Nursing Care Plan for a Patient with Acute on Chronic Renal Failure

This assignment presents a detailed nursing care plan for a patient, David Smith, experiencing acute on chronic renal failure. The plan addresses multiple nursing problems, including acute pain, risk of fluid imbalance, risk of infection, anxiety, and impaired skin integrity. Each problem includes related factors, goals of care, specific nursing interventions with rationales, and evaluation methods. The plan encompasses comprehensive assessments of physical and vital signs, fluid balance, and acute pain, as well as a discharge plan that emphasizes infection control and fluid balance education. The clinical reasoning cycle is applied, starting with initial assessments, identifying abnormal findings, and implementing interventions such as medication administration, fluid management, and patient education. The plan highlights the importance of monitoring vital signs, fluid status, pain levels, and patient adherence to treatment plans to ensure optimal patient outcomes. The plan aims to minimize pain, maintain normovolemic condition, prevent infection, reduce anxiety, and preserve skin integrity, providing a holistic approach to patient care.

Nursing Assignment
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Task 1:
First assessment will be performed for physical and vital signs assessment. Physical
and vital signs assessment will be performed through carrying out several
procedures such as observation, palpation, percussion and auscultation. These
assessments will be beneficial in identifying signs and symptoms of current medical
condition of David
(Gabayan et al., 2017). It has been observed that values obtained for the vital signs
for David are the abnormal values because these are outside the normal values of
vital signs. Hence, to confirm normalisation of values of vital sings; it is necessary to
carry out vital sign assessment in David (Gabayan et al., 2017). If vital signs
assessment would not have been carried out in David; it would have been difficult to
plan specific intervention for the abnormal vital sign values. Data obtained through
physical and vital signs assessment will be recorded in charts such as observation
chart, medication chart and progress notes.
Second assessment will be performed for the fluid balance in case of David. Fluid
balance will be assessed trough incorporating different parameters like determination
of administered fluid volume, cardiac rhythm and neurological manifestations
(Prowle, Kirwan, and Bellomo, 2014). It is essential to carry out fluid balance
assessment in case of David because fluid imbalance is prominent manifestation of
AKI. In case of not performing fluid balance in David; there would be possibility of
accumulation of water and salt (Prowle, Kirwan, and Bellomo, 2014). Data obtained
through assessment of fluid balance will be recorded in different charts like fluid
balance chart, daily weight chart, fluid prescription chart and medication chart.
Third assessment will be performed for the acute pain for David. It necessary to
carry out acute pain assessment in David because it is one of the most prominent
symptoms of AKI. Adult patients like David are usually not willing to verbalise their
pain sensation. Hence, specific intervention for the management of pain might not be
provided for such patients. Acute pain assessment will be performed using PQRST
scale (Coluzzi, 2018). Data obtained through acute pain assessment will be recorded
in different charts such as observation chart, progress notes and medication chart.
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: Acute kidney injury
Goal of care Nursing interventions Rationale Evaluation
Minimise pain
sensation in David.
Improve awareness of David about the
identification of pain sensation,
encourage him to report it immediately
and acknowledge his concerns.
Assist David in re-positioning and
mobilisation.
Monitor non-verbal communication of
David.
Immediate reporting of pain is
attributable to the early intervention.
Untreated pain can produce varied
psychological issues like anxiety
and depression. Exchange of
information between the patient and
nurse can improve therapeutic
relationship among them which
would be helpful in providing
person-centred care for the effective
management of pain
(Duke, Botti, and Hunter, 2012).
Assistance in re-positioning and
mobilisation can be helpful in
minimising muscle discomfort, fall
risk and injury (Duke, Botti, and
Hunter, 2012).
Elder patients like David are not
willing to verbalise their pain
sensation. Hence, non-verbal
communication can be helpful in
assessing the intensity of pain
Recorded pain score for David is 2/10.
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Improve awareness of David about the
pain medication, ensure David is
consuming pain medications on regular
basis and monitor effectiveness and
adverse effects of pain medicines.
sensation (Pham et al., 2017).
Management of pain can be
effectively achieved through
administration of pain medicines.
Regular monitoring of pain
medicines is beneficial in improving
effectiveness and reducing adverse
effects because pain medications
are associated with several
psychological side-effects (Pham et
al., 2017).
David reported pain relief after
consumption of pain medication.
Nursing problem: Risk of fluid imbalance
Related to: Urine retention and AKI
Goal of care Nursing interventions Rationale Evaluation
Administer adequate
amount of fluid and
maintain
normovolumic
condition.
