NURSING CARE PLAN

CHRONIC RENAL FAILURE WITH CKD

SUBMITTED TO SUBMITTED BY

MS CHRISTA MATHEW SHREYA PANDEY

ASSOCIATE. PROFESSOR M.SC. NURSING 2ND YEAR

SSNR 202313178
 I. IDENTIFICATION DATA

Name Mr. Altaf Khan

REG NO 356210
AGE 58 years
SEX Male
WARD Medical Intensive Care Unit
BED NO 09
DATE OF ADMISSION 3-05-25
DOCTOR’S NAME Dr . Pankog Kumar
DIAGNOSIS Chronic Renal Failure with CKD
NAME OF SURGERY Not Significant
DATE OF SURGERY Not Significant

II. Student data

Name of student Shreya Pandey

Date of care started 3-05-25
Date of care ended 15-05-25
III. HISTORY COLLECTION
Present complaints: Mr. Altaf Khan had admitted in the hospital with history of
• Dry cough for last 10-15 days
• Decrease urine out for last 15-20 days
 • Shortness of breath for last 15-20 days .
• Left side chest pain with fatigue and palpitation
• H/o periorbital swealing on B/L feet .

Patient’s Complaints during admission:

Mr. Altaf Khan came to emergency department with the chief complain of shortness of breathing associated with dry
cough, chest pain. Patient has a history of periorbital swealing or swealing in B/L feet.

Past Medical & surgical Treatments :

• No H/o DM,HTN & TB.

• No significant medical & surgical treatment.

Family history :

Mr. Altaf Khan belongs to a joint family.

• The family consists of members and maintain a healthy relationship with her family,

• There is no history of any medical condition, genetic disease and communicable disease.

• His father had problem with DM with kidney disease.

Personal history :

Ethnic background- muslin

Appearance - moderate build
Nutritional status – non vegetarian
Hygiene –poor hygiene due to disease condition
Bad habits–No bad habits

Socio-economic status :

• Mr. Altaf Khan belongs to a middle -class family, whose family income is 40,000/ month.
• He maintains a good and healthy relationship with her family and friends. ✓ He is the ownner of the
family; they live in their own house with all the basic necessities require for healthy living.
• Her family members are some educated as per his saying
Lists of problems identified:

• Shortness of breathing
• Dry cough
• Chest pain
• Decreased urine output
• Swealing on B/L feet
A. PHYSICAL EXAMINATION
1. GENERAL APPEARANCE
▪ Sensorium : Conscious
▪ Co-cooperativeness : Co-operative
▪ Gait & posture : Slower and small steps movement
▪ Activity : Patient’s activity level is decreased
▪ Nourishment : Not well nourished
▪ Body Build : Moderate
2. Anthropometric Measurement:
▪ Height : 5’2”
▪ Weight : 46kg
▪ Mild upper arm circumferences : 15cm
▪ BMI : 18.4
• Vitals:

VITAL SIGNS Findings

TEMPERATURE 101.3 ° F

PULSE 80 beats/ min

RESPIRATION 18 breaths /min

BLOOD PRESSURE 144/90 mm of Hg

 ▪ Skin :
▪ Uremic fetor (foul smell)
▪ Uremic frost on the face (deposits of tiny, white, friable, crystalline material)[1] [2]
▪ Poor skin turgor
▪ Excoriations (scratching)
▪ Localized erythema
▪ Blister
▪ Bruises
▪ Lindsey's nails (half and half nails), where proximal half of nails is white (edema) and distalhalf is pink
(normal)

