NURSING CARE PLAN Actual Problem Systemic Infection CUES y
y y y y y
BP 160/90 mmHg Restlessness ligur ia ia Oligur Hct.level Hct.level 0.25 Na level 134 Hb. Hb. 0.83gm/ .83gm/ll
Nursing Diagnosis Risk for system systemic inf inf ectio tion r elated elated to hemodialysis modialysis proced procedur ur e as manif anif ested ested by by f atigu atigue, e, weakness and low Hb., Hb., Hct.level Hct.level
Inference
Goal/ Plan
Fr equ equent IV cannnu annnula will intro introd duce uce microorganis croorganism m in the blood oo d circulati rculatio on that would would tr igge gger system systemic inf inf ectio tion.
At the end of t of the shif t, t, patient will ex pe per ienc ience no sig signs/ ns/symp sympttoms oms of in of inf f ectio tion.
Nursing Intervention Promoted Promoted good good hand wash ashing ing by by client and staff staff . pticc Use ase pti tech techniq niqu ue when when mani pulatin pulating g IV/invasive IV/invasive lines. y
Rationale
y
y
y y
Encour aged dee p br eath eathing ing, coughin coughing g, fr equ equent positi positio on chan chang ges.
y
y
Assessed skin integr integr ity ity
Reduc Reduces es r isk isk of crosscrossconta contam minatio inatio n
y
Reduc Reduces es ba bacter ter ial ial col colonizatio nization and r isk of isk of asc ascending ending UTI. Pr events events atelec atelectasis and mobilizes mobilizes secr secr etio etions to r edu edue r isk of isk of pul pulmona monar r y inf inf ectio tions.
iations Excor iatio from scr atch atchin ing g may become come
Evaluation Goal metPatient had ex pe per ienc ienced no sig signs of inf inf ectio tion.
seco seconda ndar r ily ily inf inf ected.
y y
nitor ed ed Monitor vital sig signs
Fever ever wit w ith h incr incr eased eased pulse pulse and a r es es pi pir atio ation is ty pi pical of incr incr ease ease meta boli bolicc r ate ate r esu esulting lting from inf inf lamm lammat ator or y process, process, although although se psis psis can occur wit withou houtt a f e br ile ile r es es ponse. ponse.
Decreased Tissue Perfusion CUES y y y y
Oligur ligur ia ia
Hy pe per tensive tensive Restlessness Cold and clamm lammy y skin
Nursing Diagnosis Decr eased eased tissu tissue perfusi rfusio on r elated elated to pe per phe ipher al al vasoco vasoconst nstr r ictio tion
Inference
Goal/ Plan nstr ictio tion At the Constr of t of the end of pe per phe ipher al al my bl blood oo d shif t, t, vessels will patient patient
Nursing Intervention
. Measur easur e and r ecor ded ded blood oo d pr essur essur e as indic indicated
y
y
bser r ved ved O bse
skin
Rationale y
Evaluation
Goal Goal not Provides Provides obje objective data for met. Patient¶s monit monitor or ing ing. bl blood oo d pr essur essur e
as manif anif ested ested by by high bl blood oo d pr essur essur e
alter alter tthe f low of bl blood oo d to pe perfuse rfuse the diff diff er ent ent cells of t of the body. body.
will decr decr ease ease bl blood oo d pr essur essur e from 160/90 to 130/90
col color , moist moistur ur e, e, temp tempeer atur atur e, e, and ca pilla pillar r y r ef ill ill tim ti me.
y
Noted
de pendent pendent/g /gene ener r al edem edema
y
Pr esenc esence of pall pallor: or: cool, cool, moist moist skin; and delays ca pilla pillar r y r ef ill ill tim time may be be due to pe per phe ipher al al vasoco vasoconst nstr r ictio tion. indicate May indic hear ear t or r enal enal f ailur ailur e
y
y
y
y
Provided Provided calm alm, r estfu estfull surroundin urrounding gs, minim inimize enviro environ nmental activity/ tivity/noise. Limit the numbe umber of visitor visitor s and leng length of stay. of stay. Maintain activity r estr estr ictio tions; such as bed r est/ch est/chai air r r est; est; sched chedu ule pe per iods of uninterrup ninterrupted ted
y
y
Hel ps ps r educ educee symp sympat ath hetic etic stimu stimulati latio on; promotes promotes r elaxatio elaxation. Reduc Reduces es physi physiccal str str ess ess and tensio tensio n that aff ect bl blood oo d pr essur essur e and the cour se se of hy pe per tensio tensio n. Decr eases eases discomfor discomfor t and may r educ educee symp sympat ath hetic etic stimu stimulati latio on
r emained 160/90. 160/90.
r est; est; assisted client with ith self self car e activities as needed.
y
y
Provided Provided comfor t measur easur e such ba back massag assage, elevatio elevation of head.
y
Administer inister ed ed per tensive antih antihy pe tensive medic edicatio ations as pr escr escr i bed bed
y
y
Encour aged complian compliancce with ith dietar dietar y and f luid r estr estr ictio tion ther a py. py.
Antih ntihy pe per t ensive medic edicatio ations play play a key role role in tr eatm eatment of hy pe per tensio tensio n assoc associated iated with ith chroni chronicc r enal enal f ailur ailur e. e. Adher enc ence to diet and f luid r estr estr ictio tions and dialysis sched chedu ule pr events events exc excess f luid and sodium dium accumulati ccumulatio on.
