This document presents a comprehensive nursing care plan for a patient, David, suffering from acute on chronic renal failure. The assessment phase details the collection of baseline data, including vital signs, urine analysis, and pain assessment using the PQRST scale, leading to the formulation of nursing diagnoses. The care plan addresses key nursing problems such as acute pain, risk of fluid imbalance, risk of infection, anxiety, and impaired skin integrity, with specific goals, interventions, and rationales outlined for each. Interventions include medication administration (analgesics, antibiotics, diuretics), fluid management, infection control measures, psychological support, and skin care. The evaluation section assesses the effectiveness of interventions based on patient outcomes and laboratory results. The document also includes patient education on medication management, symptom recognition, dietary restrictions, and hygiene practices, alongside a nursing handover report summarizing the patient's condition and care provided. The nursing care plan emphasizes a holistic approach to patient care, addressing both physical and psychological needs.
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