HEAD TO FOOT EXAMINATION

BODY TECHNIQUE NORMAL FINDINGS ACTUAL FINDING ANALYSIS

PARTS USED
SKULL Inspection, Proportional to the size of the body, round with The skull is normocephalic and symmetrical Normal
palpation prominences in the frontal and occipital area, to the body with prominences in the frontal
symmetrical in all place and occipital area, symmetrical in all place
Skin Inspection Normal skull is smooth, on-tender and without Smooth and non-tender. Normal
masses or depression.
Scalp Inspection The scalp should be shiny, intact and without No lesions and masses found Normal
lesions or masses.
Hair Inspection Hair varies from dark black to pale brown. Dry hair, and the color is black to gray Normal
Face Inspection Oblong or round or square/heart shaped, facial Oblong. No facial movement is Not normall.
expression that is dependent on the mood or true observed. There was presence of acne Indicates impairment
feelings, no involuntary muscle, Symmetric around his forehead. of facial nerves which
facial movements. cause paralysis.
Eyes Inspection Parallel and evenly spaced symmetrical, on- Dilated pupils which is black in color and Not normal ,indicates
protruding, pink palpebral conjunctiva, and non-reacting to light. He have some altered level of
pupils black in colour, equal in size, round and discharges around the lacrimal area. consciousness.
constricts in response to light.
Eyebrows Inspection Symmetrical and evenly distributed above the Symmetrical and evenly distributed above Normal
eyelids the eyelids.
EARS Inspection Parallel symmetrical, proportional to the size of Parallel symmetrical, Not normal. Indicates
the head, bean-shaped, skin is same colour as proportional to the size of the head, bean- poor personal
the surrounding colour, clean firm cartilage. shaped, skin is same colour as the hygiene inadequate
surrounding colour, with dust accumulation selfcare primarily
on firm cartilage. caused
MOUTH Inspection Symmetrical, gums pinkish in colour, lips Symmetrical, gums slightly dark in colour Normal
margin is symmetrical, no lesion and with yellowish teeth, lips margin is
tenderness, without involuntary movement symmetrical, no lesion tenderness
BODY TECHNIQUE NORMAL FINDINGS ACTUAL FINDING ANALYSIS
PARTS USED
Skin Inspection Varies from light to deep brown, from ruddy With uniform deep brown skin colour with Not normal. The
pink to light pink, from yellow overtones to slightly elevated temperature. Poor skin client has impaired
olive, generally uniform skin temperature integrity and redness on bony prominences. skin integrity with
hyperthermia.
HAIR Inspection Thick, silky, resilient, free from Thick, oily with traces of white hairs evenly Normal
infestation, evenly distributed and distributed which covers the whole scalp
covers whole scalp and free from infestation.

CHEST/ ANTERIOR THORAX AND LUNGS:

BODY TECHNIQUE NORMAL FINDINGS ACTUAL FINDING ANALYSIS

PARTS USED
HEART Auscultation A dynamic pericardium, normal- Palpitations with elevated Not Normal. It indicates increase
rate, regular rhythm, no murmur. heart rate of 115 bpm cardiac overload due to increase blood
pressure
Barrel shape chest Not normal .

Inspection Chest is elliptical in shape with a Configuration:partially Not normal .

lateral diameter expanded
Chest expansion : Not normal
asymmetrical
Lungs Palpation Symmetrical chest expansion, Difficulty of breathing with Normal
clear breath sounds. breath sounds (bronchi)
audible even without the use of
stethoscope having the
respiration rate of 38 Bpm.

Abdomen inspection :

Size Flat
Symmetry Symmetrical

Scar No

Tenderness No

Fluid collection No

Any mass No

Lymph node Enlarged

Bowel sound 12/min

EXTREMITIES: UPPER & LOWER

Upper extremities :

 Inspection: Immobilization of all the extremities.

  Cyanosis-absent
 Cannula present over left forearm
 Range of movement- all ROM can’t be possible
 Skin and nails: skin was dry &shape of nails was normal

Lower extremities:

 Inspection: Immobilization of all the extremities.

 Range of movement- all ROM can’t be possible

 Skin and nails: skin was dry &shape of nails was normal

• CENTRAL NERVOUS SYSTEM

 MENTAL STATUS - Altered
 ORIENTATION - Disorientation
 SPEECH - unresponsive
• RESPIRATORY SYSTEM
 BREATHING SOUND - Ronchi
 COUGH - present
 AIR ENTRY - left side lung has diminished air entry
• CARDIO VASCULAR SYSTEM
  Chest pain - present
 Palpation -present
 Oedema - present (lower & upper extremities )
 Numbness - present
 Syncope – dizziness
 S1 AND S2 - Audible .
 Murmur - no
 Carotid pulse rate 78 b/min
 Varicose ulcers -no
 ABNORMAL SOUND - Nothing significant .
• GASTRO INTESTINAL SYSTEM
 PERISTALSIS - present.
 CONSTIPATION / DIARRHOEA - Absent,
 ABDOMINAL DISTENTION - Abscent .
• URINARY SYSTEM
 Frequency of urination : 2-3 times in a day (decreased)
 COLOUR OF URINE – pale yellow .
 SEDIMENTATION - Abscent
 RETENTION/ INCONTINENCE – Abscent .
 • INTEGUMENTORY SYSTEM
 ICTERUS - Absent & CYANOSIS - Absent .
 CAPILLARY REFILL - Present < 3sec .

