Tiare Palimoo, Concept Map: Care Plan, NURS 360 – Med/Surg, Professor Rosado
Desired Outcomes Before Discharge
Impaired Renal Function:
 Patient achieves optimal urinary
elimination as evidenced by the following:
urine output greater than 30 mL/hr,
electrolytes, BUN within or near normal
levels, and normal specific gravity.
1.
2.
3.
4.
5.
6.
Fluid Volume Deficient:
 Patient experiences normal fluid volume as
evidenced by urine output equal to fluid
intake, absence of thirst, normal serum
sodium level, and stable weight.
1.
2.
3.
4.
5.
6.
Altered Nutrition
 Patient will maintain adequate nutritional
status as evidenced by normal BUN and
serum albumin, Hct, Hgb, and lymphocyte
level, and healthy oral mucous membrane.
1.
2.
3.
4.
Infection/Skin Integrity
 Patient remains free of infection as
evidenced by normal vital signs, absence of
pain, swelling, redness, and skin break
down.
1.
2.
3.
4.
Interventions
Monitor intake and output, urine
output, and patient weight.
Monitor patient for signs of electrolyte
imbalance.
Monitor urine specific gravity.
Minimize the patient’s exposure to
nephrotoxic drug.
Maintain surveillance for signs and
symptoms of fluid overload.
Administer fluids and diuretics as
prescribed.
Monitor intake and output. Report
urine volume greater than 200 mL for
each of 2 consecutive hours or 500 mL
in a 2-hour period.
Monitor for increased thirst
(polydipsia).
Weigh daily.
Strict I&O.
Monitor urine specific gravity.
Provide easily accessible fluid source
and encourage fluid intake.
Assess for and report signs and
symptoms of malnutrition: weight
below patient’s usual weight or below
normal for client’s age, height, and
frame, abnormal BUN and low serum
albumin, Hct, Hb, and lymphocyte
levels, weakness, fatigue, and sore
inflamed oral mucous membrane.
Monitor percentage of meals and
snacks patient consumes.
Serve frequent, small meals rather than
large ones.
Suggest ways to assist patient with
meals as needed: ensure a pleasant
environment, facilitate proper position,
and provide good oral hygiene.
Monitor vital signs.
Promote good hand washing by patient
and staff.
Note signs of localized or systemic
infection; report promptly.
Administer prescribed antibiotics and
medication.
Tiare Palimoo, Concept Map: Care Plan, NURS 360 – Med/Surg, Professor Rosado
Activity Intolerance
 Patient participates in activities.
 Patient maintains activity level within
capabilities as evidenced by absence of
weakness and fatigue.
5.
6.
1.
2.
3.
4.
5.
6.
7.
Electrolyte Imbalance
 Patient’s serum calcium and phosphorus
are within normal range.
 Patient will not experience hypocalcemia
and hyperphosphatemia as evidenced by
absence of tingling and fatigue.
1.
2.
3.
4.
Provide meticulous skin care.
Encourage ambulation.
Assess the patient’s level of mobility.
Assess emotional response to
limitations in physical abilities.
Monitor the patient’s sleep pattern and
amount of sleep achieved over the past
few days.
Observe and document response to
activity. Signs of abnormal response to
be reported include: increased heart rate
of 20 to 3- beats/min over resting, or
120 beats/min, palpitations/noticeable
change in heart rhythm, significant
increase or decrease in systolic BP,
excessive weakness, fatigue, dyspnea,
labored breathing dizziness, and lightheadedness.
Anticipate the patient’s needs (e.g. keep
telephone and call light within reach).
Encourage adequate rest periods,
especially before meals, other ADLs,
exercise sessions, and ambulation.
Encourage verbalization of feelings
regarding limitations.
Monitor serum electrolytes lab.
Evaluate signs and symptoms of
hypocalcemia and hyperphosphatemia.
Administer stool softeners as needed.
Collaborate with physician about
appropriate medications.
