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Nursing Care Plan

Nursing Diagnoses

- Swelling of the ankles and legs

- Excessive drowsiness, as well as fatigue (Stern, Van der Heijden & Dunkle, 2020).

- Shortness of breath

- Reduced amount of urine

- High blood pressure

- High temperature

Assessment Data (objective and subjective)

Temperature, 99.6°F; heart rate, 93 bpm, blood pressure, 126/77 mm Hg; respiratory rate, 32 breaths/min.

Interview Results

The patient has a high temperature and high blood pressure. There is shortness of breath, which is 32 breaths/min. This is proof that the patient has difficulties in the kidney.

Desired Outcomes

To maintain and ensure that there is sound cardiac output through the evidence from blood pressure as well as the heart rate within the clients' normal and healthy range.

The peripheral pulses are very robust, and they are also equal and aligning with the prompt capillary refill time.

Evaluation Criteria

The patient will be identified with kidney failure through the evidence in his/her blood pressure as well as shortness of breath. The swelling of feet and ankles is also proof that the patient has kidney failure.

Actions and Interventions

· The auscultate lung and heart sounds. They are evaluating the presence of peripheral edema, reports of dyspnea as well as the vascular congestion. S3 and S4 heart sounds with irregular heart rate, crackles, muffled tones, dyspnea, tachycardia, edema as well as jugular distension which suggests HF.

· Assessing presence as well as the degree of the patient's hypertension, I monitor the blood pressure and also postural changes, which include how the patient lies, sits, and stands. The occurrence of significant hypertension can happen because of distortions in the renin-angiotensin-aldosterone system, which is caused by renal dysfunction (Rigas, 2015).

· They are investigating the patient's report on the noting location, chest pain as well as the severity of the chest pain on a range of 0-10 scale. Sometimes, hypertension and chronic HF can result in MI. Almost 50% of all patients with kidney failure develop pericarditis as well as increasing the risk of pericardial effusion.

· They were evaluating the heart sounds, the peripheral pulses, vascular congestion, blood pressure, temperature as well as the sensorium. Positive hypotension results in narrow pulse pressure, pallor, diminished peripheral pulses, as well as rapid mental deterioration (Campbell & Ahmed, 2012).

· They are assessing the activity levels of the patient and their response to activity.

· The guardians should also keep close contact and monitoring of the behavior of the patient to identify any improvement or adverse effects on medication.

Evaluation of Patient Outcomes

The patients can maintain a stable and moderate pulse rate, and they and can now undertake their daily duties in proper ways. They no longer seem to keep having shortness of breath. They can also undertake physical activities such as walking and exercising for body fitness with having shortness of breath. Their feet and ankles become normal, and their previous swelling disappears. They can walk with no difficulties or pain. They are also able to wear their footwear with no problems. The blood can be pumped throughout the body with a lot of ease, and therefore it becomes

The patients' blood pressure comes back to normal, and they are no longer at risk of experiencing further chronic high blood pressure. When the kidney’s functioning is returned to its normalcy, filtration of blood is made possible, and therefore, the vessels that carry the blood are made clear, and the passage of blood is made easy. The heart also receives pure blood, and therefore it can efficiently pump it through the body.

References