kidney failure nursing diagnoses

[all4ofus, ASN, RN]

My patient has a primary diagnosis of acute renal failure (due to kidney stones), with diabetes type II, coronary artery disease, and hypertension, as well as COPD. She has high WBCs, low RBCs, platelets, hemoglobin, and hematocrtit. Her uric acid, BUN, and creatinine are elevated, as well as potassium and phosphorous. Total protein and albumin are low. I did her physical assessment, and VS actually appear to be under control, with 118/49, pulse 66, respirations 18. O2 sats were low (92%). Her blood sugar was 68. Her lung sounds were clear, but she has shortness of breath on exertion and appears to have labored breathing. She is afraid to lay flat - she is scared for her heart when lying flat but doesn't know why, so she sits up in bed all the time. She shifts positions frequently (all sitting up). She speaks slowly and a little slurred, and is groggy with her eyes closed, but is oriented and answers questions appropriately. Her peripheral pulses were strong and easy to find. Her output for my 8 hour shift was 425 ml; her intake was about 1120. I know her output the previous day was only 50 ml, but I can't use data from a previous shift in my care plan. I could not find any pitting edema, although she "looks" swollen to me, especially in her calves and around her face and neck (although she is obese). She denies any recent weight changes. She is nauseous and vomited once on my shift, just a small amount. No BM for 3 days. She is NPO, waiting on cytoscopy with any necessary procedures. She is on a lot of meds to reduce her BP and cholesterol, increase urine output, control her blood sugar, etc.

The problem that I am having is that I feel like I am missing the "big picture" for her nursing diagnoses. I looked at Excess Fluid Volume, but given her lack of edema and no weight gain, plus urine output within the minimum daily limits in just an 8 hour shift, I don't think I have the data to support that she has an actual fluid volume excess, and "Risk for" Fluid Volume Excess is not on the approved NANDA list we were given. I was going to use Risk for Imbalanced Fluid Volume, but the criteria for that is a pending major surgery, rather than imbalanced regulatory mechanisms. Another possibility is Risk for Electrolyte Imbalance, but she already has an Electrolyte Imbalance, so the "Risk for" piece is out the window, and just plain old Electrolyte Imbalance is not on the NANDA list. Her labs appear to be so significant to her condition, I want to be able to use them in my care plan, but can't seem to make them quite fit anywhere. Does anyone have any suggestions as to what would be pertinent physiological care plans? There must be quite a lot of interaction between her different medical conditions and treatments. I just think I am missing something when I look at this data.

[mother_baby_RN]

all4ofus,

I hear you! I have been in the exact same situation, struggling with trying to come up with an appropriate primary nursing diagnosis when the conditions appear to be under control during your shift. We are instructed to use physiological nursing diagnosis (not psychological), and not use a "risk for" diagnosis as the primary problem.

Have you discussed with your clinical instructor?

I look forward to hearing ideas and suggestions!

[all4ofus, ASN, RN]

My clinical instructor has not responded to emails from several of us. I think she is probably just getting unindated with questions right now. The care plan is due today. I ended up using acute pain and impaired gas exchange. We'll see how it goes... I have a feeling she is going to point out the obvious that I overlooked and make it all look too easy while she's at it. Wish me luck!

[NP Sam]

Just as a few ideas what about:

1. Decreased cardiac output

2. Activity Intolerance

3. Inbalanced nutriton

Maybe taking a look at these three might help..

[traumaRUs, MSN, APRN]

The whole idea behind this type of ARF is that it is caused by obstructive uropathy so the plan of care would be to cysto and/or put in nephrostomy tubes to try to alleviate the obstruction so:

1. Fluid overload r/t obstructive uropathy as evidenced by increased BUN/Creat/K+/phosphorous.