Diagnosis help and priority with renal failure

lifelearningrn, BSN, RN · Feb 6, 2014

Ineffective tissue perfusion (renal) and excess fluid volume are a couple. Do you have a good nursing diagnosis book? That is your best bet for the more difficult cases.

tnstudent21 · Feb 6, 2014

Yes I have three nursing diagnosis books. I thought about the ineffective tissue perfusion but I have no data to support that other than elevated BUN and creatinine levels, do you think that would be enough? The intake is pretty much equal to the output, so I can't use excess fluid volume unless I used it as an at risk for.

Esme12, ASN, BSN, RN · Feb 6, 2014

Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Tell me your assessment...what are the vital signs? Is there edema? What does this patient need? Is this patients confusion new? or related to the elevated BUN? Here is a few off the top of my head

Acute Confusion
Chronic Confusion
Impaired physical Mobility
Acute Pain

tnstudent21 · Feb 6, 2014

No edema is present. Vital signs: BP 132/74. RR-12, HR-65, Temp-96.5, O2 saturation 94% on room air. I do not know if the confusion is r/t to the increase in BUN, this was a one day rotation for me. Thank you for the advice, it seems I am on the right path because that's how I've been doing my care plans. I put all my abnormal data into columns based on what body system they affect, relate them to their medical diagnosis (if applicable) then go from there. It's just that in this case, I'm stumped. I can use the acute pain, but my instructor said that the renal issue was more pressing (because it interferes with homeostasis). I just can't think of a renal-related nursing diagnosis that aligns with the info I have

Esme12, ASN, BSN, RN · Feb 7, 2014

a renal patient is at risk for a lot....the confusion, electrolyte imbalance, fluid overload, cardiac output, pulmonary edema(impaired gas exchange). If she wants to look at risk for diagnosis.

what was the BUN and Creat?

tnstudent21 · Feb 7, 2014

The instructor just pointed me toward the renal system as the primary concern-she did no specify if she wanted an actual or an at risk for diagnosis. I would prefer an actual diagnosis though, but with the absence of an urinary analysis and kidney scan, thats kinda hard. BUN was 37 and creatinine was 1.8

Esme12, ASN, BSN, RN · Feb 7, 2014

The instructor just pointed me toward the renal system as the primary concern-she did no specify if she wanted an actual or an at risk for diagnosis. I would prefer an actual diagnosis though, but with the absence of an urinary analysis and kidney scan, thats kinda hard. BUN was 37 and creatinine was 1.8

Not high enough for confusion....hummmm.......this can also be dehydration.

If you look at you out put for 20 hours....the patient is only putting out 25cc/hr which in indicative of poor end organ perfusion which should be 30cc/hr. Indicating a fluid volume disturbance. So I would say fluid volume deficit if the I/O is relatively even...this may help. How the body conserves volume

tnstudent21 · Feb 7, 2014

I was thinking of that also, however, skin turgor and mucour membranes are both excellent. Nothing to indicate dehydration. This is a tough call, I need more info than what I have. I think I'll just knock something out on paper and turn it in, we aren't graded on these. I hate to do that, but the feedback I'll get ( in red ink pen) should be helpful.

Esme12, ASN, BSN, RN · Feb 7, 2014

right but your kidney functions aren't I see grntea here maybe she can brain storm

tnstudent21 · Feb 7, 2014

Hopefully she can! By the way, thank you guys for all the help you have given me. I really, really appreciate it.

nurseprnRN, BSN, RN · Feb 7, 2014

Yes I have three nursing diagnosis books. I thought about the ineffective tissue perfusion but I have no data to support that other than elevated BUN and creatinine levels, do you think that would be enough? The intake is pretty much equal to the output, so I can't use excess fluid volume unless I used it as an at risk for.

1) If I've said it once, I've said it a thousand times: The idea that "risk for" diagnoses are somehow less real or less serious or less genuine is BOGUS. There is a whole section in the NANDA-I 2012-2014 (the only authoritative work on nursing diagnosis) on safety, and almost all the NDs there are "risk for.." ones. Nursing's most important charge is to keep patients safe. Somebody want to tell me why that's not a priority?

Urine appears slightly concentrated w/ 500 mL output in last 20 hours (intake roughly the same). BUN elevated to double normal level, creatinine elevated slightly. Hemoglobin and Hemtocrit decreased also. Electrolytes all in balance except calcium, which is low. Pt. is not dehydrated, no signs of edema.

Highly concentrated urine, elevated BUN, and oliguria (500cc/20 hours) -- of course he's dehydrated. Elevated creatinine is an indication of renal failure, or at least renal unhappiness, likely related to decreased blood flow to those ancient kidneys as well as to just, well, ancient kidneys. Wouldn't YOU be dehydrated if you took in only about two cups of fluid in that period of time?

2) There is no nursing diagnosis for "ineffective renal perfusion." So that is out. No, there isn't. You can look it up. You may find it in outdated "nursing diagnosis handbooks" (i.e., based on old editions of NANDA-I, like before 2012), but not in the current list.

"Risk for ineffective renal perfusion" is defined as, "At risk for a decrease in blood circulation to the kidney that may compromise health." It has a number of risk factors, to be found on page 238 of your NANDA-I 2012-2014. "Advanced age" is a listed risk factor for this diagnosis. So is "hypovolemia," though your nursing assessment so far apparently doesn't include vital signs, assessment of mucous membranes, jugular venous distention (of lack thereof, more likely), skin turgor, how hard and dry his stools are, whether his breath sounds are dry or not (I'm betting "dry as a bone") and other measurements of hydration and fluid balance other than the fact that he has no edema (I'll bet he doesn't). Finally, a history of "hypertension" is another risk factor for this diagnosis.

If you don't have the NANDA-I 2012-2014 you are totally missing the boat on nursing diagnosis. A cursory review of the diagnosis and defining characteristics for this nursing diagnosis would have shown you a clear path.