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Here 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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