INVESTIGATION :

BLOOD CHEMISTRY

Test Results Normal Values

ABG

pO2 25.7.mmhg 80-100 mmhg

pCo2 42.5 mmhg 35-45 mmhg

pH 7.152 7.35-7.45

HCO3 14.4mmol/L 22-28 mEq/L

Glucose HGT 105 mg/dl 75-115mg/dl

Creatinine 1.7 mg/dl 0.6-1.1mg/dl

Sodium 142 mmol/L 135-140mmol/L

Potassium 3.5 mmol/L 3.5-5.3mmol/L

Blood urea 278mg/dl 10-50 mg/dl

Uric acid 4.5mg/d 3.4-7.0mg/dl

 Serum ALT 14U/L Up to 40 U/L

Serum Alkaline Phosphate 106 U/L 39-117 U/L

Serum protein 7.0mg /dl 6-8 mg /dl

Albumin 3.5gm/dl 3.8-4.4gm/dl

S. bilirubin total 0.5mg/dl 0.2-0.8 mg/dl

Lipid profile

S.Triglycerides 133 133mg/d <200mg/dl

S.Cholesterol 105mg/dl 130-230 mg/dl

HDL 40.8 40-58.7mg/dl

LDL 36mg/dl Upto 160 mg/dl

VLDL 15mg/dl 16-32 mg/dl

BLOOD HEMATOLOGY

Test Results Normal Values

RBC 8.0 4.5-5.8 x 12/L
WBC 15,900 5000-10000/cumm
Hgb 21 14-18 x 12/L
Hct 0.62 0.42-0.52 x 12/L
Platelet count 300000 150000-450000/cumm
 Imaging test :
USG whole abdomen + KUB

I. Right kidney normal 8.4cm * 2.2 cm

II. Left kidney normal 7.5 *3.3 cm .
III. B/L kidney shows raised echogeniticity with purley defined CKD.
IV. Left kidney also shows a substantial cyst at mid pole.
V. Liver ,spleen , pancreas are normal.

