Care Plan

Student: Evelina Balzhyk Date: 7/19/2019

Course: NSG-300CC Instructor: Professor Collins

Clincial Site: Glencroft Long-Term Care Client Identifier: K.N. Age: 86

Reason for Admission:

Client admitted to long-term facility due to self-care deficit caused by chronic kidney disease.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

K.N. was admitted with hypertensive chronic kidney disease with stage 1 K.N.’s clinical manifestations are hypertension, fatigue and
through 4 kidney disease. weakness, sleep problems, and edema in lower extremities.
 According to NCBI, chronic kidney disease is kidney damage for ≥ Potential clinical manifestations for CKD are: urinary changes
3 months, as defined by structural or functional abnormalities of (polyuria, oliguria), dyspnea, shortness of breath, and muscle
the kidney, with or without decreased GFR, that can lead to cramps (“Chronic Kidney Disease”, 2019).
decreased GFR, manifest by either pathologic abnormalities or
markers of kidney damage, including abnormalities in the
composition of the blood or urine, or abnormalities in imaging
tests (Matovinovic, 2009). Decreased renal function interferes
with the kidneys’ ability to maintain fluid and electrolyte
homeostasis. Risk factors for CKD include: baseline BP, cigarette
smoking, gender, and diabbetes status (Haroun, 2003).
Hypertension and smoking are most often the reason for kidney
disease.

Assessment Data
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
Subjective Data:
K.N. states that she feels fatigued after walking to lunch, she uses an assistive device (walker) for support while ambulating. Patiet states that
she is worried about getting variscose veins, and the worsening hump on her back which makes it more difficult for her to ambulate. She also
mentions that she has dark red patches under her skin that randomly show up. Patient denied pain.

VS: T : 97.9 Labs: Diagnostics:

BP: 149/88  Uric acid (normal 2.4-6.0 mg/dL): 6.3, K.N. had an X-ray done which revealed a cardiomegaly
high. The patient’s kidneys are not with congestive heart failure as well as chronic lung
HR: 60 bpm
eliminating uric acid efficiently, may be disease with increased interstitial markings in bases.
RR: 12 caused by certain diuretics.
O2 Sat: 94 on RA  Calcium (normal 8.6-10.3): 8.6, low.
Possibly because patient has poor
Pain: 0/10 on a 1-10 calcium intake or medications that
numerical pain scale. decrease calcium absorption)
 Sodium (normal 135-145): 141, within
normal range
 Potassium (normal 3.5-5.0): 5.1,
moderate hyperkalemia, caused by
kidney disease
 Chloride (normal 96-106): 105, within
the normal range
 BUN (normal 7-20): 30, high. Possibly
caused by dehydration or medications.
 Creatinine (normal 0.6-1.2): 1.1, within
norml range
 GFR (normal 90-120): 46, low, possibly

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 due to hypertension.

Assessment: Orders:
Pt history: patient has a history of hypertension and sleep apnea  PT/OT
 Assess skin for bruising weekly, follow up with physicain for
Neuro:
bruising and dark red patches on skin
 Patient is alert and oriented x 3- person, place, and time.  BUN levels are high, report to physician. Drink plenty of
 Speech is clear, cranial nerve XII – hypoglossal is intact. fluids
 Cranial nerve V- trigeminal, and VII-facial are intact.  Report vision problems to physician and order appointment
 Eyes are symmetrical. Conjuctiva is pink, scela is white, no with eye doctor
jaundice or drainage noted bilatrerally. Pupils are reactive to  Report GFR levels to physician.
light bilaterally and are 3 mm in size bilaterally. (Patient states
that vision is blurry on sides of eyes).
 External ears are intact. Patient wears hearing aids. Color is
consistent, no drainage noted. Tragus is mobile and non-tender.
Respiratory:
 Lung sounds are clear to auscultation bilaterally
 Unlabored breathing noted
 Chest is symmetrical
Cardiovascular:

 Regular rate and rhythm

 No edema noted in upper body. Mild edema of 1+ in lower
extremities.
 S1 and S2 sounds present. No S3 and S4 sounds.
 Capillary refill is <3 seconds bilaterally in fingers
 Radial pulses are 2+ bilaterally

