NANDA Nursing Diagnosis

Suggestion on using NANDA Nursing Diagnosis Acute Pain: Distinguish between acute pain Nursing diagnosis with the chronicles pain Nursing diagnosis. One of the two sets is that diagnosis of a painful time. ONSET acute pain is less than 6 months, while the painful chronicles ONSET it is more than 6 months.  If you only have two diagnoses to indicate, pain is acute pain and chronic pain. Thus, there is no automatic diagnosis Crashes feel comfortable or feel comfortable painful chronic pain.

Definition Nursing Diagnosis for Acute Pain:

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Nursing Outcomes Client Will:

• Report pain is relieved / controlled.
• Follow prescribed pharmacological regimen.
• Verbalize methods that provide relief.
• Demonstrate use of relaxation skills and diversion activities as indicated for individual situation.

Nursing Priority Nursing Diagnosis for Acute Pain

• To assess etiology/precipitating contributory factors:
• evaluate client’s response to pain:
• assist client to explore methods for alleviation/control of pain

Sample Clinical Applications using Nursing Diagnosis for Acute Pain:

Traumatic injuries, surgical procedures, infections, cancer, burns, skin lesions, gangrene, thrombophlebitis/pulmonary embolus, neuralgia

Nursing diagnosis Diabetes mellitus. Diabetes mellitus

Focused Nursing assessment For Diabetes Mellitus

• Patient history Patients with type 2 diabetes generally report a family history of diabetes mellitus, gestational diabetes
• Skin changes, especially on the legs and feet, may represent impaired peripheral circulation
• Ask if the patient has experienced excessive thirst (polydipsia), excessive urination (polyuria), or excessive hunger (polyphagia).
• In diagnostic test at least two occasions where the fasting plasma glucose level has been greater than or equal to 126 mg/dl, random blood glucose level greater than or equal to 200 mg/dl, blood glucose level greater than or equal to 200 mg/dl 2 hours after ingestion of 75 g of oral dextrose.

Common nursing diagnosis found in Diabetes Mellitus care plans

Imbalanced Nutrition: More than Body Requirements, Fear, Risk for Injury, Activity Intolerance, Deficient Knowledge, Risk for Impaired Skin Integrity, Ineffective Coping, Deficient knowledge (diagnosis and treatment), Disturbed sensory perception: Visual, tactile, Imbalanced nutrition: Less than body requirements, Impaired urinary elimination, Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral, Risk for infection, Sexual dysfunction

Nursing diagnosis Diabetes Mellitus by nursing priority

1. Imbalanced Nutrition: Less/More than Body Requirements
2. Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
3. Impaired urinary elimination
4. Disturbed sensory perception: Visual, tactile
5. Activity Intolerance
6. Ineffective Coping
7. Sexual dysfunction
8. Fear
9. Deficient Knowledge
10. Deficient knowledge (diagnosis and treatment)
11. Risk for Impaired Skin Integrity
12. Risk for Injury
13. Risk for infection

Respiratory System

Nursing diagnosis pneumonia. Pneumonia, acute infection of the lung parenchyma that often impairs gas exchange. Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood cells escape into the alveoli. The inflammatory process causes the lung tissue to stiffen, thus resulting in a decrease in lung compliance and an increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood passes  unventilated portions of lung tissue and returns to the left atrium unoxygenated, patient begins to exhibit the signs and symptoms of hypoxemi

Focused Nursing assessment in  pneumonia care plans

• Vital sign: blood pressure,  body temperature, the pulse or rate of heartbeats, the respiration or rate of breathing
• Crackles, wheezing, or rhonchi over the affected lung area
• Dullness when you percuss
• Presence of cyanosis, and presence of dyspnea or tachypnea

Common nursing diagnosis found in pneumonia

Impaired gas exchange, Ineffective coping, Risk for deficient fluid Volume, Risk for infection Ineffective airway clearance, Acute pain, Anxiety, Hyperthermia, Imbalanced nutrition: Less than body requirements,

Nursing diagnosis for pneumonia base in nursing priority

1. Ineffective airway clearance
2. Impaired gas exchange
3. Imbalanced nutrition: Less than body requirements
4. Acute pain
5. Hyperthermia
6. Anxiety
7. Ineffective coping
8. Risk for deficient fluid volume
9. Risk for infection

Nursing Care Plans for Traumatic Amputation

Causes for Traumatic Amputation

A traumatic amputation may result from a cutting, tearing, or crushing insult involving the use of factory, farm, or power tools, or from a motor vehicle accident.