TREATMENT

NAME OF Classification/ Indication Contraindication DOSE ROUTE TIME

MEDICINE Action
Generic name: Inhibits calcium ion influx Treatment of Hypersensitivity, 180mg oral BD
nifedipine across all membrane during vasospastic, cardiovascular shock,
cardiac depolarization, angina, chronic stable combination with
produces relaxation of angina, hypertension rifampicine contraindicated
coronary vascular smooth (sustained released tablets in unstable angina and after
muscle and peripheral only. resent MI severe
vascular smooth muscle, hypotension, with systolic
increase myocardial pressure less than 90 mmHg
oxygen delivery in patients decompensate heart failure
with vasospastic pregnancy and lactation
NAME OF Classification/ Indication Contraindication DOSE ROUTE TIME
MEDICINE Action
Mannitol Increases the osmotic acute oliguric renal Hypersensitivity , anuria, Adult 0.25-2 g/kg 5 IV 4X
pressure of the glomerular failure, edema, reduction dehydration, intracranial to 25% solution daily
filtrate, thereby inhibiting of intraocular pressure, bleeding. over 30 to 60 min.
reabsorption of water and excretion of certain toxic
electrolytes. substances.
Dapagliflozin SGLT2 inhibitors. This type 2 diabetes,heart ESRD / undergoing dialysis 5 mg orally OD
reduces the chances of failure .
serious complications of
diabetes and also helps
prevent CKD
Amlodipine Inhibits influx of calcium Hypertension, chronic Sick sinus syndrome; 5 mg Oral Daily
ion across cell membranes stable angina, vasospastic second or-third- degree
to produce relaxation of angina atrioventricular block
coronary vascular smooth except with a functioning
muscle decrease peripheral pacemaker
vascular resistance
Acetomenophen Inhibits the synthesis of Mild to moderate pain Previous hypertensive 325-1000mg IV every 4
prostaglandin that may Fever Product containing alcohol, to 6
serve as mediators of pain aspartame, saccharin, sugar hours
and fever. or tartrazine. needed
NAME OF Classification/ Indication Contraindication DOSE ROUTE TIME
MEDICINE Action
Atorvastatin HMG CoA inhibitors. It is hyperlipidemia and mixed active liver disease, 10 mg or 20 mg Orally Od
used to lower cholesterol dyslipidemia, pregnancy, hypersensitivity orally
and to reduce the risk of hypertriglyceridemia,
renal disease & heart primary
disease. dysbetalipoproteinemia,
homozygous familial
hypercholesterolemia,
and heterozygous familial
hypercholesterolemia
Inj. Lasix Essential for improving Edema, SC, HTN, anuria and in patients with a 40mg Iv SOS
Furosemid
urineoutput Hypermagnesemia in history of hypersensitivity
e
ACLS to furosemide.
Inj monocef Bacterial action against to treat many kinds of liver or kidney disease, 1gm Iv BD
Ceftriaxone susceptible bacteria bacterial infections, such gallbladder disease,
sodium as E. coli, pneumonia, or diabetes/bleeding problem
meningitis.
Inj Erypeg Erythropoiesis-Stimulating Cancer patients with 2000 units IV OD
Chronic Kidney Disease-
Epoetin Alpha Agents Associated Anemia, anemia, Uncontrolled
Chemotherapy-Related
hypertension, Pure red-cell
Anemia
aplasia
NAME OF Classification/ Contraindication DOSE ROUTE TIME
Indication
MEDICINE Action
Inj NahCo3 Alkalinizing Agents Congestive heart failure, 50 mEq IV over 5 Iv SOS
Metabolic acidosis,
Sodium by Cardiac Arrest, severe renal insufficiency, minutes
Hyperkalemia
carbonate edematous or sodium-
retaining states, HTN,
children with DKA, and
concurrent corticosteroid
use
Nursing process

1. Nursing Assessment
Subjective Data:
Muscular pain, cramps, hypotonia (loss of tone of muscles) and Limited range of motion.
Weakness, confusion, and fatigue.
Loss of appetite (anorexia), metallic taste, mouth ulceration.
Pleuritic pain and shortness of breath.

Objectives data :

Altered level of consciousness, seizures, and tremors.

Hypertension, Juglar venous distention, edema.

Kussmaul breathing, increased respiratory rate (tachypnea), crackles at lung bases upon auscultation.

Uremia & vomiting

2. NURSING DIAGNOSIS :

Impaired comfort related to flank pain secondary to renal ischemia as evidenced by pain scale score 7
Excess fluid volume related to inability of kidney to excrete fluid secondary to renal ischemia as
evidenced by pedal edema.
Imbalanced nutrition less than body requirement related to dietary restriction as evidenced by anorexia
Risk of electrolyte imbalance related to impaired renal function.
Risk for decreased cardiac output related to electrolyte imbalance and fluid deficit.
3. SHORT TERM GOAL
To relieve patient from pain
To maintain normal fluid volume
To maintain nutritional balance
To prevent patient from electrolyte imbalance and decreased cardiac output
NURSING CARE PLAN
 On 1st Day

NURSING NURSING GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
ASSESSMENT

Subjective data: Impaired Patient Assess general condition of To know the status of patient about Patient got relieved from
patient says that comfort related will get patient. disease condition . pain.
he is having to flank pain relief
flank pain , secondary to from
nausea renal ischemia pain Monitor vital sign and pain level To understand the base line status &
vomiting. as evidenced using pain scale. know the pain relief measures.
by pain scale
Objective data:
score 7
observed that Provide comfort measure and To provide comfort and distraction
patient have divertional therapy. form pain.
flank pain by
verbalization

Provide adequate rest to patient & To reduce pain

Administer pain relief medication

Monitor for pain that starts during Pain develops when acidic dialysate
inflow and lasts through the produces chemical irritation
equilibration phase.