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Skin:

 Skin is intact with dark red patches (look like bruises) under the
skin in the right hand, upper arm, and left lower arm.
 Warm, dry, skin turgor is appropriate, no tenting noted, color
appropriate for ethnicity.
Wounds: no wounds present
Musculoskeletal:

 Ambulates with walker

 ROM equal and strong in upper extreremities with and without
resistance
 ROM equal weak with resistance in lower extremities.
Diet: regular diet

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 Medications
ALLERGIES:
Actonel, Amoxicillin, Ciprofloxin, Diovan, Evista, Fosaxhydralazine, Nifedlac CC

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing Considerations

Effect
Acetaminophen 650 oral Q4hr/ PRN To decrease pain CNS: agitation, anxiety, Do not confuse Tylenol with
mg headache, fatigue, Tylenol PM. To prevent fatal
insomnia Resp: atelectasis, medication errors, ensure
dyspnea CV: hypertension, dose in (mg) and (mL) is not
hypotension. GI: confused; and total daily
hepatotoxicity, dose of acetaminophen from
constipation (Vallerand, all sources does not exceed
2017). maximum daily limits.
Common side effects:
headache, insomnia,
anorexia, nausea, vomiting
(Vallerand, 2017).
Artificial Tears 1 drop opthalmic qid Dry eyes in both eyes Burning, irritation, redness If a patient experiences
discomfort with this product,
it would be worthwhile to try
some of the competitors
(Chaudhary, 2013)

Aspercreme 10% topical qd To decrease pain of Rash, itching/swelling Avoid eyes, mouth, nose,
(Trolamine muscles and joints (tongue/throat), severe mucous membranes, and
Salicylate) dizziness, trouble breathing wounds. Consult provider if
(Vallerand, 2017) area becomes irritated
(Vallerand, 2017).
81 mg oral qd Treatment for atrial EENT: tinnitus. GI: GI Patients who have asthma,

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Aspirin fibrillation. BLEEDING, dyspepsia,
epigastric distress, nausea,
abdominal pain, anorexia,
hepatotoxicity, vomiting.
Hemat: anemia, hemolysis.
Derm: rash
(Vallerand, 2017).
25 mg oral BID Treatment for CNS: dizziness, fatigue,
Carvedilol hypertension weakness, anxiety,
depression, drowsiness,
insomnia, memory loss,
mental status changes,
nervousness, nightmares.
EENT: blurred vision, dry
eyes, intraoperative floppy
iris syndrome, nasal
stuffiness. Resp:
bronchospasm, wheezing.
CV: BRADYCARDIA, HF,
PULMONARY EDEMA.
(Vallerand, 2017)
1 drop opthalmic qd Treatment for glaucoma, Angioedema, bronchosasm,
Cosopt treats elevated agranulocytosis, Stevens-
(dorzolamide) intraocular pressure Johnson syndrome,
conjuctivitis, blurred vision,
photophobia (Vallerand,
allergies, and nasal polyps or
who are allergic to tartrazine
are at an increased risk for
developing hypersensitivity
reactions. Pain: Assess pain
and limitation of movement;
note type, location, and
intensity before and at the
peak after administration.
Side effects: nausea,
vomiting, anemia, abdominal
pain (Vallerand, 2017).
PO: Take apical pulse before
administering. If 50 bpm or if
arrhythmia occurs, withhold
medication and notify health
care professional
Administer with food to
minimize orthostatic
hypotension.
(Vallerand, 2017)
Since dorzolamide is a
sulfonamide derivative, it
should not be used in patients
with sulfonamide
hypersensitivity. Dorzolamide
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 2017)
50 nasal BID Treatment for sinusitis CNS: headache. EENT:
Flonase mcg epistaxis, nasal burning,
(Fluticazone) nasal irritation,
nasopharyngeal fungal
infection, pharyngitis. GI:
nausea, vomiting (Vallerand,
2017)
110 inhalation BID Treatment of mild CNS: headache, dizziness.
Flovent (HFA) mcg asthma EENT: dysphonia,
hoarseness, oropharyngeal
fungal infections, nasal
stuffiness, rhinorrhea,
sinusitis. Resp:
bronchospasm, cough, upper
respiratory tract infection,
wheezing. GI: diarrhea
is primarily excreted by the
kidney, with a prolonged
terminal half-life. Use of
dorzolamide is not
recommended in patients with
renal impairment (Vallerand,
2017).
Monitor degree of nasal
stuffiness, amount and color
of nasal discharge, frequency
of sneezing. Patients on long-
term therapy should have
periodic otolaryngologic
examinations to monitor nasal
mucosa and passages for
infection or ulceration.
Monitor for signs and
symptoms of hypersensitivity
reactions (rash, pruritis,
swelling of face and neck,
dyspnea) periodically during
therapy (Vallerand, 2017).
Do not confuse Flovent with
Flonase. After the desired
clinical effect has been
obtained, attempts should be
made to decrease dose to
lowest amount required to
control symptoms. Gradually
decrease dose every 2– 4 wk
as long as desired effect is
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 (Vallerand, 2017) maintained. If symptoms
return, dose may briefly
return to starting dose
(Vallerand, 2017).