Complications for Traumatic Amputation

Hypovolemic shock and sepsis are possible complications in traumatic amputation. If reimplantation is attempted, residual paralysis may occur.

Levels of Amputation

• Below the knee
• Syme procedure
• Transmetatarsal/toe Amputation
• Hip disarticulation/extensive hemipelvectomy
• Upper extremity

Nursing assessment Nursing Care Plans for Traumatic Amputation

• Patient history reveals the type of accident that caused the amputation.
• Inspection:   partially or completely severed body lost, hemorrhage and soft tissue damage, type of wound well-defined edges and damage is local/ crush amputation, damage involves the tissue and arterial.
• Psychosocial:   patient with a traumatic amputation may be in the denial phase of grief

Traumatic Amputation Treatment

Blood loss and hypovolemic shock is the greatest immediate threat in traumatic amputation.

• Control bleeding,
• Fluid replacement with sterile normal saline or lactated ringer’s solution, colloids, and
• Blood replacement as needed.
• Reimplantation
• Early prosthesis fitting and rehabilitation.

Nursing diagnosis Nursing Care Plans for  Amputation

Common Nursing diagnosis found in Nursing Care Plans for Traumatic Amputation:

• Acute pain
• Deficient fluid volume
• Disturbed body image
• Dressing or grooming self-care deficit
• Fear
• Hopelessness
• Impaired physical mobility
• Impaired skin integrity
• Ineffective coping
• Ineffective role performance
• Ineffective tissue perfusion: Peripheral
• Risk for disuse syndrome
• Risk for infection
• Risk for post trauma syndrome

Nursing key outcomes, Interventions and patient teaching Nursing Care Plans for Traumatic Amputation

Appendicitis

Nursing Care Plans For Appendicitis, Appendicitis is an acute inflammation of the vermiform appendix, a narrow, blind tube that extends from the inferior part of the cecum just below the ileocecal valve. Although the appendix has no known function, it does regularly fill and empty itself of food. Appendicitis occurs when the appendix becomes inflamed from ulceration of the mucosa or obstruction of the lumen. If untreated, this disease is fatal.

Causes For Appendicitis

Obstruction of the vermiform appendix. Since the appendix is a small, finger-like Appendage of the cecum, it is prone to obstruction as it regularly fills and empties with intestinal contents. obstruction caused by a fecal mass, stricture, barium ingestion, or viral infection. This obstruction sets off an inflammatory process that can lead to infection, thrombosis, necrosis, and perforation.

Complications For Appendicitis

Common complication of appendicitis:

• Appendix ruptures or Perforates.
• Peritonitis.

Other complications include:

• Appendiceal abscess
• Pyelophlebitis.

Diagnostik tes

• Complete blood count
• Abdominal ultrasound
• Abdominal computed tomography (CT) scan

Nursing Assessment Nursing Care Plans For Appendicitis

Because other disorders can mimic appendicitis in sign and symptoms, diagnosis must rule out illnesses with similar symptoms: bladder infection, gastroenteritis, ileitis, colitis, acute salpingitis, tubo-ovarian abscess, diverticulitis, gastritis, ovarian cyst, pancreatitis, renal colic, and uterine disease

• Patients history of midabdominal pain as the disease process progresses, patients usually complain of a constant epigastric or periumbilical pain that eventually localizes in the right lower quadrant of the abdomen.
• The patient may also report anorexia, nausea, one or two episodes of vomiting, and a low-grade fever. Later signs and symptoms include malaise, constipation and, rarely, diarrhea.
• Inspection typically shows a patient who walks bent over to reduce right lower quadrant pain. When sleeping or lying in a supine position, he may keep his right knee bent up to decrease pain.
• Auscultation usually reveals normal bowel sounds.
• Palpation and percussion disclose no localized abdominal findings except diffuse tenderness in the midepigastric area and around the umbilicus. Tenderness in the right lowers abdominal. There may be pain in the right lower quadrant resulting from palpating the lower left quadrant (Rovsing’s sign).