Abdominal distension and strain of the

Avoid air from entering the diaphragm during infusions cause of
peritoneal cavity during infusion. Discomfort.
Monitor complaints of pain in the
shoulder blade.
Positioning modifications and light
massage may ease stomach and
general muscular pain.

Raise the head of the bed at regular Warming the solution enhances urea
intervals. Turn the patient from elimination’s efficacy through
side to side. dilating peritoneal vessels
Warm the dialysate at body
temperature before administering.
Warming the solution
enhances urea elimination’s
efficacy through dilating
peritoneal vessels
 On 2nd day

NURSING NURSING GOAL INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS
ASSESSMENT

Subjective data: Excess fluid Patient -Assess the general To know the status of Assessed the skin Patient
volume maintains condition including patient. turgidity,and colour, maintained
Patient says he related to normal skin turgidity, color normal fluid
is having edema inability of fluid -Monitor the To maintain the fluid Monitored the patient volume
on both legs kidney to volume patient weight balance . weight daily.
excrete fluid daily.
Objective data:
secondary to
observed that -Restriction of fluid
renal intake to patient. To prevent and reduce fluid Restricted of fluid intake
patient have
ischemia as overload. to 1 litre/day
pedal edema and
evidenced by
weight gain
pedal edema. -Provide care of
edematous To prevent the development Provided care of
extremities. of pressure ulcer and edematous extremities by
improve blood flow and elevation
reduce swelling.

Administered diuretics
-Administer To increase urinary Lasix as per doctors order
diuretics elimination of fluids and
medications . reduce retention and
complication.
 0n 3rd

NURSING NURSING GOAL INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS
ASSESSMENT

SUBJECTIVE Imbalanced Patient -Assess the general To collect baseline Assessed the general Patient maintained
DATA: nutrition less maintains Condition of the patient. data Condition of the normal nutritional
than body normal patient. status
Patient -Advice the patient. to To maintain
requirement nutritional
complaints that have Small and frequent nutritional status -Advised the patient. to
related to status
he is having dietary meals have Small and
anorexia restriction as frequent meals.
-Ask the patient about his To help for diet
OBJECTIVE evidenced by likes and dislikes in food Asked the patient about
planning
DATA: anorexia his likes and dislikes in
-Provide health education food
On observation on renal diet. To improve the
the patient looks patient’s knowledge -Provided health
weak and education on renal
fatigue. - Monitor input and diet.
output chart
To maintain balance
nutritional status
- Monitored input and
-Advise patient to take output chart
To maintain balance
fluid restricted diet
input output

Advised patient to take

fluid restricted diet
 On 4th

NURSING NURSING GOAL INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS
ASSESSMENT

Objective data; Risk of To Asses the laboratory value To identify the patient Assesed the laboratory Patient
electrolyte prevent as prescribed. underlying problem value as per prescribed. maintained
Observed that
imbalance patient normal
there are risk Assess and Monitor vital To rule out the signs Assessed and Monitored
related to from electrolyte
for electrolyte sign including cardiac & of dysrhythmias and vital sign including cardiac
impaired electrolyte imbalance.
imbalance due respiratory function respiratory failure. and respiratory function
renal function imbalance
unstable vital
Provide and restrict To maintain the Provided and restricted
and decreased
sodium & potassium rich electrolyte balanced sodium and potassium rich
urine output
based food. through food based food.
restriction.
Monitor input and output Monitored input and
chart. To manage and output chart hourly
prevent complication
Educate the patient & Educated the patient and
as early as possible.
family about purpose, family about the purpose,
dosage & potential side To prevent further dosage, and potential side
effects of electrolyte complication effects of electrolyte
medications medications
 On 5th day