2.5 inhalation BID Maintenance therapy of CNS: dizziness, headache, Instruct patient in proper use
Ipratropium- mg reversible airway nervousness. EENT: blurred of inhaler, nebulizer, or nasal
Albuterol obstruction due to vision, sore throat-nasal spray and to take medication
COPD only, epistaxis, nasal as directed. Take missed
dryness/irritation. Resp: doses as soon as remembered
bronchospasm, cough. CV: unless almost time for the
hypotension, palpitations. next dose; space remaining
(Vallerand, 2017). doses evenly during day. Do
not double doses. Advise
patient that rinsing mouth
after using inhaler, good oral
hygiene, and sugarless gum
or candy may minimize dry
mouth. Health care
professional should be
notified if stomatitis occurs or
if dry mouth persists for more
than 2 wk (Vallerand, 2017).
20 mg oral qd Edema due to heart CNS: blurred vision, Do not confuse Lasix with
Lasix failure, hepatic dizziness, headache, vertigo. Luvox. If administering twice
(Furosemide) impairment or renal EENT: hearing loss, daily, give last dose no later
disease. Hypertension. tinnitus. CV: hypotension. than 5 pm to minimize
GI: anorexia, constipation, disruption of sleep cycle. IV
diarrhea, dry mouth, route is preferred over IM
dyspepsia route for parenteral
(Vallerand, 2017) administration.
(Vallerand, 2017)
Levothyroxine 50 oral qd Treatment for CV: angina pectoris, Administer as a single dose
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 mcg hypothyroidism arrhythmias, tachycardia. with a full glass of water,
GI: abdominal cramps, preferably before breakfast
diarrhea, vomiting. Derm: to prevent insomnia. Initial
sweating (Vallerand, 2017). dose is low, especially in
geriatric and cardiac patients.
Dose is increased gradually,
based on thyroid function
tests. Side effects: sweating,
diarrhea, vomiting
(Vallerand, 2017)
Modafinil 100 oral qd Hypersomnia, treatment CNS: headache, amnesia, Monitor alertness in patients
mcg of obstructive sleep anxiety, cataplexy, with narcolepsy; document
apnea confusion, depression, the frequency and duration
dizziness, insomnia, of sleeping episodes to help
nervousness. EENT: rhinitis, determine the effects of drug
abnormal vision, amblyopia, therapy. Be alert for signs of
epistaxis, adverse changes in mood and
pharyngitis. Resp: dyspnea,
behavior, including anxiety,
lung
confusion, nervousness,
disorder. CV: arrhythmias,
chest pain, hypertension, depression, or memory loss.
hypotension, syncope, Report these signs to the
vasodilation. physician. Assess heart rate,
(Vallerand, 2017) ECG, and heart sounds,
especially during exercise
(Vallerand, 2017)
0.4 sublingual PRN, up to Treatment for chest pain CNS: dizziness, headache, Tablet should be held under
Nitroglycerin mg 3 times apprehension, restlessness, tongue until dissolved. Avoid
within 15 weakness. EENT: blurred eating, drinking, or smoking
minutes vision. CV: hypotension, until tablet is dissolved.
tachycardia, syncope. (Vallerand, 2017)
(Vallerand, 2017)
0.4 oral qd Treatment for urinary CNS: dizziness, headache. May cause dizziness. Advise
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Tamsulosin mg retension EENT: rhinitis. CV: patient to avoid driving or
orthostatic hypotension. other activities requiring
(Vallerand, 2017) alertness until response to
medication is known.
Caution patient to change
positions slowly to minimize
orthostatic hypotension
(Vallerand, 2017)
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time- Nursing or interprofessional Provide reason why Was goal met? Revise
specific, reasonable, and interventions. intervention is the plan of care
attainable. indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)