Appendicitis Treatment

1. Appendectomy
2. If peritonitis develops, treatment involves GI intubation, parenteral replacement of fluids and electrolytes, and administration of antibiotics.

Nursing diagnosis Nursing Care Plans For Appendicitis

Common nursing diagnosis found in Nursing Care Plans For Appendicitis

• Acute pain
• Imbalanced nutrition: Less than body requirements
• Impaired skin integrity
• Ineffective tissue perfusion: GI
• Risk for deficient fluid volume
• Risk for infection
• Risk for injury

Nursing Key outcomes, Interventions and patients teaching Nursing Care Plans for Appendicitis

Nursing care plans for Myocardial infarction (MI)

Nursing care plans for Myocardial infarction (MI). Myocardial infarction (MI) or acute Myocardial infarction is an acute coronary syndrome, results from reduced blood flow through one or more coronary arteries, which causes myocardial ischemia and necrosis. Myocardial infarction (MI) results when myocardial tissue becomes necrotic because of absent or diminished blood supply. When myocardial tissue is deprived of oxygenated blood supply for a period of time, an area of myocardial necrosis develops, this necrosis is surrounded by injured and ischemic tissue.

The infarction site depends on the vessels involved. For instance:

• Occlusion of the circumflex coronary artery causes a lateral Myocardial infarction (MI).
• Occlusion of the left anterior coronary artery causes an anterior Myocardial infarction (MI).
• Occlusion of the right coronary artery or one of its branches causes True posterior and inferior Myocardial infarction (MI)
• Right ventricular infarctions can also result from right coronary artery occlusion, can accompany inferior MI, and may cause right-sided heart failure.
• If a thrombus partially occludes a coronary vessel, distal microthrombi may cause necrosis in some myocytes, leading to a non-ST-segment elevation MI (NSTEMI).
• If a thrombus fully occludes the vessel for a prolonged time, an ST-segment elevation MI (STEMI) usually develops.

Men are more susceptible to Myocardial infarction (MI) than premenopausal women, although incidence is rising among women who smoke and take a hormonal contraceptive. The incidence in postmenopausal women resembles that in men.

Causes for Myocardial Infarction (MI)

A Myocardial infarction (MI) results from occlusion of one of the coronary arteries. The occlusion can stem from atherosclerosis, thrombosis, platelet aggregation, or coronary artery stenosis or spasm. Predisposing risk factors include:

• Aging
• Diabetes Mellitus
• Elevated serum triglyceride, low-density lipoprotein, and cholesterol levels, and decreased serum high-density lipoprotein levels
• Excessive intake of saturated fats, carbohydrates, or salt
• Hypertension
• Obesity
• Positive family history of coronary artery disease
• Sedentary lifestyle
• Smoking
• Stress or a type a personality (aggressive, competitive attitude, addiction to work, chronic impatience).
• In addition, use of such drugs as amphetamines or cocaine can cause a Myocardial infarction (MI).

Complications for Myocardial Infarction (MI)

Cardiac complications of Acute Myocardial infarction (MI)

• Arrhythmia.
• Cardiogenic shock.
• Heart failure.
• Pulmonary edema
• Pericarditis.

Other complications for Myocardial Infarction (MI) include

• Rupture of the atrial or
• Ventricular septum,
• Ventricular wall, or valves;
• Ventricular aneurysms
• Cerebral or pulmonary emboli.
• Dressler’s syndrome can occur days to weeks after an Myocardial infarction (MI) and cause residual pain, malaise, and fever.

