Care Plan

Student: Kailey Koons Date: 7/16/19

Course: NSG 430 Instructor: Professor Pionk

Clincial Site: Mayo Clinic Hospital Client Identifier: SD Age: 69

Reason for Admission: The patient was admitted for a kidney transplant related to end stage renal disease.
Medical Diagnoses: (Include Pathophysiology and Risk Factors): The Clinical Manifestation(s): (Things that lead up to the transplant)
pathophysiology of end stage renal disease is “the decline of kidney
function is gradual and initially may present asymptomatically. The The main factor that lead up to this patient getting a transplant is
natural history of renal failure depends on the etiology of the disease but their high blood pressure from a younger age.
ultimately involves early homeostatic mechanisms involving Some clinical manifestations the patient may experience include
hyperfiltration of the nephrons. As nephrons become damaged, the “fatigue, drowsiness, decrease in urination or inability to urinate,
kidney increases the rate of filtration in the residual normal ones. As a dry skin, itchy skin, headache, weight loss, nausea, bone pain, skin
result, the patient with mild renal impairment can show normal and nail changes and easy bruising” (Johns Hopkins Medicine,
creatinine values, and the disease can go undetected for some time. This 2019).
adaptive mechanism will run its course and will eventually cause
damage to the glomeruli of the remaining nephrons” (Benjamin &
Lappin, 2018).
Some risk factors associated with end stage renal disease are “diabetes,
high blood pressure, heart disease, drug abuse, blockages in the urinary
tract, family history, inflammation, and some genetic disorders” (Johns
Hopkins Medicine, 2019).
Assessment Data
Subjective Data: The patient states that they are fine and in no pain. The patient also states they have no concerns about surgery.

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

VS: The first set of vital Labs: Diagnostics:
signs is taken before surgery.
HCO3 (22-26): 18 (L) The patient had surgery o 7/16 ECG showed first degree heart block
T : 36.6 a few hours ago and o 7/16 Kidney ultrasound showed satisfactory renal
was under anestesia. transplant doppler evaluation
BP: 154/78
o 7/16 Chest X-ray showed that the right catether tip
HR: 65 BUN (7-20): 40.3 (H) The patinets earlier unchanged in position at the cavoatrial junction
level was 50.1. This is
RR: 16 an improvement due to
the kidney transplant.
O2 Sat: 99%, RA
Cre (0.5-1.1): 2.84 (H) The patinets earlier
level was 3.82. This is
The second set of vitals was an improvement due to
taken from the chart after the kidney transplant.
surgery.
Calcium (8.6-10.2): 7.4 The damaged kidneys
T : 36.7 (L) cannot maintain the
normal balance.
BP: 154/77
HR: 104 Hgb (11.7-16): 10.6 (L) The patient had surgery
a few hours ago and
RR: 14 bled during it. This is
expected.
O2 Sat: 100% RA
Hct (35-47): 33.5 (L) The patient had surgery
a few hours ago and
bled during it. This is
expected.

WBC (4-10): 10.8 (H) The patient had surgery

a few hours ago. This is
an invasive procedure
and is an expected
result.

2
Assessment: PMH: The patient has a histor of hypertension, GERD, Orders:
obstrutive sleep apnea, and a left arm fistula. Hemodialysis was
Pre Op:
started in August of 2018 and they are going 2 days a week. The
patient had a stage 2 adenocarcinoma and had a left upper lobectomy o Hibiclense Shower
in November of 2015. o Vital Signs Q 4 hours
o Basic Metablic Panel
o Neuro: The patient is alert and oriented x 4. Their speech is clear.
o CBC with Differential
The pupils are equal round and reactive to light and 3-4mm. The
o Daily Weight
patient’s eyes open spontaneously. They are cooperative.
o Resp: The patient is on room air and sating at 99%. Their Post Op:
respirations are 16 a minute and nonlabored. Their lung sounds are
clear and equal bilaterally. They do not have a cough and are not o SCDs
producing sputum. o Cardiac Diet
o CV: The patient has a regular heart rate at 65 beats per minute. o Medications as ordered
Their blood pressure is 154/78. S1 and S2 sounds are heard. o Cardiac monitoring
Pulses are 2+. Capilary refill is <3 seconds and the nail beds are o Continuous pulse oxyemtry
pink. The patient has no edema or JVD. o If need reinforce dressing but do not remove
o GI: The abdomen is soft and slightly rounded. She has no o Incentive Speromiter
abdomenal tenderness and nomoactive bowel sounds. The patient o Foley care
is NPO before surgery. o Magnesium Labs
o GU: The paient is voiding and it is clear and yellow. There is no o Phosperous Labs
pain or burning with voiding. o Noify provider if: Systolic is >170 or >110, Diastolic >110 or <50,
o Skin: The patients skin is warm, clean, dry, and intact. The patient HR >110 or <60, RR >24 or <10, or O2 <90%
has 3 well healed and epithlialized wounds from previous
surgeries. The first is an 11 cm scar on the left arm from the
fistula. Next is a 7 cm scar on the left shoulder from the
lobectomy. Lastly, there is a 8 cm scar about 4 finger breaths
below the umbilicus.
o Hygine: The patient took a shower at 0900 with antibaterial soap
before surgery.
o IV/Lines: The patient has a permanat hemodialysis catheter that is
tunneled and implanted in the right chest. The patient also has a
left arm fistula and bruits and thrills are present.