Fatigue related to physical deconditioning as evidence by sleep apnea and sleep pattern.
This has been selected as a nursing diagnosis because fatigue is a concern for physiological needs, which is the first tier in Maslow’s Hierarchy
of Needs.
Patient will employ K.N. will identigy 1. Prevent unnecessary 1. Using energy- Goal met.
measures to prevent and measures to prevent or fatigue; for example, conserving
modify fatigue. modify fatigue, before avoid scheduling 2 techniques avoide 1. client prevented
discharge. energy-draining overexertion and unnecessary
(Phelps, Ralph, & Taylor, processes on same potential for fatigue.
2017). (Phelps, Ralph, & Taylor, day. exhaustion. 2. Client
2017). 2. Establish regular 2. Getting 8-10 hrs. established
sleeping pattern. of sleep nightly regular 8-10
3. Structure patient’s helps reduce fatigue hour sleeping
environment; for 3. This encourages routine
example, set up compliance with 3. Client’s

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 daily schedule based treatment regimen. environment was
on patient’s needs structured, daily
and desires (Phelps, Ralph, & Taylor, schedule was set.
(Phelps, Ralph, & Taylor, 2017). (Phelps, Ralph, & Taylor,
2017). 2017).

Secondary Nursing Diagnosis:

Risk for impaired physical mobility related to musculoskeletal (lower extremity) weakness.
This has been selected as the secondary diagnosis because physical mobility is a concern for physiological needs, which is the first tier in
Maslow’s Hierarchy of Needs.
Patient will maintain Patient will show no 1. Perform ROM exercises 1. this prevents joint Goal met.
muscle strength and joint evidence of comlications, to joints, unless contractures and muscular 1. Patient performed ROM
ROM. such as contractures, contraindicated, at least atrophy. exercises to joints
venuos stasis, thrombus once every shift. Progress 2. patients with history of 2. patient’s daily evidence
formation, skin from passive to active, as neuromuscular disorders of immobility was
breakdown, and tolerated. or disfunction may be monitored
hypotention pneumonia 2. monitor and record more prone to developing
by discharge. 3. patient was refered to
daily any evidence of complicaitons. physicl therapist for
immobility complications 3. To help rehabilate development of mobility
(Phelps, Ralph, & Taylor, (such as contractures, musculoskeletal deficits regimen.
2017). venous stasis, thrombus
pneumonia, and UTI). (Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,
3. refer patient to physical 2017). 2017).
therapist for development
of mobility regimen

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 (Phelps, Ralph, & Taylor,
2017).

Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

References
Chronic kidney disease. (n.d.). Retrieved from http://www.kidneyfund.org/kidney-disease/symptoms/
Haroun, M. K., Jaar, B. G., Hoffman, S. C., Comstock, G. W., Klag, M. J., & Coresh, J. (2003, November 01). Risk Factors for
Chronic Kidney Disease: A Prospective Study of 23,534 Men and Women in Washington County, Maryland. Retrieved from
https://jasn.asnjournals.org/content/14/11/2934.short
Matovinović, M. S. (2009, April 20). 1. Pathophysiology and Classification of Kidney Diseases. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975264/
Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:
Wolters Kluwer.
Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.

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