Nursing Care Plan
Student name: Mohamed Abd-Elazeiz Elattomy
Patient's name:Mr's Gehan
Age: 40 years old
Sex:Female
Past history: She has a 16-year history of diabetes mellitus and a 7-year history of hypertension.
Diagnosis:Renal failure
Type of Diet:renal diet )limit fluids, eat a low-protein diet, limit salt, potassium, phosphorous, and other electrolytes, and getting enough
calories
Problems with renal failure :
• Shortness of breath
• Urinary retention
• Chest pain
• Headache
• Loss of appetite
• Fatigue
• Hypertention
• Edema
• Weight loss
Patient' Problem/ Objectives Nursing Intervention Evaluation
Nursing Diagnosis
Ineffective breathing Patient will maintain Assessment The goal was met.
pattern an effective breathing • Assess vital signs
pattern, • Assess level of consciousness
Related to: within • Assess the ability to mobilize secretions
• Fluid 20 minutes • Assess the position that the client
accumulation in assumes for breathing.
the lungs as evidenced by : • Monitor for diaphragmatic muscle fatigue
• Renal failure • relaxed or weakness (paradoxical motion).
• Stress breathing at a • Inquire about precipitating and alleviating
normal rate factors
Signs and symptoms: and depth • .Observe for retractions or flaring of
• Flaring nose • absence of nostrils
• Using abdominal dyspnea. • Evaluate nutritional status (e.g., weight,
muscles albumin level, electrolyte level).
• Fatigue
• Chest retraction Intervention
during inhalation • Place the client with proper body
• Working hard to alignment for maximum breathing
get a deep breath pattern.
• Noisy breathing • Maintain a clear airwaySuction secretions,
• Chest tightness as necessary
• Instruct the client in controlled coughing
• Provide assistance during chest
physiotherapy and postural drainage
• Promote adequate gas exchange
• Assess ABG levels according to facility
policy.
• Utilize pulse oximetry to check oxygen
saturation and pulse rate.
• Note for changes in the level of
consciousness.
• Evaluate skin color, temperature, and
capillary refill; observe central versus
peripheral cyanosis.
• Administer supplemental oxygen as
indicated.
• Encourage small frequent meals and
adhere to nutritional interventions.
• Relieving anxiety and distress
• Encourage frequent rest periods and teach
the client to pace activity.
• Promote exercise interventions as
tolerated
• Give medication as prescribed.
Signature:Mohamed Abd-Elazeiz Elattomy.
Urinary retention Patient will be able to void Assessment The goal was partially met.
sufficient amounts of urine, • Assess Urinary Patterns
Within 3 days and Etiology.
Related to: • Assess the voiding
Renal failure As evidenced by pattern (frequency and
• accurately amount).
Signs and symptoms: explaining the • Compare urine output
• Inability to urinate. condition. with fluid intake
• Lower abdominal pain. • its impact on her • Palpate for bladder
• Urgent need to urinate. daily life during distension and observe
• Swelling of lower education. for overflow.
abdominal area. • counseling • Assess the availability of
sessions with toileting facilities and
healthcare barriers that affect
providers. toileting.
• Observe for cloudy or
bloody urine and foul
odor.
• Dipstick urine as
indicated.
• Measure residual urine
via postvoid
catheterization or
ultrasound.
• Determine the client’s
weight and BMI.
Intervention
• Provide the patient with
routine voiding
measures including
privacy, normal voiding
positions or the sound
of running water.
• Encourage/provide
appropriate perineal
cleansing.
• Provide appropriate
catheter care when a
catheter is present.
• Educate patients (and
family members) on
catheter care and the
importance of catheter
care if she will be
discharged home with
the catheter in place.
• Teach abdominal strain
and Valsalva maneuver.
• Give medication as
prescribed.
Signature: Mohamed Abd-Elazeiz Elattomy
High risk for Patient will • Assass vital _______________________
infection remain free signs.
from infection • Assess level
Related to: during the of
Hospitalization period of consciousness.
hospitalization • Assess risk
factors of
infection.
• Prevent risk
factors of
infections.
• Assess history
of any
previous
infection.
• Assess
immunity
status.
• Monitor and
report any
signs of
infection.
• Wash hands
before and
after any
procedure.
• Use personal
equipment
and ask her
not to share it.
• Encourage her
to eat food
high in Fe,
vitamin C,
follic acid and
B12.
• Take vaccine if
needed to
protect her
from
infection.
Signature: Mohamed Abd-Elazeiz Elattomy