ASSESSMENT Diagnosis Objective Planning Intervention Rational Evaluation

Objective Cues: Risk for After giving Plan Note for general debilitation, To assess aggravating After two hours
• Reddened impaired skin nursing strategies reduced mobility, changes in skin factor to skin breakdown of nursing
skin Integrity intervention the on how to and muscle mass, poor nutritional and make appropriate intervention the
• poor skin related to client relatives eliminate status and problems of self-care. intervention to it.
possibilities for
turgor impaired skin
physical will identify risk the risk
• immobility Maintain strict skin hygiene, integrity of the
friction immobilizati factors for for client is
on. impaired skin impaired using mild non-detergent soap, To prevent skin irritation
eliminated.
integrity, skin drying gently and thoroughly.
verbalize integrity. and lubricating with lotion.
understanding To reduce tissue pressure
Instruct the relative to turn the
of therapy and prevent pressure sore.
patient every two hours
regimens and
Scientific demonstrate To prevent a shearing
Explanation: behaviors and Avoid friction when changing force on the skin.
At risk for techniques to position
skin being prevent skin
To increase circulation
potentially breakdown.
Provide protection by use of and eliminate excessive
vulnerable to tissue pressure.
pads, pillows, foam mattress.
breakdown
because of
immobilizati Observe for blanched areas and Reduces likelihood of
on. give proper management. progression to skin
breakdown.
Patient health education & discharge plan on “Chronic Renal Failure with CKD ”:

HEALTH EDUCATION

DIET

▪ Advised patient to follow any instructions for eating and drinking given to you by healthcare provider.
▪ Drink less fluid, if instructed by your healthcare provider.
▪ Keep a record of everything you eat and drink.

Measure the amount of urine and stool you have each day.

Advised patient to Maintain urine output chart at home

Weight management

Advised patient to Weigh every day, at the same time of day, and in the same kind of clothes and to keep a daily record of
daily weights.

Vital sign record

Advised patient to monitor blood pressure (BP) and to keep a record of results. Advised him to bring the record to his
follow-up appointments.

Personal hygiene

Advised patient to practice good personal hygiene, to wash hands often, to bath everyday and to change clothes everyday.
Medication

Advised patient to take medicines exactly as directed and not to skip the medication

Follow up

Advised patient to go for regular follow up and need frequent blood and urine tests. These are done to monitor the
kidney function.

Discharge plan

M(medicine) • Instruct the patient relative to follow medication regimen.

E(encourage) • Encourage the relative to do some exercises like a passive range of motion in affected and
unaffected parts of the body of the client.

T(treatment) • Educate & instruct the family to monitor the blood pressure, glucose level, urine output and
pulse rate before administering medication.

H(habits) • Inform the relative the importance of proper hygiene of the patient from head to toe..

• Instruct them to turn the client every 2 hrs to avoid pressure sores.

O(ordered follow) • Inform the family of the patient to have a regular check-up for the continuity of treatment.

• Instruct the family of the patient

D(diet) • Instruct the relative to feed the client on time with nutrition food that is low in sodium, low in
cholesterol, low in fat and give citrus fruits, moderate in fluid intake and increase fiber diet to
improve health
CONCLUSION

Mr. Altaf Khan was admitted to Sharda Hospital on 3-01-24 with the complaints of Dry cough for last 10-15 days ,Decrease urine out
for last 15-20 days, shortness of breath for last 15-20 days , left side chest pain with fatigue and palpitation

H/o periorbital swealing on B/L feet, and was diagnosed with Chronic renal failure renal failure, several investigation was done. He
was on diuretics, antihypertensives and on renal diet. Psychological support and nursing management was given. Patient was supportive
and I managed interpersonal relationship with the patient. His condition has improved and urine output has increased to 1000ml/day.
He was discharged on 19/13/2022 and I advised Mr. Khan to come for follow up.
RERENCES:

1. Brunners&Suddarth’s (2008)” Textbook of Medical Surgical Nursing” (11th edition).Published by

WoltersKulwer. New Delhi. Volume-1. Pg. No: 304-316.

2. Smeltezer&Bares (2008)” Text book of Medical surgical Nursing”, New Delhi, LippincottWilliams&Winkins.P.vt.ltd.591- 592.

3. Mani MrinaliniChintamani “Lewis’s Medical Surgical Nursing” Elsevier Second south Asia Edition 2015, volume2, page no – 1420
to 1427.

4. Joyce M. black “Medical Surgical Nursing” published by Elsevier, 8th Edition volume 1, page no 685 to 689. 5.Davidson’s
Principle and Practice of Medicine, published by Elsevier 2010, 21st edition, page no -874 to 875.