i think one of the problems you are having here is that you are ignoring the symptoms you do have. from your post i have that the patient has the following symptoms from your assessment data:
- elevated calcium
- a wound of some sort that is draining (where is this wound?)
- urinary retention
from this list you develop your nursing diagnoses. these items are what will support the nursing diagnoses you choose.
the question of calcium and acute renal failure was discussed recently on this thread:
basically, what it says is:
one of the functions of the kidney is to eliminate phosphorous from the body. when renal failure occurs that ability is lost. the body attempts to compensate for the build up of phosphorous that starts to occur in acute renal failure by binding phosphorous with any free calcium that is available. it will pull calcium from the bone to do this. over a long term this leads to osteoporosis amongst other problems when there is chronic renal failure. calcium that is bound to phosphorus will not be detected in serum calcium lab tests. hypocalcemia in acute renal failure is inversely related to the hyperphosphatemia (calcium is low and phosphorous will be elevated). as the failing kidneys are unable to excrete phosphate, the phosphates build up and a condition called hyperphosphatemia develops. hyperphosphatemia inhibits the parathyroid hormone (pth). pth is needed to activate the renal enzyme that converts vitamin d to it's active form. this results in the failure of dietary calcium to be absorbed from the intestinal tract, so you are going to fail to capture sources of calcium from dietary replacement. in order for calcium to be released from bone, pth is required. but, since pth release is being inhibited by the elevated phosphate level, that cannot occur and results in another lost resource of calcium replacement. overall, you have hypocalcemia that is only going to be corrected by iv supplementation of calcium in the acute renal failure patient or ingestion of very high doses of oral dietary calcium replacement.
the symptoms of hypocalcemia are:
- tingling of the fingers
- tingling around the mouth and lips
- tingling of the toes
- muscle cramping
- muscles spasms and twitching (in later stages)
- hyperactive deep tendon reflexes
- positive trousseau's sign
- positive chvostek's sign
- generalized or focal convulsions
- laryngeal muscle spasms
- decreased cardiac output
- prolonged qt interval on the ekg
- all kinds of cardiac arrhythmias
- emotional instability
did your patient have any of those symptoms? possible nursing diagnoses that can be used for a patient with hypocalcemia and acute renal failure are:
- imbalanced nutrition:less than body requirements r/t deficient quantities of vitamin d and malabsorbtion of calcium from the gi track aeb hypocalcemia
- activity intolerance r/t neuromuscular irritability aeb [see symptoms of hypocalcemia in above list]
- risk for ineffective breathing pattern r/t laryngospasm [secondary to hypocalcemia]
next, what is this wound you talk about that is draining? an open wound can get a nursing diagnosis of impaired tissue integrity
. if it is infected then you also need to look at the symptoms of the infection. if there has been any fever at all you can use the nursing diagnosis of hyperthermia r/t infection
. question: is the hematuria due to a urinary track infection? you can use risk for deficient fluid volume r/t increased metabolic rate
when you have an infection of a wound that is draining or an infection of the urinary track. in both cases you are going to potentially be losing fluid and electrolytes from the wound drainage and the urinary frequency. so, another question i have is why were they doing the frequent uas on the patient? what was abnormal in the results of the uas that were being done?
hematuria can be a symptom of a uti, but it can also be a symptom of hemorrhage. so, risk for deficient fluid volume r/t loss of blood through the urinary system
is a possible nursing diagnosis that you can use.
urinary retention has it's own nursing diagnosis: urinary retention r/t
[blockage, high urethral pressure caused by a weak detrusor, inhibition of reflex arc, strong sphincter--pick one or more] aeb
[bladder distension, small frequent voiding or absence of urine output, dribbling, dysuria, overflow incontinence, residual urine, sensation of bladder fullness--pick one or more]
incontinence, if it is not overflow incontinence has several choices for nursing diagnoses:
- functional urinary incontinence
- reflex urinary incontinence
- stress urinary incontinence
- total urinary incontinence
- urge urinary incontinence
each has a specific definition, so you need to know what kind of incontinence your patient has in order to choose the correct nursing diagnosis for this.
i strongly suggest that when you are in the clinical area that you scrutinize your patient's charts. read and copy down information from the history and physical, any consults, the nursing admission assessment, er forms, doctor's progress notes, doctor's orders, all the labwork and x-rays and any evaluations that were done by other healthcare professionals such at physical therapists or dieticians. all that information can be used by you in formulating your nursing diagnoses and planning care for your care plans
as long as it's subjective or objective patient assessment even though it was done by someone else. you will just add their data to the data you will collect yourself from your own physical assessment and observations of the patient.
now, you will notice that the diagnosis of risk for deficient fluid volume
has come up a couple of times. i know you have your heart set on including it in your care plan. you can combine the related factors (the information after the "r/t") and the defining characteristics (the information after the "aeb") to make one single nursing diagnosis as long as you address all the problems together.
there are two threads in the nursing student forums on writing care plans that you should check out for help:
you will get more help for your care plans by posting your questions about them in either one of these nursing student forums rather than posting here in the general nursing discussion forum:
hope you have found this information helpful.