Case # 1: Nursing Diagnosis Goal Interventions Expected Outcome

CASE # 1
You are assigned to take care of a 66-year old woman diagnosed with chronic kidney disease, on her first hospitalization. According to the
medical history, her co-morbidities include diabetes mellitus type 2 and hypertension. She refused to have dialysis for the past four sessions and had
increasing lethargy for two days.
Her vital signs were: Blood Pressure 136/92mmHg, Heart Rate 77bpm, Oxygen Saturation 96% on room air, and Temperature of 36.6 degrees
Celsius. She was agitated and reaching the objects in the sky. Her speech was slurred, and she has altered mental status. She had 2+ pitting
edema bilaterally to her legs, extending to distal knees
Pertinent laboratory evaluation was notable for a white blood cell count of 11.2, hemoglobin of 6.8g/dL, hematocrit of 21.3, and a platelet level
of 370. Basic metabolic panel revealed a hyponatremia of 129, hyperkalemia of 7.8 (non-hemolyzed), blood/urea/nitrogen (BUN) of 81, creatinine
of 8.3, glomerular filtration rate (GFR) 4.5, and blood glucose of 99. Arterial blood gas was notable for a pH of 7.51, pCO2 28, pO2 54, HCO3 22, and
a lactic acid of 1.6. Other relevant laboratory abnormalities included an ammonia level 45, brain natriuretic peptide (BNP) of 2572 and troponin of .
05.
NURSING DIAGNOSIS GOAL INTERVENTIONS EXPECTED OUTCOME

(List 5 unique to the given Nursing Dx)
Actual Short Term 1. Assess understanding of cause of • Verbalizes relationship of cause of

renal failure, consequences of renal renal failure to consequences
Deficient knowledge regarding After 2-3 hours of nursing intervention failure, and its treatment:
condition and treatment patient will increased knowledge a. Cause of patient’s renal failure • Explains fluid and dietary
about condition and related treatment. b. Meaning of renal failure restrictions as they relate to failure of
c. Understanding of renal function kidney’s regulatory functions
d. Relationship of fluid and dietary
restrictions to renal failure • States in own words relationship of
e. Rationale for treatment renal failure and need for treatment
(hemodialysis, peritoneal dialysis,
transplantation) • Asks questions about treatment
options, indicating readiness to learn
2. Provide explanation of renal function
and consequences of renal failure at • Verbalizes plans to continue as
patient’s level of understanding and normal a life as possible
guided by patient’s readiness to
learn. • Uses written information and
instructions to clarify questions and
3. Assist patient to identify ways to seek additional information
incorporate changes related to
illness and its treatment into lifestyle.
4. Provide oral and written information
as appropriate about:
a. Renal function and failure
b. Fluid and dietary restrictions
c. Medications
d. Reportable problems, signs, and
symptoms
e. Follow-up schedule
f. Community resources
g. Treatment options
5. Discuss drug therapy, including use of

calcium supplements and phosphate
binders such as aluminum hydroxide
antacids (Amphojel, Basalgel) and
avoidance of magnesium antacids
(Mylanta, Maalox, Gelusil); vitamin D.
Risk/Potential Short term 1. Assess patient’s and family’s • Identifies previously used coping
responses and reactions to illness styles that have been effective and
Risk for situational low self-esteem After 2-3 hours of nursing intervention and treatment. those no longer possible due to
related to dependency, role changes, patient will improved self-esteem disease and treatment (alcohol or
change in body image, and 2. Assess relationship of patient and drug use; extreme physical exertion)
change in sexual function significant family members.
• Patient and family identify and
3. Assess usual coping patterns of verbalize feelings and reactions to
patient and family members. disease and necessary changes in their
lives
4. Encourage open discussion of
concerns about changes produced by • Seeks professional counseling, if
disease and treatment: necessary, to cope with changes
a. Role changes resulting from renal failure
b. Changes in lifestyle
c. Changes in occupation • Reports satisfaction with method of
d. Sexual changes sexual expression
e. Dependence on health care team
5. Explore alternate ways of sexual

expression other than sexual
intercourse.
Psycho-social Long Term 1. Assess extent of impairment in •Regain/maintain optimal level of

thinking ability, memory, and mentation.
Disturbed Thought Process related to After 2-3 days of nursing intervention orientation. Note attention span.
Physiological changes: electrolyte patient would regain/maintain optimal •Identify ways to compensate for
imbalances, calcifications in the brain level of mentation. 2. Reorient to surroundings, person, and cognitive impairment/memory
evidenced by disorientation to person, so forth. Provide calendars, clocks, deficits.
place, time outside window.
3. Communicate information and

instructions in simple, short sentences.
Ask direct, yes or no questions. Repeat
explanations as necessary.
4. Promote adequate rest and

undisturbed periods for sleep.
5. Present reality concisely, briefly, and

do not challenge illogical thinking.

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CASE # 1

NURSING DIAGNOSIS GOAL INTERVENTIONS EXPECTED OUTCOME

Actual Short Term 1. Assess understanding of cause of • Verbalizes relationship of cause of

5. Discuss drug therapy, including use of

5. Explore alternate ways of sexual

Psycho-social Long Term 1. Assess extent of impairment in •Regain/maintain optimal level of

3. Communicate information and

4. Promote adequate rest and

5. Present reality concisely, briefly, and

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