Topic: Chronic Renal Failure Nursing Care Plan

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I will post 3 documents. It will be an example of a completed case study, the topic of the case study, and the blank care plan template where the care plan is suppose to be completed.The instructor did not give us any instructions. He only gave us the example of another case study and the topic. All the information about patient the case study is in the “topic” document. Please just follow the steps on how the example case study did it. The main purpose of this is the make a care plan on the patient with the given information we have. The given information is in the “topic” document. Thank you! Please message me if any questions.

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CASE STUDY SCENARIO #5

D.T. is an 84-year-old Middle Eastern male, who arrived into the ER with worsening shortness of breath, anxiety, forgetfulness, and difficulty urinating. Patient brought into the ER by his wife, and has a family who is very involve in his care. Patient is at times non-compliant with diet.

Patient with multiple comorbidities including the following: Hypertension, presence of permanent pacemaker, CHF, COPD, Chronic kidney disease stage IIII, anxiety

Patient with a long surgical history as follows: pacemaker placement, open heart surgery, x 3 myocardial infarctions, vascular surgery in bilateral lower extremities, circumcision

Upon assessment, patient with crackles in bilateral lower lobes, +2 pitting edema in bilateral feet, and dyspnea upon exertion and lying flat.

Admitting Diagnosis: Acute VS chronic renal failure

H:5’9”
W: 250 lbs
FULL CODE
NKDA

Labs drawn and results as follows:
Sodium: 138
Potassium: 3.8
Magnesium: 1.9
WBC: 10
BUN: 34
Creatinine: 2.9
Troponin: 0.14
BNP: 8898

Vital signs as follows:
BP: 104/56
HR: 70
RR: 22
Temp: 97.9
Oxygen Saturation: 89% on room air

Orders as follows:
Bumex 1 mg/hr x 4 hours via IV piggyback
Foley catheter
Strict intake and output
Ativan 1 mg PO BID
Ativan 1 mg IV push Q8H PRN anxiety/insomnia
Oxygen 2 liter per minute via nasal cannula
Chest x-ray 1 view, STAT