs and feet have edema +4, high blood pressure and gasps for air| One Short term R.P will be able to have a fluid balance (urine output 600-1000ml/day) within one day.| 3 Diagnostic**Monitor Respiratory Patterns for symptoms of respiratory difficulty that are indicators of fluid excess** Weigh patient daily and monitor trends to evaluate interventions**Instruct caregiver to measure input/output**assess blood pressure Q4H| **Acute Kidney Failure causes problems with the respiratory system including fluid overload in lungs and pulmonary edema (Medical Surgical Nursing 8th edition (Lewis/Dirksen/Heitkemper/Bucher/Camera) pg1173)**Weight gain is common and should not exceed 4lb/week (pg 1179**Fluid allotment should be spaced through the day so the patient does not become thirsy and so urine output can be controlled (Pg 1178)| *Respirations will be between 12-20/min*Patient will not gain more than 1 to 3 kg per week*I&O will be at recommended levels| | One Long Term Goal.R.P will have edema reduced from+ 4 to +1 within one week| 3 Educational**Work with patient to adjust fluid regulations for regular balance** Teach patient/caregiver proper technique to reduce edema**Discuss lifestyle changes with client| **A/CKF patients will have increasing difficulty with fluid retention and require the i&O to be measured daily (pg 1171)**Adema is a common side effect with RF (1169)**This infection is one of the leading causes of death and lifestyle chances...
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