Diagnosis for increased BUN

  1. Greetings

    I need help figuring out a diagnosis for this patient.

    The patient has ESRD and a BUN of 46. When I researched a diagnosis, under ESRD is excess fluid volume r/t decreased urine output AEB blah blah blah.

    This patient actually has some urinary frequency and is showing signs of dehydration (increased tenting) rather than fluid volume excess, so I'll give a diagnosis of fluid volume deficit.

    Since the patient shows clinical signs of fluid volume deficit, how to I address the ESRD and increased BUN?
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  2. 10 Comments

  3. by   luckylucyrn
    How is the creatinine? And electrolytes? Most ESRD patients have some electrolyte imbalances. (at least they do when they show up in the ED). Also, renal failure doesn't always mean that the patient doesn't urinate, just that the kidneys don't filter well. Some renal failure patients can produce urine.
  4. by   Natkat
    The patient still has normal urinary output - >30 mL per hour. Electrolytes are normal except for a slightly increased potassium (5.7). He is not on dialysis. He makes urine but the BUN indicates they aren't filtering correctly.
  5. by   CritterLover
    Quote from natkat
    the patient still has normal urinary output - >30 ml per hour. electrolytes are normal except for a slightly increased potassium (5.7). he is not on dialysis. he makes urine but the bun indicates they aren't filtering correctly.

    why does the patient have a dx of esrd if he isn't on dialysis, has adeq uop, and fairly normal electrolytes? that sounds more like chronic renal insufficiency. or maybe chronic renal failure that isn't end-stage yet.

    what is his creatinine?

    bun can increase in dehydration, but there are usually other electrolyte abnormaliites.

    bun can also increase in gi bleeds (from the destruction of rbcs in the gi tract). in this case, the other electrolytes may be normal.

    really, i'm questioning the dx of esrd. this is always reserved for patients that need to be on dialysis, in my experience. that is what the "end stage" part means. did this dx come from a physician? a nephrologist, specifically?
  6. by   laurainri
    dont forget that bun indicates how much protein the pt is eating. A pt with esrd should be on a high protein, low sodium, low potassium diet with fluid restrictions. stage 3 ESRD is defined as excessive amount of metabolic waste such as uria & creatnine in blood.. tx is dialysis. we are actually having our exam on this next week and we were told that a pt with ESRD thier main nrsg diag is deficient fluid volume
    Last edit by laurainri on Apr 14, '07
  7. by   Daytonite
    The decision of which nursing diagnoses to use is based upon the symptoms the patient is having, NOT upon his medical diagnoses. This concept is clearly delineated in almost all nursing care plan books in the first chapter(s). The value of knowing a patient's medical diagnoses is to point you in the direction of possible nursing diagnoses you MIGHT be able to use so you won't be spending time searching the 188 NANDA diagnoses looking for just the right one. In other words, it narrows down your search. You still have to assure that your assessment data matches the defining characteristics listed with the nursing diagnoses you are choosing. Knowing a patient's medical diagnoses can also remind you of some of the symptoms you should be seeing in the patient in the event that you've overlooked them in your own data assessment process.

    I suspect that you are not fully understanding renal failure. There is such a thing as high output renal failure. An elevated BUN is ALSO a symptom of dehydration. It is possible for a patient with high output renal failure to become dehydrated. You tend to see high output failure in persons who have not yet completed the process of complete renal failure. You have two symptoms supporting a medical diagnosis of dehydration and a nursing diagnosis of Deficient Fluid Volume. You need to address that. You questioning about why you can't use Excess Fluid Volume lies in learning about the pathophysiology of renal disease and renal failure. What's going on with this urinary frequency? Is there a possibility that this patient has a UTI? Is he incontinent?

    So, far you've got Deficient Fluid Volume R/T failure of regulatory mechanisms secondary to ESRD AEB tenting of skin and elevated BUN.

    http://www.emedicine.com/ped/topic3086.htm - Chronic Kidney Disease
    http://www.emedicine.com/med/topic374.htm - Chronic Renal Failure
    http://www.kidneyschool.org/splash/toc.shtml - Kidney School
    http://www.nlm.nih.gov/medlineplus/kidneydiseases.html - Kidney Diseases - links to more information
    http://www.nephrologychannel.com/arf/ - Acute Renal Failure - includes information on nonoliguric renal failure

    Read up on the pathophysiology of the different types of renal failure. Review your assessment data. I'm guessing that you've missed a few things during your assessment and reading of the patient's medical record. These patients usually have multiple problems and complications going on as a result of the renal disease.
  8. by   group_theory
    Stage 3 Chronic Kidney Disease is when the Glomerular Filtration Rate (GFR) is between 30-60ml/hr. Stage 5 CKD (end-stage renal) is when it drops below 15ml/hr. You don't necessarily have to put patients who are ESRD on dialysis if they have good urine output and are asymptomatic from their azotemia because you want to try to hold off on dialysis as long as possible due to possible complications associated with hemodialysis. For most Stage 3 CKDers, they don't need dialysis unless there is a clear indication for one. It's usually management of their underlying causes, and management of their chronic kidney disease.