Typically, elderly patients are more prone to complications and death. Psychological problems can also occur, either from the patient’s fear of another Myocardial infarction (MI) or from an organic brain disorder caused by tissue hypoxia. Occasionally, a patient may have a personality change.

Nursing Assessment nursing care plans for Myocardial infarction (MI)

PATIENT HISTORY

Symptomatology is very important in diagnosing Myocardial infarction (MI). Ask about chest, jaw, arm, and epigastric pain. Remember that not all people have the “typical” chest pain; evaluate the whole clinical picture because some people may experience no pain at all. Ask about shortness of breath, racing heart rate, diaphoresis, clammy skin, dizziness, nausea, and vomiting. Note that sudden death and full cardiac arrest may be the first indication of Myocardial infarction (MI).

Patients with coronary artery disease may report increasing anginal frequency, severity, or duration (especially when not precipitated by exertion, a heavy meal, or cold and wind). The patient may also report a feeling of impending doom, fatigue, nausea, vomiting, and shortness of breath. Sudden death, however, may be the first and only indication of an Myocardial infarction (MI).

Physical Examination

• Inspection may reveal an extremely anxious and restless patient with dyspnea and diaphoresis.
• If right-sided heart failure is present, you may note jugular vein distention.
• anterior Myocardial infarction (MI), patients exhibit sympathetic nervous system hyperactivity, such as tachycardia and hypertension.
• Patients with an inferior Myocardial infarction (MI) exhibit parasympathetic nervous system hyperactivity, such as bradycardia and hypotension.
• In patients who develop ventricular dysfunction, auscultation may disclose an S4, an S3, paradoxical splitting of S2, and decreased heart sounds.
• A systolic murmur of mitral insufficiency may be heard with papillary muscle dysfunction secondary to infarction.
• A pericardial friction rub may also be heard, especially in patients who have a transmural Myocardial infarction (MI) or have developed pericarditis.
• Fever is unusual at the onset of MI, but a low-grade fever may develop during the next few days.

Diagnostic tests for Myocardial infarction (MI)

Persistent chest pain, ST-segment changes on ECG, and elevated levels of total creatine kinase (CK) and the CK-MB isoenzyme over a 72-hour period usually confirm Myocardial infarction (MI). Cardiac troponins are useful in differentiating MI from skeletal muscle injury, or when CK-MB measurements are low and a small MI has actually occurred.

Diagnostic Highlights

• Electrocardiogram
• Creatine kinase isoenzyme (MB-CK)
• Cardiac troponin I (cTnI)
• cardiac troponin T (cTnT)

Elevated homocysteine and C-reactive protein levels have been found incidentally in patients with Myocardial infarction (MI) and may indicate a newer risk factor. The practical value of these tests remains unknown. Folic acid supplementation is used as treatment for elevated homocysteine levels

Nursing diagnosis Nursing Care Plans For Myocardial Infarction (MI).

Primary Nursing Diagnosis: Altered tissue perfusion (myocardial) related to narrowing of the coronary arteryies associated with atherosclerosis, spasm, or thrombosis

Common nursing diagnosis found on Myocardial infarction (MI).

• Activity intolerance
• Acute pain
• Anxiety
• Decreased cardiac output
• Excess fluid volume
• Fatigue
• Imbalanced nutrition: Less than body requirements
• Ineffective coping
• Ineffective denial
• Ineffective sexuality patterns
• Ineffective tissue perfusion: Cardiopulmonary

Nursing outcomes for Myocardial Infarction (MI), Patients will

• Perform activities of daily living without excessive fatigue or exhaustion.
• Express feelings of comfort and decreased pain.
• Verbalize strategies to reduce anxiety and stress.
• Maintain adequate cardiac output.
• Develop no complications of fluid volume excess.
• Verbalize the importance of balancing activities, as tolerated, with adequate rest periods.
• Achieve ideal weight.
• Develop adequate coping skills.
• The patient will recognize his acute condition and accept the lifestyle changes he needs to make.
• Express feelings about changes in sexual patterns.
• Maintain hemodynamic stability and develop no arrhythmias.

