CLINICAL DOCUMENTATION, Assignments of Nursing

Download CLINICAL DOCUMENTATION and more Assignments Nursing in PDF only on Docsity! T E XTB O OK P ICT U R E MEDICAL DIAGNOSIS CLINICAL SIGNS/SYMPTOMS MEDICAL MANAGEMENT NAM E : Acute Kidney Injury ranges from a slight deterioration in kidney function to severe impairment. AKI is characterized by a rapid loss of kidney function. This loss is accompanied by a rise in serum creatinine and/or a reduction in urine output. AKI can develop over hours or days with progressive elevations of blood urea nitrogen (BUN), creatinine, and potassium with or without a reduction in urine output. The severity of dysfunction can range from a small increase in serum creatinine or reduction in urine output to the development of azotemia, an accumulation of nitrogenous waste products (urea nitrogen, creatinine) in the blood. DES C RI P T IO N : SI G NS/ S Y M P T O M S :  Reduced urine output or changes to urine color  Fluid retention, causing swelling in your legs, ankles, or feet  Shortness of breath  Nausea and vomiting  Dehydration  Confusion  High blood pressure  Abdominal pain COMPLI C A T IO N S :  Fluid buildup. Acute kidney failure may lead to a buildup of fluid in your lungs, which can cause shortness of breath.  Chest pain. ...  Muscle weakness. ...  Permanent kidney damage. ...  Death. MEDIC A L MAN A G EMENT : • History and physical examination • Identify precipitating cause • Serum creatinine and BUN levels • Serum electrolytes • Urinalysis • Renal ultrasound • Renal scan • CT scan S U R G ICAL M ANA G EMEN T : None in intrarenal Postrenal if cause is Kidney Stones surgical management is lithotripsy. NURSING MANAGEMENT Concept Risk for Decreased Cardiac Output Concept Risk for Fluid Volume Excess Concept Risk for Electrolyte Imbalance N U RSING IN T E R VEN T IO NS : N U RSING IN T E R VEN T IO NS : N U RSING IN T E R VEN T IO NS : 1. Weigh daily at the same time of day, on the same scale, with the same equipment and clothing. 1. Assess the level of consciousness. Investigate changes in mentation and the presence of restlessness. 1. Administer and/or restrict fluids as indicated. 2. Monitor urine-specific gravity. 2. Assess skin, face, and dependent areas for edema. Evaluate the degree of edema (on a scale of +1–+4). 2. Monitor Serum Electrolyte Values 3. Assess heart and lung sounds. 3. Monitor heart rate (HR), BP, and JVD/CVP. 3. Encourage a low sodium diet, limit foods with high potassium like bananas, oranges, and tomatoes REFERENCE(S) Elsevier health sciences. (2019). Problems of Urinary Function. In Lewis's medical-surgical nursing: Assessment and management of clinical problems (pp. 1064).