NURSING CARE PLAN Actual Problem Systemic Infection CUES y y y y y y BP 160/90 mmHg Restlessness Oliguria Hct.level 0.

25 Na level 134 Hb. 0.83gm/l Nursing Diagnosis Risk for systemic infection related to hemodialysis procedure as manifested by fatigue, weakness and low Hb., Hct.level Inference Frequent IV cannnula will introduce microorganism in the blood circulation that would trigger systemic infection. Goal/ Plan At the end of the shift, patient will experience no signs/symptoms of infection. Nursing Intervention y Promoted good hand washing by client and staff. y Use aseptic technique when manipulating IV/invasive lines. y Encouraged deep breathing, coughing, frequent position changes. Rationale y Reduces risk of crosscontaminatio n y Reduces bacterial colonization and risk of ascending UTI. Prevents atelectasis and mobilizes secretions to redue risk of pulmo nary infections. Evaluation Goal metPatient had experienced no signs of infection.

y y Assessed skin integrity

Excoriations from scratching may become

secondarily infected.

y y Monitored vital signs

Fever with increased pulse and a respiration is typical of increase metabo lic rate resulting from inflammatory process, although sepsis can occur without a febrile response.

Decreased Tissue Perfusion CUES y y y y Oliguria Hypertensive Restlessness Cold and clammy skin Nursing Diagnosis Decreased tissue perfusio n related to peripheral vasoconstriction Inference Goal/ Plan Constriction At the of the end of peripheral my blood shift, vessels will patient Nursing Intervention y . Measure and recorded blood pressure as indicated y Observed skin Rationale y Evaluation

Goal not Provides objective data for met. Patients mo nitoring. blood pressure

as manifested by high blood pressure

alter the flow of blood to perfuse the different cells of the body.

will decrease blood pressure from 160/90 to 130/90

color, moisture, temperature, and capillary refill time.

Noted dependent/gener al edema

Presence of pallor: cool, mo ist skin; and delays capillary refill time may be due to peripheral vasoconstriction. y May indicate heart or renal failure

remained 160/90.

y y Provided calm, restful surroundings, minimize environmental activity/no ise. Limit the number of visitors and length of stay. Maintain activity restrictions; such as bed rest/chair rest; schedule periods of uninterrupted

Helps reduce sympathetic stimulation; promotes relaxation. Reduces physical stress and tensio n that affect blood pressure and the course of hypertensio n. Decreases discomfort and may reduce sympathetic stimulation

rest; assisted client with selfcare activities as needed.

Provided comfort measure such back massage, elevation of head. Administered antihypertensive medications as prescribed

Antihypert ensive medications play a key role in treatment of hypertensio n associated with chronic renal failure. Adherence to diet and fluid restrictions and dialysis schedule prevents excess fluid and sodium accumulation.

y Encouraged compliance wit h dietary and fluid restriction therapy.

Oliguria CUES y Decreased of urine output 380cc y Dribbling of urine y Potassium7.47 increased (3.5- 5.0 mg/dl) y Sodium- 134 decreased (135-145 mg/dl) Nursing Diagnosis Oliguria related to End Stage Renal Disease Goal/ Plan The After 1 production week if of an nursing abnormally interventio small n the vo lume of patient urine. This will may be a demonstrat result of e an copious increase in sweating, amount of kidney urine disease, loss vo ided of blood each time. Inference Nursing Intervention y Assess the cause of decrease urinary output Encourage client to void every 2-4 hrs & when urge is noted Determine the initial fluids and electrolytes level Monitor intake & output hourly Percuss/palpate suprapubic area. y Rationale To be able to apply the proper therapeutic regimen. May minimize urinary retention/overdist ention of the bladder Serve as baseline for progress. Evaluation After 1 week of nursing intervention the patients urine output increased

y y

y y Observe Signs and symptoms of fluids & electrolytes imbalance such as dyspnea changes in ECG and restlessness. Ensure clients compliance on

To determine the progress of the disease A distended bladder can be felt in the suprapubic area. To be able to prevent further complication and administer proper therapeutic agents as prescribed.

hemodialysis procedure

To promote continuous elimination of fluids and waste products.

Potential Problem Anxiety CUES Nursing Diagnosis Anxiety related to chronic illness w/ changes in roles/ body image. Inference Goal/ Plan Nursing Intervention y Assessed level of fear of client. Rationale Evaluation

y y

Body malaise Blurred in visio n Restlessness

Anxiety is a normal experience. Moderate or high level of anxiety can increase alertness and performance in particular situations. However, people who experience continues or recurring

After 1 hour of nursing intervention, the patient will verbalize awareness of feelings of anxiety.

Explained procedures/ care as delivered. Repeated explanations frequently as needed.

Helps determine the kind of intervention s required. Fear of unknown is lessened by information & may enhance acceptance of permanence of ESRD and necessity for dialysis.

Patient verbalized acceptance of self in situation.

fears or episodes of intense fear can feel powerless to manage their symptoms and their lives can become severely restricted.

y y Provided opportunities for client to ask questions & verbalization of concern.

Creates feeling of openness & cooperation & provides information that will assist in problem identificatio n/ so lving.

Lack of Sleep CUES y y y Restlessness Dark circles under eyes Irritable Nursing Diagnosis Sleep pattern disturbance r/t urinary frequency Inference The client is Unable to sleep because she frequent urge to empty urinary bladder. Thus her sleeping pattern is disrupted. Goal/ Plan At the end of my shift, the clients will increase the sleeping hours from 5 hrs. to 8 hrs. Nursing Intervention y Assess the cause of inability to sleep. Assist patient in observing any previous b Bedtime ritual. Rationale Evaluation Goal partially met. Patients sleeping pattern increased from 5-7 hrs.

To determine the proper y To promote relaxation.

Advised daytime physical activities as indicated.

Limit fluids before bedtime.

To promote urinary eliminati on thus reducing bladder distentio n to promote sleep during night time.

To prevent urinary bladder retention causing dribbling of urine.