Nursing interventions Nursing Care Plans for Myocardial Infarction (MI)

• Nursing Care for patients who have suffered a Myocardial Infarction (MI), Most most of them receive treatment in the coronary care unit (CCU), where they’re under constant observation for complications.
• On admission to the CCU, monitor and record the patient’s ECG readings, blood pressure, temperature, and heart and breath sounds.
• Assess pain and give an analgesic as ordered.
• Record the severity of pain, location, type, and duration of pain.
• Check the patient’s blood pressure before and after giving nitroglycerin, especially the first dose.
• Frequently monitor ECG rhythm strips to detect rate changes and arrhythmias. if any new arrhythmias are documented, if chest pain occurs, or at least every shift change or according to facility protocol.
• Obtain ECG readings and blood pressure and pulmonary artery catheter measurements, if applicable, to determine changes. During episodes of chest pain
• Watch for crackles, cough, tachypnea, and edema, which may indicate impending left-sided heart failure.
• Monitor daily weight, intake and output, respiratory rate, serum enzyme levels, ECG readings, and blood pressure.
• Organize patient care and activities to maximize periods of uninterrupted rest.
• Provide a clear liquid diet dietary until nausea subsides. A low-cholesterol, low-sodium diet, without caffeine-containing beverages, may be ordered.
• Provide a stool softener to prevent straining during defecation, which causes vagal stimulation and may slow heart rate.
• Allow the patient to use a bedside commode, and provide as much privacy as possible.
• Assist with ROM exercises.
• If the patient is immobilized by a severe Myocardial Infarction (MI), turn him often.
• Give Antiembolism stockings to prevent venostasis and thrombophlebitis.
• Provide emotional support, and help reduce stress and anxiety .
• If the patient has undergone PTCA, sheath care is necessary. Keep the sheath line open with a heparin drip. Observe the patient for generalized and site bleeding. Keep the leg with the sheath insertion site immobile. Maintain strict bed rest. Check peripheral pulses in the affected leg frequently. Provide an analgesic for back pain if needed.
• After thrombolytic therapy, administer continuous heparin as ordered. Monitor the partial thromboplastin time every 6 hours, and monitor the patient for evidence of bleeding.

Patient Teaching and Home Healthcare Guide for Patients with Myocardial Infarction (MI)

Explain procedures and answer questions for both the patient and family. Explain the CCU environment and routine. Remember that you may need to repeat explanations after the emergency situation has resolved.

• To promote compliance with the prescribed medication regimen and other treatment measures, thoroughly explain dosages and therapy. Inform the patient of the drug’s adverse reactions, and advise him to watch for and report signs and symptoms of toxicity (for example, anorexia, nausea, vomiting, mental depression, vertigo, blurred vision, and yellow vision, if the patient is receiving a cardiac glycoside).
• Explain the need to treat recurrent chest pain or Myocardial Infarction (MI) discomfort with sublingual nitroglycerin every 5 minutes for three doses. If the pain persists for 20 minutes, teach the patient to seek medical attention. If the patient has severe pain or becomes short of breath with chest pain, teach the patient to take nitroglycerin and seek medical attention right away
• Review dietary restrictions with the patient. If he must follow a low-sodium, low-fat, or low-cholesterol diet, provide a list of foods to avoid. Ask the dietitian to speak to the patient and family.
• Explore mechanisms to implement diet control, an exercise program, and smoking cessation if appropriate.
• Encourage the patient to participate in a cardiac rehabilitation exercise program. The physician and the exercise physiologist should determine the level of exercise and then discuss it with the patient and secure his agreement to a stepped-care program.
• Counsel the patient to resume sexual activity progressively. He may need to take nitroglycerin before sexual intercourse to prevent chest pain from the increased activity.
• Advise the patient about appropriate responses to new or recurrent symptoms.
• Advise the patient to report typical or atypical chest pain. Post Myocardial Infarction (MI) syndrome may develop, producing chest pain that must be differentiated from a recurrent MI, pulmonary infarction, and heart failure.
• Stress the need to stop smoking. If necessary, refer the patient to a support group.
• Be sure the patient understands all the medications, including the dosage, route, action, and adverse effects.
• Instruct the patient to keep the nitroglycerin bottle sealed and away from heat.
• The medication may lose patients potency.