3
 Medications
ALLERGIES: No Know Allergies
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing Considerations
Effect
Tylenol 650 mg PO Q 6 hrs The patient would recive Hepatotoxicity, renal failure, Assess pain level and intensity
PRN this medication for neutropenia, pancytopenia, acute before administration.
moderate pain. generalized exanthematous pustulosis,
stevens-johnsons syndrome, toxic
epidermal necrolysis, rash, uritacardia
Acyclovir 400 mg PO BID The patient is receiving Seizures, dizziness, headache, diarrhea, Monitor BUN and serum
this as a prophylactic nausea, vomiting, stevens-johnson creatinine especially in a new
antiviral. syndrome, pain, phlebitis kidney transplant patient.
Cefazolin 2g IVPB Q 8 hrs The patient is receiving Seizures, pseudomembranous colitis, Monitor bowel function during
this is a prophylactic diarrhea, nausea, vomiting, stevens- treatment. Assess patient for skin
antibiotic. johnson syndrome, rash, pain, phlebitis rash frequently during treatment.
Fentanyl 25 mcg IV Q 2 hrs The patient would receive Apnea, laryngospasm, confusion, Assess pain level and intensity
this medication for severe respiratory depression, nausea, before administration. Monitor
pain. vomiting, bradycardia, respiratory rate and BP
frequently.
Famotidine 20 mg PO Daily The patient is receiving Confusion, arrhythmias, Monitor CBC with differential
this as an antiulcer. agranulocytosis, aplastic anemia, periodically throughout therapy.
dizziness, headache, diarrhea, nausea This medication may cause fales
positive results for urine protein.
Mycophenolate 1000 PO BID This is the antirejection Progressive multifocal Monitor for signs of a GI bleed.
mg medication that the patient leukoencephalopathy, anxiety, Assess blood pressure
will be taking for life. dizziness, headache, insomnia, periodically and compare to
paresthesia, tremor, edema, normal values. Assess heart rate,
hypertension, tachycardia, GI bleeding, ECG and heart sounds especially
hyperglycemia, hyperkalemia during exercise. Monitor for
hypocalcemia, diarrhea, nausea, signs and symptoms of infection.
vomiting, leukocytosis, Monitor WBCs for signs of
thrombocytopenia, fever, infection infection.
Oxycodone 5 mg PO Q 4 hrs The patient would receive Confusion, sedation, respiratory Assess pain level and intensity
this medication if the other depression, constipation, headache, before administation. Assess BP,
pain medications are not blurred vision, nausea, vomiting, pulse, and respirations before and
taking away the pain. sweating, floating feeling periodically during
administration.
(Vallerand, Sanoski, & Deglin, 2017) (Vallerand, Sanoski, & Deglin,
2017)

4
5

Goal
Client or family focused.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis) Risk for infection R/T kidney transplant. In a
transplant patient infection is a high risk because they are given immunosupressant to prevent rejection. This makes them very suseptible to
infection.
The patient will not get an
infection.
Secondary Nursing Diagnosis: Deficient knowledge R/T insufficient information AEB new transplant patinet and needing to take antirejection
medications for life.
The patient will have the
knowledge they need.
Nursing Diagnoses and Plan of Care
Expected Outcome
Measurable, time-specific,
reasonable, and attainable.
The patient will be able to
state 3 ways to reduce the
risk for infection by the end
of my shift.
The patient will be able to
state 3 new things that they
learned about their
medications and new
lifestyle by the end of my
shift.
Intervention(s)
Nursing or interprofessional
interventions.
1 Teach the patient proper
hand washing techniques
2 Teach the patient to wash all
veggitables well before eating
3 Teach the patient not to
consume raw fish
1 Teach the patient about
taking antirejection
medications for life
2 Teach the patient about hand
hygine to prevent infection
3 Teach the patient about
washing foods throughly to
prevent infection
Rationale
Provide reason why intervention
is indicated/therapeutic.
Provide references.
1 “It is also important to
frequently wash your hands or
use an antimicrobial gel during
cold and flu season”
2 “Some germs cause bacterial
infections. Some bacterial
infections can be picked up from
food”
3 “It is recommended to avoid
foods that are spoiled, moldy or
past its “use by” date, as well as
avoid raw or undercooked
meats”
(National Kidney Foundation,
2017)
1 “You should never stop taking
your anti-rejection medication
no matter how good you feel and
even if you think your
transplanted kidney is working
well. Stopping or missing them
may cause a rejection to occur”
2 “It is also important to
frequently wash your hands or
use an antimicrobial gel during
cold and flu season”
3 “Practice safe food handling.”
(National Kidney Foundation,
2017)
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
1 The goal was not met
because the patient did not
come back from surgery
before the end of my shift.
2 The goal was not met
because the patient did not
come back from surgery
before the end of my shift.
3 The goal was not met
because the patient did not
come back from surgery
before the end of my shift.
1 The goal was not met
because the patient did not
come back from surgery
before the end of my shift.
2 The goal was not met
because the patient did not
come back from surgery
before the end of my shift.
3 The goal was not met
because the patient did not
come back from surgery
before the end of my shift.
6
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence-based care for the achievement of
quality client outcomes.”

Benjamin, O. & Lappin, S.L. (2018). End-Stage Renal Disease. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.

Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499861/

Johns Hopkins Medicine. (2019). End Stage Renal Disease (ESRD). Retrieved from

https://www.hopkinsmedicine.org/health/conditions-and-diseases/end-stage-renal-failure

National Kidney Foundation. (2017). Care After Kidney Transplant. Retrieved from

https://www.kidney.org/atoz/content/immunosuppression

National Kidney Foundation. (2017). Foods to Avoid After Transplantation. Retrieved from

https://www.kidney.org/atoz/content/foods-avoid-after-transplantation

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's drug guide for nurses [Online Version]. Philadelphia, PA: F. A.

Davis Company