    You would expect increase BUN in patients with CKD. The creatine level in the blood, creatine clearance, albumin level, and also the BUN/creatine ratio will be helpful in determining what's going on. Also look at the meds ... is the patient on lasix, bumex, or other diuretics? Would that explain why you have good urinary output but still clinical evidence of dehydration?

    There are other potential causes of elevated BUN, such as lower GI bleed as another poster have mentioned. Does the patient also have CHF? Did the patient suffer a recent fall? Did the patient suddenly start an Atkens diet?
  9. by   Natkat
    "I suspect that you are not fully understanding renal failure."

    Okay, everyone, get a grip!

    I've worked in dialysis for 2 years. Believe me. I understand renal failure very, very well.

    The patient was given the diagnosis of ESRD by the PHYSICIAN. The only way I see it manifested though is through the elevated BUN. The creatinine is fine. All other electrolytes are fine except for a slightly elevated potassium, which tells me his kidney function is going donwhill.

    At the same time he has ESRD he is showing signs of dehydration. So my question was how do I address the increased BUN and diagnosis of ESRD in the face of dehydration.

    The other thing is that this is not my patient. It was someone else's patient and I don't have all the data. It's part of a group project where my portion of the project is to develop the nursing diagnoses. I was trying to explain how to prioritize the diagnoses to the class and ran into some confusing information that I wanted clarified. I didn't expect people to suggest that maybe I'm just not smart enough to figure it out. I had hoped I would have someone point me in the right direction and show me some details I might have missed.

    My mistake. Sorry.
  10. by   Daytonite
    1. I was never suggesting that you weren't smart enough to figure this all out. That thought is coming from you, not from me.
    2. The pathophysiology of a patient's disease process IS necessary to understanding the etiology of his problems and needs in determining a nursing diagnosis.
    3. You asked for help in figuring out a nursing diagnosis for this patient and that's what I gave you.
    4. I did point you in the right direction and show you some details you missed.
    5. Is it my fault you don't have all the data? This is your assignment not mine. I did read your OP over very carefully when I was answering it, copied it to a word document and picked it apart so I wouldn't miss addressing anything in it.
    6. Your question about prioritizing diagnoses was asked on another thread, not this one, and I answered that question for you too.
    I was in no way trying to belittle you and I am sorry you got that impression from my reply. I am always trying to help you and other student nurses learn this very complex thing of choosing nursing diagnoses and writing care plans. I thought that's the kind of help you were looking for.

    My mistake. Sorry. Won't happen again.
  11. by   mayfairsnitch
    i need help on how to state the nursing diagnosis for my patient:

    Infected wound on left thigh
    creatinine: 700
    liver cirrhosis
    ascites
    BP of 180/90
    respiratory rate:28 cycles/min.

    how to state the nsg diagnosis is my weakness. I need help. thanks!
  12. by   Daytonite
    Quote from mayfairsnitch
    i need help on how to state the nursing diagnosis for my patient:

    infected wound on left thigh
    creatinine: 700
    liver cirrhosis
    ascites
    bp of 180/90
    respiratory rate:28 cycles/min.

    how to state the nsg diagnosis is my weakness. i need help. thanks!
    please read the information on this thread:
    then, go through the list you posted and narrow it down to just the patient's symptoms. liver cirrhosis and ascites are medical diagnoses, not symptoms. do you have a better description of the hip wound? what are the symptoms of the infection? what are the symptoms of the cirrhosis? describe what was abnormal about the patient's abdominal assessment. ascites is not a symptom that you, as a nursing student, can use on a care plan; it is a medical condition. are there any symptoms of the high blood pressure? what was 700? i've never heard of a bun or creatinine that high. is this patient in acute or chronic renal failure? is there an underlying diabetes problem? are there any electrolytes that are out of whack?

    you cannot begin to pick out nursing diagnoses, let alone make nursing diagnostic statements until you have a clear picture of what the patients symptoms are. all care plans begin with a thorough assessment from which you isolate the abnormal data. so, post a better list so i can help you.

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