Nursing Care Plans for Acute Renal Failure; Acute renal failure is a syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 ml urine/24 hours), hyperkalemia, and sodium retention (Williams & Wilkins, 2006).

Acute renal failure (ARF) is a sudden and almost complete loss of kidney function (decreased Glomerular filtration rate GFR) over a period of hours to days. Acute Renal Failure ARF manifests with oliguria, anuria, or normal urine volume. Oliguria (less than 400 ml/day of urine) is the most common clinical situation seen in Acute Renal Failure ARF; anuria (less than 50 ml/day of urine) and normal urine output are not as common. Regardless of the volume of urine excreted, the patient with ARF experiences rising serum creatinine and BUN levels and retention of other metabolic waste products (azotemia) normally excreted by the kidneys (Brunner and Suddarth,2003 ).

Acute renal failure (ARF) is the abrupt deterioration of renal function that results in the accumulation of fluids, electrolytes, and metabolic waste products. The sudden interruption of renal function resulting from obstruction, reduced circulation, or renal parenchymal disease. This condition is classified as prerenal, intrarenal, or postrenal and normally passes through three distinct phases: oliguric, diuretic, and recovery. It’s usually reversible with medical treatment. If not treated, it may progress to end-stage renal disease, uremia, and death.

Causes for Acute Renal Failure

Prerenal Failure

Prerenal conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the Glomerular filtration rate GFR.

• Volume depletion resulting from:

1. Hemorrhage
2. Renal losses (diuretics, osmotic diuresis)
3. Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

• Impaired cardiac efficiency resulting from:

1. Myocardial infarction
2. Heart failure
3. Dysrhythmias
4. Cardiogenic shock

• Vasodilation resulting from:

1. Sepsis
2. Anaphylaxis
3. Antihypertensive medications or other medications that cause
4. Vasodilation

Intrarenal Failure

Intrarenal causes of ARF are the result of actual parenchymal damage to the glomeruli or kidney tubules. Intrarenal causes result from injury to renal tissue and are usually associated with intrarenal ischemia, toxins, immunologic processes, systemic and vascular disorders.

• Prolonged renal ischemia resulting from:

1. Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
2. Myoglobinuria (trauma, crush injuries, burns)
3. Hemoglobinuria (transfusion reaction, hemolytic anemia)

• Nephrotoxic agents such as:

1. Aminoglycoside antibiotics (gentamicin, tobramycin)
2. Radiopaque contrast agents
3. Heavy metals (lead, mercury)
4. Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
5. Nonsteroidal anti-inflammatory drugs (NSAIDs)
6. Angiotensin-converting enzyme inhibitors (ACE inhibitors)

• Infectious processes such as:

1. Acute pyelonephritis
2. Acute glomerulonephritis

Postrenal Failure

Postrenal causes of ARF are usually the result of an obstruction somewhere distal to the kidney. Pressure raises in the kidney tubules eventually, the Glomerular filtration rate GFR decreases.

• Urinary tract obstruction, including:

1. Calculi (stones)
2. Tumors
3. Benign prostatic hyperplasia
4. Strictures
5. Blood clots

Pathophysiology of Acute Renal Failure

There are four clinical phases of Acute Renal Failure ARF:

Pathophysiology of Acute Renal Failure

1. The initiation period begins with the initial insult and ends when oliguria develops.
2. The oliguria period is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 ml. In this phase uremic symptoms first appear life-threatening conditions such as hyperkalemia develop.
3. The diuresis period, the third phase, the patient experiences gradually increasing urine output which signals that Glomerular filtration has started to recover. Laboratory values stop rising and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues.
4. The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory values return to the patient’s normal level. Although a permanent 1% to reduction in the GFR is common, it is not clinically significant.

