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acute renal failure care plan, Please help

Posted
12learn 12learn (New) New

Hello all,

Ok, here's the situation. My client is a 81 yrs old female who was admitted with hyperkalemia, dehydration, and acute renal failure. (labs on admission was K+8. BUN 27, Creatine 1.18)

Medical HX:

Anxiety, depression, insomia, heart dz, HTN, high cholesterol, GERD, osteoporosis, DM type 2, pressure ucler, diverticulitis, MRSA.

Abnormal ssessment findings on day 14 (day I care for her):

Vital signs: BP 138/70

Stage 4 pressure ulcer on coccyx measured 13.3cmx13.1cm

c/o pain 5/10 on right flank and buttock area

c/o being "cold" all the time

appeared tired, lethargic, weak voice,lack of energy, weak muscle strength, pedal pulses +1/+1

clostomy on abdomin,

she does not ambulate, 2 person assists.

Has a indwelling catheter

Braden scale: 12

Morse scale: 70

H&H: 10/30, RBC: 3.53, WBC: 15.3, Na: 134, Ca: 8, glucose: 130

I come up with these two nursing diagnosis:

Impaired Tissue integrity R/T altered circulation AEB 13.3cmx13.1cm pressure ucler wound on coccyx.

Fatigue R/T anemia AEB lethargic, tired, weak, Hct 29.0, Hgb, RBC 3.41.

Did I pick the right diagnosis?

I don't know if these are right and which should be my #1 priority.

I know she was admitted for acute renal failure, but right now her Creatinine, BUN, and potassium levels are all within normal range.

please help

TIA