Update, observe and monitor fluid
prescription chart and fluid balance
chart.
Ensure availability of varied safety
measures such as soft restraints and
side rails and improve awareness of
David about use of these safety
measures.
Take body weight of David on regular
basis and enter the data in progress
report.
These charts will give idea about
the volume of administered fluid and
requirement of volume of fluid.
Hence, accurate amount of fluid can
be administered without producing
hypovolemic or hypervolumic
condition (McGloin, 2015).
Fluid imbalance is responsible for
the development of pitting oedema;
hence risk free mobilisation can be
achieved through use of these
safety measures (McGloin, 2015).
Unexpected change in the body
weight is indication of fluid
imbalance (Pinnington, Ingleby,
Normovolumic condition maintained.
Signs and symptoms of fluid imbalance
are not evident.
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Observe mucous membrane and skin
turgor.
Order diuretics to David and assess its
effectiveness in maintaining normal
fluid volume.
Hanumapura, and Waring, 2016).
Fluid imbalance produces impaired
skin integrity which can be
assessed through dried mucous
membrane and skin turgor
(Pinnington, Ingleby, Hanumapura,
and Waring, 2016).
Diuretics eliminate fluid from the
body which is useful in maintaining
optimum fluid volume in the body
(McGloin, 2015).
No change in boy weight of David.
Dehydration is not evident in David.
Nursing problem: Risk of infection
Related to: Pyelonephritis
Goal of care Nursing interventions Rationale Evaluation
David is infection
free.
Ensure David is consuming calorie-rich
and protein-rich food.
Advise David and ensure that he is
taking ample amount of water and
other fluids.
Improve awareness of David about
hygienic condition and ensure he is
These types of foods are beneficial
in improving immune system to fight
against micro-organisms (Bursle et
al., 2015).
Water and other fluids consumption
in ample amount would lead to urine
dilution which consequently lead to
emptying of urinary bladder, more
urine output and elimination of
microorganism through urine
(Fasugba, Koerner, Mitchell, and
Gardner, 2017).
Hygienic condition would be helpful
in minimising risk of infection and
Microorganisms not detected in blood
and urine samples of David.
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using antiseptic solution.
Administer specific antibiotic to David
and ensure he is adhering to the
antibiotic course completion
antiseptic solution is beneficial in
preventing growth of micro-
organisms (Fasugba, Koerner,
Mitchell, and Gardner, 2017).
Infection can be effectively
controlled through use of antibiotics
and course completion of antibiotics
can be beneficial in minimising risk
of re-infection (Fasugba, Koerner,
Mitchell, and Gardner, 2017).
Nursing problem: Anxiety
Related to: Health and well-being related factors such as pain and disability.
Goal of care Nursing interventions Rationale Evaluation
Improve awareness
of David about the
management of
anxiety.
Perform assessment of David’s
awareness about anxiety.
Educate and train David about the slow
breathing and muscle relaxation
techniques and advise him to practice
these techniques on the regular basis.
Patients do not verbalise about
consequences of anxiety because
patients are not aware of the
anxiety symptoms. Hence,
assessment of awareness of
anxiety in David can be beneficial in
implementing relevant intervention
for the management of anxiety
(Gulanick and Myers, 2016).
Practicing relaxation techniques
proved helpful in bringing vital signs
such as BP and RR in the normal
range which would be beneficial in
the management of anxiety
(Gulanick and Myers, 2016).
David not experiencing signs and
symptoms of anxiety.
Relaxation techniques minimised signs
and symptoms of anxiety.
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Develop positive communication with
David.
Administer David with anti-anxiety
medications, assess effectiveness of
these medications in David and ensure
he is adhering to these medications.
Negative communication can
transmit anxiety to patients. Hence,
it is essential to develop positive
communication with patient.
Anti-anxiety medications are
beneficial in reducing anxiety
symptoms. Assessment of
effectiveness of anti-anxiety
medications is essential because
these medications are associated
with multiple adverse effects. It is
necessary to ensure adherence to
anti-anxiety medications because
most of the patients discontinue
these medications; since, these
medications exhibit delayed effect
(Gulanick and Myers, 2016).
No observation of anxiety in David.
Nursing problem: Impaired skin integrity
Related to: Hyperthermia and altered fluid status.
Goal of care Nursing interventions Rationale Evaluation
Skin remain intact
without rash or injury.
Prohibit David from raising bed most
often and make sure he is lifting bed by
means of using bed lines.
