Patient's Initials _JD_______

COMMUNITY COLLEGE OF RHODE ISLAND

Student's Name Mary Prefontaine_
Medical Diagnosis ____Urinary tract infection, dehydration, delirium, acute renal failure______NURSING CARE PLAN
Date_10/22/2012_____
NANDA
NURSING
DIAGNOSIS
(WITH
ETIOLOGY /RISK
FACTORS)
Risk for
ineffective renal
perfusion: r/t
urinary tract
infection

Defining
Characteristics
Subjective:
I dont have
pain, I go
number one in
the morning and
late in the
afternoon

Objective:
Lab results were
RAC(08/04)

NOC BASED PATIENT

OUTCOME
AND MEASUREMENT SCALE
NOC Label: Kidney
Function
Scale: B
Patient Outcome:
Maintain serum
electrolytes within normal
limits.
BUN- 17-18mg/dL
Creatinine- 0.4-1.5 mg/dL

Initial Rating: 3 End

Rating: 4

NIC BASED INTERVENTIONS

NIC Label(s): Fluid/Electrolyte
Management, Laboratory
Data Interpretation
Individualized Interventions:
1.) Monitor vital signs.
Compare blood pressure to
patients normal range.

2.) Monitor

for changes in
mental status.

Date:
10/22/12Date:10/27/12
Time:
_0930_Time:0930____
Evaluative Statement:
Improve lab results within
normal limits.
Pt lab results are
improving.
Goals partially met
continue with plan of
care.

3.) Measure intake and output

on a regular basis. Calculate
intake against the output to
monitor fluid status.

4.) Monitor laboratory data as

ordered or per protocol.

RATIONALES

1.) Long-term
hypertension can cause
decreased renal
perfusion; it also can be a
symptom of decreased
renal function.

2.) Changes in mental

status from impaired
renal function can range
from seizures, confusion,
difficulty in concentration,
and coma as the result of
uremic toxins and
electrolyte imbalances
that can cause
encephalopathy.

3.) Oliguria and or anuria

are signs of acute renal
failure. Intake greater
than output is a sign of
fluid retention and renal
insufficiency which may
be caused by ineffective
renal perfusion.

APPROVED: 05/16/02; 03/20/03: 08/04

REFLECTION/SELF
ASSESSMENT
I found this care
plan to be a little
challenging
because many of
the nursing
diagnosis could
apply. I chose this
particular one
because I thought it
encompassed most
of his medical
diagnosis,
especially safety.
Also not knowing
about the specific
labs was
frustrating.
Caring for this
patient was
challenging
because the
medications he is
on affect his
physical mobility,
i.e. Uncontrollable
hand shaking. This
increases the
difficulty for him to
feed himself.
Also he wants to

not with in
normal range.
BUN-57
Creatinine-1.3
(toward the
high
limit=dehydratio
n)

Laboratory data could include

BUN, serum creatinine, serum
and urine electrolytes,
calcium, phosphatase,
complete blood count, urine
total protein, albumin,
alkaline phosphatase, and
urinalysis. Report
abnormalities to attending
provider
5.) Monitor for edema.

RAC(08/04)

4.) The laboratory studies

are used in the diagnosis
and monitoring of renal
insufficiency and renal
failure. Monitoring these
labs will help direct
therapy.

5.) Edema may be

present with increased
fluid retention due to
impaired renal function
related to decrease renal
perfusion.

APPROVED: 05/16/02; 03/20/03: 08/04

talk with his

daughter but she is
not on the contact
list and his
granddaughter has
not answered his
calls. No one has
been up to see him
in several weeks.

MEASUREMENT SCALES USED IN NOC *

Sca

le
A

Severely compromised

Substantially compromised

Moderately compromised

Mildly compromised

Not compromised

Severe deviation from normal

Substantial deviation from normal

Moderate deviation from normal

Mild deviation from normal

No deviation from normal

range

range

range

range

range

Not adequate

Slightly adequate

Moderately adequate

Substantially adequate

Totally adequate

10 and over

7-9

4-6

1-3

None

Extensive

Substantial

Moderate

Limited

None

None

Limited

Moderate

Substantial

Extensive

Never positive

Rarely positive

Sometimes positive

Often positive

Consistently positive

Very weak

Weak

Moderate

Strong

Very strong

Never demonstrated

Rarely demonstrated

Sometimes demonstrated

Often demonstrated

Consistently demonstrated

Severe

Substantial

Moderate

Mild

None

Poor

Fair

Good

Very good

Excellent

Not at all satisfied

Somewhat satisfied

Moderately satisfied

Very good

Excellent

Consistently demonstrated

Often demonstrated

Sometimes demonstrated

Rarely demonstrated

Never demonstrated

* Johnson, M., & Maas, M. & Moorhead, S., (2004), Nursing Outcomes Classification (NOC), (3 rd ed.), St. Louis: Mosby, p. 44-48

RAC(08/04)

APPROVED: 05/16/02; 03/20/03: 08/04