Clinical Manifestations

• Prerenal decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia
• Postrenal obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis
• Intrarenal presentation based on cause; edema usually present
• Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above

Assessment and Diagnostic Findings Nursing Care Plans for Acute Renal Failure:

• Changes in urine
• Change in kidney contour
• Increased bun and creatinine levels (azotemia)
• Hyperkalemia
• Metabolic acidosis
• Calcium and phosphorus abnormalities
• Anemia

Complications

• Infection
• Arrhythmias due to hyperkalemia
• Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities
• GI bleeding due to stress ulcers
• Multiple organ systems failure

Nursing Process

Nursing Assessment Nursing Care Plans for Acute Renal Failure

• Determine if there is a history of cardiac disease, malignancy, sepsis, or intercurrent illness.
• Determine if patient has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents).
• Conduct an ongoing physical examination for tissue turgor, pallor, alteration in mucous membranes, blood pressure, heart rate changes, pulmonary edema, and peripheral edema.
• Monitor intake and output

Nursing Diagnosis Nursing Care Plans for Acute Renal Failure

Common nursing diagnosis found in Nursing Care Plans for  Acute renal failure:

1. Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention
2. Risk for Infection related to alterations in the immune system and host defenses
3. Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure
4. Risk for Injury related to GI bleeding
5. Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS)

Key outcomes nursing care plans for Hypertension Patient will:

• Remain free from complications.
• Identify appropriate food choices.
• Express that he has more energy.
• Maintain adequate cardiac output and hemodynamic stability.
• Demonstrate adaptive coping behaviors
• Comply with his therapy regimen.
• Demonstrates increased knowledge about high blood pressure , medication effects, and prescribed therapeutic activities
• Takes medications, keeps follow-up appointments

Nursing Interventions nursing care plans for Hypertension

Nursing Interventions nursing care plans for Hypertension with nursing diagnosis; Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease process

Nursing Interventions Providing Basic Education:

• Explain the meaning of high blood pressure, risk factors, and
• Explain the influences of high blood pressure on the cardiovascular, cerebral, and renal systems.
• Stresses that Hypertension can never be total cure, only control, of essential hypertension; emphasize the consequences of uncontrolled hypertension.
• Stress the fact that there may be no correlation between high blood pressure  and symptoms; the patient cannot tell by the way he feels whether blood pressure  is normal or elevated.
• Have the patient recognize that hypertension is chronic and requires persistent therapy and periodic evaluation.
• Present a coordinated and complementary plan of guidance.
  • Inform the patient of the meaning of the various diagnostic and therapeutic activities to minimize anxiety and to obtain cooperation.
  • Solicit the assistance of the patient’s spouse, family, and friends provide information regarding the total treatment plan.
  • Be aware of the dietary plan developed for this particular patient.
• Explain the pharmacologic control of hypertension.
  • Explain that the drugs used for effective control of elevated blood pressure will likely produce adverse effects.
  • Warn the patient of the possibility that orthostatic hypotension may occur initially with some drug therapy:  Instruct the patient to get up slowly to offset the feeling of dizziness, Encourage the patient to sit or lie down immediately if he feels faint
  • Alert the patient to expect initial effects, such as anorexia, light-headedness, and fatigue, with many medications.
  • Inform the patient that the goal of treatment is to control blood pressure, reduce the possibility of complications, and use the minimum number of drugs with the lowest dosage necessary to accomplish this.

• Educate the patient to be aware of serious adverse effects and report them immediately so that adjustments can be made in individual pharmacotherapy.
• Note that dosages are individualized; therefore, they may need to be adjusted because it is often impossible to predict reactions.
• Warn the patient on vasodilating drugs to use caution in certain circumstances that produce vasodilation a hot bath, hot weather, febrile illness, consumption of alcohol which may exacerbate blood pressure reduction.
• Warn patients that blood pressure is often decreased when circulating blood volume is reduced as in dehydration, diarrhea, and hemorrhage so blood pressure should be monitored closely and treatment adjusted.