Advise him to follow hygienic practices
like application of antiseptic solution
and pat drying. Teach hygienic
practices such as use of antiseptic
Friction of heel and rubbing of
elbow can affect skin integrity
(Murphree, 2017).
Risk of infection can be effectively
reduced through use of antiseptic
solution. Pat drying is safer than
rubbing because it can give rashes
Skin remains intact.
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solution and pat drying to David.
David should be advised to consume
ample amount of water and fluids.
to skin (Murphree, 2017).
More amount of fluid in the body
can be helpful in maintaining skin
integrity (Murphree, 2017).
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Task 3
Discharge plan of David should incorporate infection control and fluid balance.
Recommendations for infection control and fluid balance are essential in case of
David because these are the two important factors associated with AKI.
Nurse should educate David about the signs and symptoms of fluid imbalance like
lethargy, fatigue, confusion, muscle weakness and muscle cramping. Knowledge of
these symptoms can be helpful for David to inform nurse about his fluid imbalance
status. Hence, nurse can plan appropriate nursing intervention to David for the
management of fluid imbalance. David should be instructed to drink abundant
amount of water and fluids. He should be advised to keep updating nurse about his
improvement after drinking plenty water and fluids. In case, there is no progress in
his condition; nurse can discuss with physician to initiate IV fluid administration (Xue,
Li, Liu, and Sun, 2016; Lemone et al., 2017). It is advisable to educate David to
record body weight on daily basis. It would be beneficial in assessing fluid balance
because sudden change in body is attributable to fluid imbalance.
Nurse should ensure that David is aware of signs and symptoms of infection such as
fever and pain. Improvement of awareness about fever and pain is essential because
these are the two prominent symptoms of infection. Improved awareness about these
symptoms would be helpful for David to monitor progress in resolution of infection
post administration of antibiotics. David should also be informed that he should
appraise these symptoms for 2-3 days and alert nurse about reduction of these
symptoms after administration of antibiotics. In case, there is no improvement in the
treatment of infection; nurse can discuss with physician to change the dose of
existing antibiotic or change it to another antibiotic. Moreover, nurse should instruct
him to complete the antibiotic course without its discontinuation without knowledge of
nurse or physician. Discontinuation of antibiotic consumption prior to completion of
antibiotic course is attributable to reinfection and/or resistance development. Nurse
should educate him to drink abundant water on daily basis because it would be
helpful in eliminating microorganisms through diluting urine and increasing urine
output (Ward, 2011; Bryant, Knights, Darroch, and Rowland, 2018).
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Task 4
Nursing care was provided to David through adopting clinical reasoning cycle. Upon
admission to the hospital; physical and vital signs of David were assessed. During
physical assessment, it was evident that David was experiencing acute pain,
tiredness and disability. During vital signs assessment, it was evident that his
recorded vital signs were abnormal. Recorded vital signs for David were HR (96
bpm), BP (160/95 mmHg) and RR (22). Atypical vital signs of David produce both
physiological and psychological complications. Psychological complications include
anxiety and non-alert to time and place. Acute pain in David is also a major
contributing factor for psychological complications. Hence, he looks unwell and his
behaviour is restless. Urine quantity and quality in David affected due to AKI. Urine
quantity in David is low which is recorded as 100 ml in last four hours. Urine quality in
David is abnormal which is evident from dark color and offensive smell. Urinary tract
infection in David is evident form the diminished quantity and quality of urine. Last
time, he opened bowel today morning. He is acclimatised to consume diabetic food.
His skin is intact which is evident from the non-appearance of turgor. Increase in
WBC count (1.5 X 109/L) specify infection in him.
Medications were administered for David. Morphine 2.5 mg was administered for
David for the management of acute pain. Recorded pain score was 2/10 after the
administration of these medications for pain relief. Recorded BP after the
administration of Ramipril 10 mg OD was above the normal range. Recorded
temperature in David was above normal level post administration of paracetamol 1 g
QID. Since, he is associated with renal infection; antibiotic is ordered for him. Doctor
recommended discharge and advised to visit again after two weeks for F/U.
Paperwork of D/C completed. Education extended for infection and acute pain and
advised to monitor these conditions on daily basis.
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Key (if required)
AKI – Acute kidney injury
BP – Blood pressure
RR – Respiratory rate
HR – Heart rate
D/C discharge
F/U follow-up
ADL’s activities of daily living
PQRST provocation/palliation, quality/quantity, region/radiation, severity
scale, timing
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