Question

Synopsis

This case involves follow-up care related to hypovolemic acute renal failure in a 68-year-old male. The patient is at risk for falls because of an inability to maintain balance. He lives in a split-level home in which the kitchen and bedroom are on different levels.

Home Medications

Albuterol (90 mcg) 2 puffs every 4 hours as needed

Allopurinol 300 mg orally daily

Digoxin 0.125 mg orally daily

Levothyroxine 0.1 mg orally daily

Enalapril 10 mg orally daily

Nebivolol 5 mg orally daily

Omeprazole (Prilosec) 40 mg daily orally

Warfarin 2 mg orally daily

Learning Stimulus

Develop two priority nursing diagnoses for this patient (NANDA).

Develop at least three essential patient outcomes (NOC).

Develop at least three patient interventions (NIC).

Answer 1

Nursing Diagnosis :

No.1 . Fluid volume deficit related to over diuresis secondary to acute renal failure as evidenced by high pulse, low blood pressure, dehydration, fatigue, weakness.

No. 2. Risk for fall related to fatigue weakness Secondary to hypovolemia

Patient outcome:

No.1. To maintain fluid volume in a functional level.

No.2. Maintain normal blood pressure, pulse and temperature .

No.3. Patient will be able to maintain Active of Daily living by Himself .

Patient Intervention :

No.1. Assess the client’s Heart Rate and Blood Pressure , including peripheral pulses.Monitor oxygen saturation and arterial blood gasses.Assess for any changes in the level of consciousness. Assess urine output.

( Rational : Increased arterial BP are seen in the early stages to maintain an adequate cardiac output. Hypotension happens as condition deteriorates.Pulse oximetry is used in measuring oxygen saturation. Restlessness and anxiety are early signs of cerebral hypoxia while confusion and loss of consciousness occur in the later stages. Oliguria is a classic sign of inadequate renal perfusion.)

No.2. Encourage to take fluid per oral. In severe condition administer fluid and blood replacement therapy as prescribed.

(Rational : To Maintain an adequate circulating blood volume.)

No.3. Assess general status of the patient. Educate patient about safety ambulation at home, including the use of safety measures such as handrails in splitting zone of his house Between kitchen and bedroom.Advice family members to label with bright colors ( eg.yellow or red) significant places in environment that must be easily located (e.g., stair edges)

(Rational : This is to determine the patient’s condition that may cause injury. Patient’s knowledge about his or her condition is vital to safety and recovery.)