Evaluation
Ineffective Renal Tissue Perfusion: Patient did not meet outcome. After reviewing patient’s
laboratory results of BUN and creatinine levels, it continues to show elevation similar to the
results on admission. Patient’s BUN level was 55 mg/dL and creatinine was 3.4 mg/dL. In
addition, patient’s urine specific gravity result was less than 1.005. However, patient did have a
urinary output of more than 30 mL/hr with pale yellow urine.
Fluid Volume Deficit: Patient partially met outcome. He maintains a stable weight of 210 lbs.
According to monitored laboratory results, his sodium level has been within normal levels.
However, patient complains of still being thirsty even when receiving ½ NS 200 mL/hr,
Tiare Palimoo, Concept Map: Care Plan, NURS 360 – Med/Surg, Professor Rosado
continuous in addition to consuming other fluids, such as cold, ice water. Patient states, “I feel
like I drink a lot of liquids, but I don’t know why I’m still thirsty.”
Altered Nutrition: Patient did not meet outcome. Monitored labs showed BUN, albumin
hemoglobin, and hematocrit levels not within normal range. Patient’s BUN level was increased
at 55 mg/dL and albumin level was decreased at 2.8 g/dL. Hemoglobin (10 gm/dL) and
hematocrit (30%) both are decreased. Patient doesn’t appear to be malnourished and has healthy
oral mucous membranes. Patient is not receiving any blood products for low hemoglobin and
hematocrit. Patient consumes approximately 75% of his meals. Patient states, “I’m slowly
tolerating solid foods.”
Infection/Skin Integrity: Patient met outcome with long-term administration of antibiotics
through PICC. Patient demonstrates normal vital signs during my care. Patient did have
swelling bilaterally in his lower extremities. Swelling and redness was also observed on
patient’s scrotum, which Clotrimazole 1% cream was applied. No other evidence of skin break
down was noted. Patient understands the importance of good hygiene and frequent
repositioning.
Activity Intolerance: Patient did not meet outcome. During my care, patient maintained in bed,
watching television. No ambulation was noted. Therapeutic communication was established.
Patient reports feeling tired and exhausted, and not having the energy to do anything. He does
have pain in his left wrist due to gout, which limits his ability to use it. He is unable to sleep
well at night. He tries to participate in OT and is being trained on his ADLs.
Electrolyte Imbalance: Patient did not meet outcome. Monitored laboratory results
demonstrated decrease calcium level (7.5 mg/dL) and increased phosphorus level (4.6 mg/dL).
Patient states, “I am not as strong as I used to be. I feel weak and sometimes I feel tingling in my
feet.” Patient appears tired during my care. Patient is not receiving any medication for his low
calcium level.
Tiare Palimoo, Concept Map: Care Plan, NURS 360 – Med/Surg, Professor Rosado
Discharge Planning
It is undetermined if patient will be discharged to a rehabilitation facility or receive home
health care. Blue Waters, short-term rehab is trying to find a caregiver for him, but are willing to
accept him as a patient. Patient lacks a support system and lives alone. He does need full, 24/7
assistance due to his inability to perform ADLs, such as bathing, dressing, and hygiene and also
assistance with complying with taking numerous medications for his health complications.
Patient does use a walker and requires assistance with ambulation.
Patient prefers to learn verbally and visually by listening to important information and
observing images. Barriers to learning include both physical and emotional due to body
weakness, not having the energy to perform activities or tasks, feelings of hopelessness, and
numerous health complications. Topics to teach are acute renal failure, maintaining adequate
fluid and nutrition, medication administration and compliance, balancing energy level, signs and
symptoms of hypocalcemia and hyperphosphatemia, diabetic precautions, and safety. Patient
should report to physician any complications, infections, decrease urinary output or urinary
retention, tingling feelings, extreme fatigue, and body weakness. Follow-up appointments will
be made by physician and nephrologist.
Tiare Palimoo, Concept Map: Care Plan, NURS 360 – Med/Surg, Professor Rosado
References
Gulanick, M., & Myers, J. (2011). Nursing care plans: diagnoses interventions, and outcomes.
(7th ed.). PA: Mosby.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., et al, L., & Camera, I. M. C. (2011).
Medical-surgical nursing, assessment and management of clinical problems. (8th ed.). St.
Louis, Missouri: Mosby