Oliguria
CUES
Decr eased eased of ur ine ine out out put put 380cc Dr i bblin bbling g of ur ine ine Potassi Potassium um-7.47 incr incr eased eased (3.5(3.5- 5.0 5.0 mg/dl) mg/dl)
y
y
y
dium-- 134 Sodium decr decr eased eased (135(135-14 145 5 mg/dl) mg/dl)
y
Nursing Inference Goal/ Diagnosis Plan Oligur T ligur ia ia he Af ter ter 1 r elated elated to prod producti uctio on week i eek if tage of an of an nur sing sing End Stag Renal a bn bnormally ormally inter inter ventio ventio Disease small n the vo lume ume of patient patient ur ine. ine. This will may be a demo demonst nstr r at at r esu esult of e an copi copious ous incr incr ease ease in sweating eating, amount mount of ur ine kidney ine disease, loss vo ided of bl blood oo d each each tim time.
Nursing Intervention y
y
y
y
y
Assess the cause of de of decr cr ease ease ur inar inar y out out put put Encour age client to void ever ever y 2-4 2-4 hr s & when when urge urge is noted Determ etermine ine the initial f luids and elec electrolytes rolytes level
nitor intake & Monitor out out put put hour ly ly Percuss rcuss/p /pal al pate pate supr a pubi pubic ar ea. ea.
Rationale y
y
y
y
y y
y
bser r ve ve Signs and O bse symp sympttoms oms of f luids & elec electrolytes rolytes imbalan mbalancce such as dys pnea pnea chan chang ges in ECG and r estlessness. estlessness. Ensur nsur e clients complian compliancce on
y
To
be be a ble ble to a pply pply the prope proper ther a pe peutic tic r egimen. minim inimize ur inar inar y r etentio etention/ove /over r dist dist entio ention of t of the bladde bladder r ve as baseline Ser ve for progr ess. ess. May
determine ine the To determ progr ess ess of t of the disease A distended bladde bladderr can can be f elt elt in the pubic ar ea. supr a pubi ea. To be be a ble ble to pr event event fur ther compli compliccatio ation and adm administer inister prope proper ther a pe peutic tic agents as pr escr escr i bed. bed.
Evaluation
Af ter ter 1 week of eek of nur sing sing inter inter ventio vention the patient¶s ur ine ine out out put put incr incr eased eased
hemodialysis modialysis proced procedur ur e
y
To promote promote contin continuou uouss elim eliminatio ination of f luids and waste prod products. ucts.
Potential Problem Anxiety CUES
y
y
y
Body Body malaise Blurr ed ed in visio visio n Restlessness
Nursing Diagnosis
Anxiety r elated elated to chroni chronicc illness w/ chan chang ges in roles roles// body body image.
Inference
Goal/ Plan
Anxiety is a normal ormal ex pe per ienc ience. der ate ate or Moder high level of anxiety can incr incr ease ease aler aler tness tness and pe performan rformancce in par ticu ticula lar r situ situatio ations. Howeve However r , pe people ople who ex pe per ienc ience contin continu ues or r ecurr ing ing
Af ter ter 1 hour of n of nur sing sing inter inter ventio vention, the patient will verb verbalize alize awar eness eness of f eeling eelings of anxiety.
Nursing Intervention y
y
Assessed level of f ear ear of client. client.
plained Ex plained proced procedur ur es/ es/ car e as deliver deliver ed. ed. Re peated peated ex planati planatio on¶s fr equ equently as needed.
Rationale
y
y
Hel ps ps determ determine ine the kind of inter inter ventio vention s r equ equir ed. ed. Fear ear of unknow nknown n is lessened by inform informati atio on & may may enh enhanc ance acce cce ptan ptancce of pe permanen rmanencce of ESR D and nec necessity for dialysis. for dialysis.
Evaluation
Patient verb verbalized alized acce cce ptan ptancce of self self in in situ situatio ation.
f ear ear s or e pis piso odes of intense f ear ear can f eel eel powe power less less to manag anage their eir symp sympttoms oms and their eir lives can be become come sever sever ely ely r estr estr icted.
y
Provided Provided oppor tunities for client client to ask q ask questio estions & verb verbalizati alizatio on of con concer n. n.
y
eates Cr eates f eeling eeling of openness openness & coope cooper atio ation & provides provides on inform informati atio that will assist in proble problem m identif identif icatio atio n/ solving lving.
Lack of Sleep CUES y y
y
Restlessness Dar k c k circles rcles under nder eyes eyes Irr ita ita ble ble
Nursing Diagnosis patter r n Slee p patte disturb disturban ancce r/t r/t ur inar inar y fr equ equenc ency
Inference
Goal/ Plan
The
At the end of my shif t, t, the clients will incr incr ease ease the slee pin ping g hour s from 5 hr s. s. to 8 hr s. s.
client is ble to slee p Una ble be because she fr equ equent urge urge to empty mpty ur inar inar y bladde bladder r . Thus hus her slee r slee pin ping g patte patter r n is disrup disrupted. ted.
Nursing Intervention y
y
Assess the cause of ina bility bility to p. slee p. Assist patient patient in obse obser r ving ving any pr eviou eviouss b Bedtim edtime r itu itual.
Rationale
To determ determine ine the prope proper
y
y
To promote promote r elaxatio elaxation.
Evaluation
Goal Goal par tially tially met. Patient¶s slee pin ping g patte patter r n incr incr eased eased from 5-7 5-7 hr s. s.
y
y
Advised daytim daytime physi physiccal activities as indic indicated.
y
Limit f luids be befor e bedti bedtim me.
y
To promote promote ur inar inar y elim eliminati on thus hus r educ educin ing g bladde bladder r distentio distentio n to promote promote slee p dur ing ing nigh nightt tim time.
To pr event event ur inar inar y bladde bladder r r etentio etention causing sing dr i bblin bbling g of ur ine. ine.
