NURSING CARE PLAN
NURSING DIAGNOSIS
NANDA LIST
Altered Tissue Perfusion:
Renal related to interruption of
flow-arterial,venous as
manifested by blood pressure
of 186/115, BUN 32 and
creatine 1.88.
PLAN
Nursing Outcomes/Goals
Classification (NOC)
SHORT-TERM/LONG-
TERM
Client will have a B/P <180/110
by end of the shift on 2/3/10.
Client will have adequate tissue
perfusion as evidenced by
normal BUN, creatine, and
abscence of excess fluid volume
by discharge.
IMPLEMENTATION
Nursing Interventions
Classifications (NIC) and
Rationales (cite source)
I. Monitor and document vital
signs; notify physician of any
changes.
R. Increase from baseline may
indicate fluid overload caused by
lack of kidney function. (Sparks
347)
I. Administer antihypertensive
medications as ordered.
R. Hypertension management is an
important component in slowing
the progression of chronic renal
failure. (McFarland 430)
I. Monitor BUN, creatine, and
electrolyte levels.
R. An alternation in electrolytes
and an elevation in BUN and
creatine may indicate and
alteration in renal function.
(McFarland 430)
I. Assess for peripheral edema.

Impaired Physical Mobility
related to neuromuscular
impairment as manifested by
right hemiplegia.
Client will demonstate
participation in activities of
daily living by 2/3/10.
Client will maintain joint
mobility and prevent
contractures by discharge.
R. When a patient with renal
impairment begins to retain fluid,
the patient develops venous
pooling and peripheral edema.
(McFarland 430)
I. Encourage indepedence in
mobility by helping client to
perform self-care activities such as
bathing, feeding, and dressing.
R. This increases muscle tone and
patient's self-esteem. (Sparks 199)
I. Place items within reach of
unaffected arm.
R. To promote patient's
independence. (Sparks 199)
I. Perform ROM exercises to
joints, unless contraindicated, at
least once every shift. Progress
from passive to active, as tolerated.
R. This prevents joint contractures
and muscular atropy. (Sparks 199)
I. Refer to physical/occupational
therapist for development of
mobility regimen.
R. To help rehabilitate
musculoskeletal deficits. (Sparks
199)
Risk for Injury related to
neuromuscular impairment as
manifested by right hemiplegia.
Powerlessness related to loss
of independence as manifested
by signs of frustration when
Client will not experience a fall
by the end of shift on 2/3/10.
Client will demonstrate
measures to prevent injuries by
discharge.
Client will identify ways to
achieve control over personal
I. Keep needed items within easy
reach and within client's visual
field.
R. Measurse to prevent a fall.
(Sparks 177)
I. Make sure client wear well-
fitting slippers/shoe with nonslip
soles when ambulating.
R. Measure to prevent a fall.
(Sparks 177)
I. Reinforce instructions from
physical therapist on correct
transfer and ambulation
techniques.
R. Physical therapists recommend
safety devices to increase strength,
mobility, safety, and independence.
(Sparks 177)
I. Keep floor free of clutter and
wipe up spills promptly.
R. To decrease potential for
injury. (Sparks 177)
I. Identify situations and/or
interactions that may add to the
patient sense of powerlessness.
R. Many medical routines are
superimposed on patients without
ever receiving their permission,
fostering a sense of powerlessness.
It is important for health care
attempting to complete usual situations by end of shift on providers to recognize the patient's
self tasks. 2/3/10. right to refuse procedures such as
feeding tubes and intubation.
(Gulanick 1133)

I. Identify strengths/assets and

past coping strategies that were
successful.

R. Helps patient to recognize own

ability to deal with difficult
situation. (Sparks 247)

I. Implement personalized
methods of providing hygiene,
diet, and sleep. Enhance basic
care by offering food, drink,
comfort, and security.

R. Allowing or helping the patient

decide when and how these things
are to be accomplished will
increase the patients sense of
autonomy. (Gulanick 153)

I. Encourage patient to express

feelings about present situation.

R. This helps patient bring

Client will continue to influence vaguely expressed emotions into
care decisions up until clear awareness and acceptance.
discharge. (Sparks 247)