CUES
Subjective:
“Diri hiya nakaihi hin iya
la” as verbalized by SO.
Objective:
 Increased creatinine:
913.5 umol/L
 Increased blood urea
nitrogen: 43.0 mmol/L
 Oliguria
NURSING DIAGNOSIS
RATIONALE
GOALS AND OBJECTIVES
Impaired Renal Tissue
Perfusion related to
glomerular malfunction
Chronic kidney disease
(CKD) is initially
described as diminished
renal reserve or renal
insufficiency, which may
progress to renal failure
(end-stage renal
disease). Initially, as
renal tissue loses
function, there are few
noticeable
abnormalities because
the remaining tissue
increases its
performance (renal
functional adaptation).
Decreased renal
function interferes with
the kidneys’ ability to
maintain fluid and
electrolyte homeostasis.
Short Term:
After 12 hours of nursing
interventions, client will
be able to:
 Demonstrate
participation in
his/her recommended
treatment program.
 Demonstrate
behavior/lifestyle
changes to prevent
complications.
INTERVENTIONS
Independent
1. Assess patient’s general
condition.
RATIONALE
1. To obtain baseline data.
2. Determine factors related to
individual situation and note
situation that can affect all
body system.
2. To assess causative and
contributing factors.
3. Note characteristic of urine:
measure urine specific
gravity.
3. To assess for hematuria
and proteinuria and renal
impairment.
4. Identify necessary changes
in lifestyle and assist client
to incorporate disease
management to ADLs.
4. To promote wellness and
prevent further
progression of
complication.
5. Give information about
positive signs of
improvement such as
improve vital signs/
circulation.
5. To provide
encouragement.
6. Provide physiologic support.
Maintain calm attitude but
admit concerns if
questioned by the client/SO.
6. Honestly can be reassuring
when so much activity or
worries are apparent to
the client or SO.
Collaborative
1. Monitor laboratory
studies, such as the
following:
Arterial blood gases
(ABGs), liver and kidney
function tests.
Decreased tissue perfusion
may lead to gradual infarction
of organ
EVALUATION
Short Term:
After 12 hours of
nursing interventions,
client will be able to:
 Demonstrate
participation in
his/her
recommended
treatment
program.
Goals were partially
met.
tissues, such as the brain,
liver, spleen, kidney, and
skeletal
muscle, with consequent
release of intracellular
enzymes.
Serum electrolytes;
provide replacements
as indicated.
2. Administer oxygen by
appropriate route and
assist with respiratory
treatment measures,
such as coughing, deep
breathing exercises, and
incentive spirometer.
Source:
Doenges, M., Moorhouse, M., &
Murr, A. (2014). Nursing Care
Plan: Guidelines for
Individualizing Client Care Across
the Life Span (9th ed.).
Philadelphia, Pennsylvania: F.A.
Davis Company.
Electrolyte losses, especially
sodium and potassium, are
increased during crisis
because of fever, diarrhea,
vomiting, and diaphoresis, and
presence of acidosis.
2. Improves oxygenation and
reduces risk of pulmonary
complications.