Top 2 Nursing Care Plans for Hemodialysis Patients


Nursing Care Plans for Hemodialysis PatientsHere the the most common Nursing Care Plans for Hemodialysis Patients used as guide in hospital setting.

1. Fluid Volume Excess

Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight

Assessment
Subjective:

(none)

 

 

Objective:

Edema

Hypertension

Weight gain

Pulmonary congestion (SOB,DOB)

Oliguria

Distended jugular vein

Changes in mental status

Planning
Short Term:

After 4-8 hours of nursing interventions, patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess

Long Term:

After 3 days of nursing intervention the patient will manifest stabilize fluid volume AEB balance I & O, normal VS, stable weight,and free from signs of edema.

Interventions Rationale
1.     Establish rapport

 

1.     To assess precipitating and causative factors
2.    Monitor and record vital signs 2.    To obtain baseline data
3.    Assess possible risk factors 3.    To obtain baseline data
4.    Monitor and record vital signs 4.    To note for presence of nausea and vomiting
5.    Assess patient’s appetite 5.    To prevent fluid overload and monitor intake and output
6.    Note amount/rate of fluid intake from all sources 6.    To monitor fluid retention and evaluate degree of excess
7.    Compare current weight gain with admission or previous stated weight 7.       For presence of crackles or congestion
8. Auscultate breath sounds 8. To evaluate degree of excess
9. Record occurrence of dyspnea 9. To determine fluid retention
10. Note presence of edema 10. May indicate increase in fluid retention
11. Measure abdominal girth for changes 11. May indicate cerebral edema
12. Evaluate mentation for confusion and personality changes 12. To evaluate degree of fluid excess
13. Observe skin mucous membrane 13. To prevent pressure ulcers
14. Change position of client timely 14. To monitor fluid and electrolyte imbalances
15. Review lab data like BUN, Creatinine, Serum electrolyte 15. To lessen fluid retention and overload
16. Restrict sodium and fluid intake if indicated 16. To monitor kidney function and fluid retention
17. Record I&O accurately and calculate fluid volume balance 17. Weight gain indicates fluid retention or edema
18. Weigh client 18. Weight gain may indicate fluid retention and edema
19. Encourage quiet, restful atmosphere 19. To conserve energy and lower tissue oxygen demand
20. Promote overall health measure 20. To promote wellness
Evaluation
Short Term:

The patient shall have demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess

Long Term:

The patient shall have manifested stabilized fluid volume AEB balance I& O, normal VS, stable weight, and free from signs of edema.

 

2. Altered Renal Tissue Perfusion

For optimal cell functioning the kidney excrete potentially harmful nitrogenous product-Urea, Creatinine, Uric Acid but because of the loss of kidney excretory functions there is impaired excretion of nitrogenous waste product causing in increase in Laboratory result of BUN, Creatinine, Uric Acid Level

Assessment
Subjective:

(none)

 

 

Objective:

Increase in Labresults (BUN,Creatinine, UricAcid Level)

Oliguria

Anuria

Edema

PulmonaryCongestion

Hypertension

Hematuria

Planning
Short Term:

After 4 hours of nursing interventions, patientwill demonstrate participation inhis/herrecommendedtreatment program.

Long Term:

After 3 days of nursing interventionthe patient will manifest demonstrate behavior/lifestyle changes to prevent complications.

Interventions Rationale
1.     Establish rapport 1.     To get the cooperation of the patient and SO
2.    Monitor and recordvital signs 2.    To obtain baseline data
3.    Assess patient’s general condition 3.    To obtain baseline data
4.    Determine factors related to individual situation and note situation that can affect all bodysystem 4.    To assess causative and contributing factors
5.    Note characteristicof urine: measureurine specific gravity 5.    To assess for hematuria and proteinuria and renal impairment
6.    Ascertain usual voiding pattern 6.    To compare withcurrent situation
7.    Note presence location intensityduration of pain 7.    May indicate pain on affected organ
8.       Note mentation status and review lab result such as BUN and creatininelevels 8.    May indicate increase BUN and creatinine levels may alter mentation
9.    Monitor BP, ascertain patient’s usual range 9.    GFR may increase rennin and raise BP
10.    Observe for dependent generalized edema 10.  To note degree of impairment of renal function
11.  Measure urine output on a regular schedule and weigh daily 11.  To assess renalperfusion andfunction

 

12.  Provide diet restriction as indicated, while providing adequate calories 12.  Calories to meet body’s need while restriction of protein helps limit BUN.
13.  Encourage discussion of feelings  regarding prognosis or longterm effects of discussion 13.  To decrease anxiety aboutcondition andcorrect his wrong ideasabout condition
14.  Identify necessary changes in lifestyle pain on affected organ

 

14.  To promote wellness and prevent further progression of complication
15.  Assess patient’s emotional/psychological factors affecting the current situation 15.  Stress ordepression maybe increasing the effect of an illness or depression might be the result of being forced into inactivity
16.  Establish realistic activity goal withpatient. 16.  Enhance commitments to promoting optical outcomes
17.  Give information about positive signsof improvement such as improve vital signs/circulation 17.  To  provide encouragement
18.  Provide physiologic support. Maintain calm attitude but admit concerns if questioned by the client/SO 18.  Honestly can be reassuring when so much activity or worries are apparent to the client or SO
Evaluation
Short Term:

The patient shall have demonstrated participation in his/her recommended treatment program

Long Term:

The patient shall have behavior/lifestyle changes to prevent complications

 

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Author: Germeline Nabua

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