Care Plan

Student: Jordyn Elwell Date: February 12, 2020

Course: NSG-320CC Instructor: Nicholle Walton

Clincial Site: Banner Boswell Client Identifier: E.S. Age: 87

Reason for Admission: E.S. was admitted on February 10 complaining of shortness of breath. When the patient was admitted her vital signs
were: blood pressure 159/112 (hypertension), heart rate 68, temperature 36.7, respirations 14, and O2 sat 96% on room air. Patient was worried
about having a seizure since she had dealt with them in the past.

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

E.S.’s primary diagnosis is stage 4 Chronic Kidney Disease. Stage 4 Clinical manifestations that E.S. present are swelling on the feet
kidney disease indicated that the person’s kidneys are no longer working and frequent urination. Common clinical manifestations include
efficiently and are severely damaged, causing the blood to not be filtered back pain, high blood pressure and anemia (American Kidney
properly (American Kidney Fund, 2019). Risk factors of this disease Fund, 2019).
include: diabetes, high blood pressure, heart disease and family history.
People that have these risk factors can try to prevent getting kidney
disease by eating well, staying active, maintaining a healthy weight and
managing the diseases such as diabetes that they might have (NIH, 2019).
Chronic kidney disease has 5 stages with stage 5 being end stage kidney
failure which leads to dialysis or a kidney transplant. It is determined
which stage the patient is in by measuring their GFR.

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 Assessment Data
Subjective Data: Patient complains of shortness of breath when admitted to the hospital. Patient also verbalizes that she is scared she will
expereince a seizure because she has had a few in the last year. Patient reports falling off a friends car when trying to help them move and hit
her head and “has been having seizures since then”, but hasn’t had one in a couple months. Today patient is feeling stronger and less weak. She
is nauseus and does not want to eat breakfast.
VS 0730 Labs: Diagnostics:
T : 36.5 BUN: 46 (high): indicates kidney disease US Retroperitoneal Renal Aorta Node: Lungs are
suboptimally expanded and the heart is enlarged in size.
BP: 181/95 Creatine: 1.78 (high): indicates kidney disease
Pulmonary vascularity is mildly crowded centerally.
HR: 76 eGFR: 25 (low): measures kidney fuction and Pnemonia positive. Hiatal hernia
RR: 16 low levels indicate low functioning

O2 Sat: 93% CO2 : 18 (low)

VS 1230 Anion Gap: 20 (high): indicates acidosis

T: 36.3 Troponin: 29 (high): indicates a possible issue

with the heart. If too high, could indicate a heart
BP: 162/84 attack
HR: 82
Sodium: 137 mmol/L (normal)
RR: 16
Potassium: 4.4 mmol/L (normal)
O2 Sat: 93%
Chloride: 100 mmol/L (normal)

Assessment: Orders:
E.S. has a current medical history that consists of seizures, congestive Latex precautions
heart failure, GERD, CKD stage 4 and fluid retention.
Sodium diet: helps manage heart failure and high blood pressure.
Neurological: Alert and oriented x4 (identifies person, place, time and Blood culture: check for WBC and RBC counts
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situation); clear speech; cooperative and pleasant; pupils are round,
equal and reactive to light; pupil size for both left and right is
approximately 3mm; eyes open spontaneously and to command;
Glascow Coma Score 15
Basic metabolic panel
Consult medication history tech: check patients past medication history
Begin tracking inputs and outputs: assess for fluid retention

Skin/Wound: skin color is appropriate for race; skin is warm and dry;
scratches/hives on back from possible allergic reaction to a medication
Respiratory: Patient is on room air; O2 sats: 92%; respiratory rate: 16;
diminished lower left and right lung sounds; clear upper left and right
upper lung sounds; no cough; unlabored respirations; no sputum.
Musculoskeletal: Patient moves upper and lower extremeties equally
and strongly with and without resistance; uses walker as assistive
device; one person assist; Morse fall risk: 45 (high risk); fall
precautions in place
Cardiac/Vascular: Cap refill less than 3 seconds on both the upper and
lower extremeties, regular heart rhythm; S1 and S2 sounds heard, no S3
or 4; radial and pedal pulses palpable 2+; lower body edema (ankles and
feet, pitting +1); no upper body edema; JVD absent
Hygiene: Bed bath and peri-care performed at 1130; performs oral care
independently; linens last changed after bed bath at 1145.
Gastrointestinal: Abdomen is round, distended and hard; normoactive
bowel sounds in all 4 quadrants; last BM reported by patient was at
home 11/11/20 and was regular color and consistency; patient is
nauseous, ate 50-75% of breakfast; low sodium diet
IV Lines/Solutions: Peripheral IV on left forearm, 22 gauge; no central
lines; no wound vacs; no drains; absent AV fistulas
Genitourinary/Renal: Pt voids urine with no pain and no difficulties;

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urine is clear and dark yellow
Pain/Nausea: Pt denies pain; nausea since waking up this morning but
is still able to eat a little bit and get up

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 Medications
ALLERGIES:
Latex, levaquin (joint pain), statins

