Risk for Disturbed Thought Processes | Nursing Care Plan for Renal Dialysis

Nursing diagnosis: risk for disturbed Thought Processes

Risk factors may include
Physiological changes—presence of uremic toxins, electrolyte imbalances, hypervolemia or fluid shifts, hyperglycemia (infusion of a dialysate with a high glucose concentration)

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Cognition
Regain usual or improved level of mentation.
Recognize changes in thinking and behavior and demonstrate behaviors to prevent or minimize changes.

Nursing intervention with rationale:
1. Assess for behavioral changes or change in level of consciousness (LOC)—disorientation, lethargy, decreased concentration, memory loss, and altered sleep patterns.
Rationale: May indicate level of uremic toxicity, response to or developing complication of dialysis such as “dialysis dementia,” and need for further assessment and intervention.

2. Keep explanations simple and reorient frequently as needed. Provide “normal” day or night lighting patterns, clock, and calendar.
Rationale: Improves reality orientation.

3. Provide a safe environment, restrain as indicated, and pad side rails during procedure, as appropriate.
Rationale: Prevents client trauma and inadvertent removal of dialysis lines or catheter.

4. Drain peritoneal dialysate promptly at end of specified equilibration period.
Rationale: Prompt outflow will decrease risk of hyperglycemia or hyperosmolar fluid shifts affecting cerebral function.

5. Investigate reports of headache, associated with onset of dizziness, nausea and vomiting, confusion or agitation, hypotension, tremors, or seizure activity.
Rationale: May reflect development of disequilibrium syndrome, which can occur near completion of or following HD and is thought to be caused by ultrafiltration or by the too-rapid removal of urea from the bloodstream not accompanied by equivalent removal from brain tissue. The hypertonic cerebrospinal fluid (CSF) causes a fluid shift into the brain, resulting in cerebral edema and increased intracranial pressure.

6. Monitor changes in speech pattern, development of dementia, and myoclonus activity during HD.
Rationale: Occasionally, accumulation of aluminum may cause dialysis dementia, progressing to death if untreated.

7. Monitor BUN/Cr and serum glucose levels, and determine urea reduction ratio (URR).
Rationale: Follows progression or resolution of azotemia. Pre- and postdialysis BUN levels are used to determine efficacy of procedure. URR greater than 65% is desirable (NKUDIC, 2005).

8. Alternate or change dialysate concentrations and add insulin, as indicated.
Rationale: Hyperglycemia may develop secondary to glucose crossing peritoneal membrane and entering circulation. May require initiation of insulin therapy.

9. Administer normal saline intravenously (IV), as appropriate.
Rationale: Volume restoration may be sufficient to reverse effects of disequilibrium syndrome.

10. Administer medication, as indicated, such as phenytoin (Dilantin), mannitol (Osmitrol), and barbiturates.
Rationale: If disequilibrium syndrome occurs during dialysis, medication may be needed to control seizures in addition to a change in dialysis prescription or discontinuation of therapy. After the procedure, an osmotic diuresis may be required to reduce cerebral edema, along with anticonvulsant therapy and barbiturates to slow brain metabolism.