care plan

Nursing Students General Students

Published

I am working on a care plan for a patient that has a Dx of acute renal failure. I have listed: Acute pain, impaired physical mobility, excess fluid volume, risk for infection, imbalanced nutrition:less than body requirements, activity intolerance, disturbed thought process, and impaired comfort. I am needing some interventions for acute pain r/t acute renal failure. I have query patient 4 hours after last dose of pain med to see if another dose is needed. What else would be good. I am having a major melt down here. It has been a really tough week. 2 exams failed:o this week. I have lost a lot of confidence in myself. any help would be greatly appreciated.

0 Votes

Do you have a care plan book? I could never have gotten thru my care plans without one. Also, your text books should have interventions as well. Do you need to list rationales?

0 Votes
Specializes in med/surg, telemetry, IV therapy, mgmt.

first of all, you cannot write a diagnosis as acute pain r/t acute renal failure because acute renal failure is a medical diagnosis and you cannot use a medical diagnosis as a related factor in your nursing diagnostic statement. the r/t (related to) part of the diagnostic statement represents the etiology, or underlying cause of the patient's pain and that is not the acute renal failure. it will be because of something else. the patient's pain must be because of damage to tissue--that is part of the definition of the nursing diagnosis of acute pain. acute renal failure does not normally cause pain. some other reason is the cause of the patient's pain. where is the location of the pain? you didn't say. this should have been something that you noted during your assessment of the patient. before you can determine any nursing diagnosis you must have done an assessment of the patient and made a list of all the abnormal findings. these become the signs and symptoms that you use to determine your nursing diagnoses. determining a nursing diagnosis also requires knowing the underlying pathophysiology of what is going on medically with the patient and how they are connected with their signs and symptoms.

there are 3 phases to acute renal failure. symptoms of acute renal failure include:

  • oliguria or anuria
  • tachycardia
  • crackles in the lungs
  • irritability, drowsiness or confusion
  • altered levels of consciousness
  • bleeding abnormalities
  • dry, itchy skin
  • dry mucous membranes
  • uremic odor to the breath

look for another reason for the pain. the only other possibility related to renal failure that i can think of might be possible swelling of the kidneys that is pressing on other internal organs and causing pain in the surrounding area. that is rare.

nursing diagnosis of acute pain - (definition): unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less tha 6 months.

related factors:
injury agents (biological, chemical, physical, biological)

defining characteristics (signs and symptoms
- this is what you develop nursing interventions for):
change in muscle tone (listless to rigid), changes in appetite, changes in blood pressure, changes in heart rate, changes in respiratory rate, coded report, diaphoresis, distraction behavior (pacing, seeking out other people and/or activities, repetitive activities), expressive behavior (restlessness, moaning, crying, vigilance, irritability, sighing), facial mask, guarding behavior, narrowed focus (altered time perception, impaired thought processes, reduced interaction with people and environment), observed evidence of pain, positioning to avoid pain, protective gestures, pupillary dilation, self-focus, sleep disturbance (eyes lack luster, beaten look, fixed or scattered movement, grimace), verbal report by patient of pain.

(page 154,
nanda-i nursing diagnoses: definitions & classification 2007-2008
published by nanda international)

links to nursing diagnosis pages on online care plan constructor websites that have nursing interventions:

i do not remember if i mentioned this in your other thread on nursing diagnoses, but there are two threads in the student forums on writing care plans that you really need to review the information in:

0 Votes
+ Add a Comment