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
G:Amlodipine 5 mg PO Daily The patient is taking this Dizziness, fatigue, peripheral Monitor blood pressure
B: Norvasc medication to help manage her edema, bradycardia, and pulse before and
hypertension by inhibiting the hypotension, nausea, flushing during the therapy and
transport of calcium which (Vallerand, 2019). be aware of
helps vasodilate the blood hypotension and
vessels bradycardia. Monitor
inputs and outputs
during therapy and
daily weights.
Aspirin 81 mg PO Daily The patient is taking this to thin Tinnitus, epigastric distress, Assess for rash
the blood to prevent blood clots nausea, abdominal pain, (Stevens-Johnson
while in the hospital. anorexia, vomitting, Stevens- syndrome) and
Johnson syndrome, increased discontinue if it is
bleeding time, anemia, severe or if fever is
anaphylaxis (Vallerand, 2019). present too. Monitor
hematocrit to assess for
GI blood loss. Take
with a full glass of
water.
G: Carvedilol 3.125 mg PO BID The patient is taking this to Dizziness, fatigue, weakness, Teach patient to sit
B: Coreg manage heart failure and anxiety, depression, memory up/stand up slowly to
hypertension. loss, pulmonary edema, prevent orthostatic
nightmares, dry eyes, hypotension. Monitor
nervousness, mental status blood pressure and
changes, bronchspasms, pulse frequently.
wheezing, angioedema, Monitor inputs, outputs
anaphylaxis (Vallerand, 2019). and daily weights to
assess for fluid
overload. May increase
blood glucose to rise.
Have patient avoid
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 driving during the
therapy because it
causes drowsiness. Do
not abuptly stop taking
this medication.
G: Famotidine 20 mg PO Daily The patient is taking this Confusion, dizziness, Assess for epigastric or
B: Pepcid medication to help prevent hallucinations, headache, abdominal pain. Assess
stomach ulcers and treat the constipation, aplastic anemia, for blood in the stools.
patient’s GERD by inhibiting thrombocytopenia, erectile Assess for confusion,
gastric acid secretion. dysfunction (Vallerand, 2019). especially in elderly
patients.
G: Folic Acid 1 mg PO Daily The patient is taking this Rash, irritability, difficulty Assess for
B: Folate supplement to prevent anemia sleeping, confusion, fever megaloblastic anemia
and to help with deficiencies. (Vallerand, 2019). (fatigue, weakness,
dyspnea) before and
during therapy. Monitor
blood counts
G: Heparin 5,000 units SQ Q12H The patient is taking this Alopecia, bleeding, osteoporosis, Assess for signs of
B: Hepalean medication to prevent blood fever, hypersensitivity, heparin- bleeding and
clots by inhibiting thrombus induced thrombocytopenia, hemorrhage. Notify
formation. anemia, pain at injection site HCP if patient falls.
Monitor for
hypersensitive reactions
(chills, fever). Assess
injection site for pain or
swelling. Monitor
platelet count
throughout therapy and
watch for
thrombocytopenia.
Watch for
hyperkalemia.
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.

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Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Excess fluid volume related to sodium retention as evidenced by edema and hypertension.
Rationale: Excess fluid retention could indicate how well the kidneys are filtering the blood. A lot of fluid retention could
mean the patient might be nearing end stage kidney failure and might need to be considered for dialysis.
Display appropriate urinary 1. Helps the nurse monitor Patient’s blood pressure
Input and output within range of output with normal vital signs 1. Accurately record inputs and kidney function (observe urine normalized by the end of the
each other outputs. Don’t forget about characteristics and amount) and day and her inputs and
hidden fluids such as IV meds) fluid retention. outputs were congruent.
2. Weigh the patient daily at the 2. This is one of the best ways to
same time assess for fluid status (more
3. Monitor serum sodium than 0.5 kg/mg suggests
retention)

3. Hyponatremia could mean

fluid overload (Phelps, Ralph &
Taylor, 2017).

Secondary Nursing Diagnosis:

Constipation related to decreased activity as evidenced by change in stool pattern.
Rationale: Constipation could be a reason her abdomen is distended and hard. It is important for the patient to have a BM
to relieve the patient of discomfort and clear any obstructions.
Patient will have a BM by the 1. Assess hydration status 1. Osmotic medicatons can Patient had a bowel
Bowel movement end of the day 2. Educate patient on the cause dehydration and if the movement by the end of the
connection of activity level patient is not hydrated they day with the help of PRN
and constipation could become constipated medications.
3. Give PRN medications 2. Regular exercise
stimulates peristaltic
movement
3. Stool softeners would help
the patient have a BM
(Phelps, Ralph & Taylor,
2017).

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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.”

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 References
American Kidney Fund. (2019). Stages of chronic kidney disease (CKD). Retrieved from https://www.kidneyfund.org/kidney-
disease/chronic-kidney-disease-ckd/stages-of-chronic-kidney-disease/#stage-4-ckd
NIH. (2019). Chronic kidney disease (CKD). Retrieved from https://www.niddk.nih.gov/health-information/kidney-disease/chronic-
kidney-disease-ckd
Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Sparks & Taylors nursing diagnosis reference manual. Philadelphia: Wolters

Kluwer Health

Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Daviss drug guide for nurses. Philadelphia, PA: F.A. Davis Company.