Nursing Care Plan for Hypertension

Nursing Assessment Nursing Care Plan for Hypertension

Assessment is the main basis of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, their families, the data obtained through interviews, observation and examination.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :

1. Data base
2. Specific data relating to the current situation of the client which can be determined by the nurse, client or family.

The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

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Nursing Diagnosis Nursing Care Plan for Hypertension

1. Risk for Decreased Cardiac Output related to Increased afterload, vasoconstriction and myocardial ischemia.


2. Acute pain related to increased cerebral vascular pressure.


3. Activity Intolerance related to general weakness, imbalance Between supply and demand of oxygen.


4. Risk for Ineffective Tissue Perfusion : cerebral, renal, cardiac related to circulatory disorders.


5. Imbalanced Nutrition: More Than body requirements related to the input of excessive, monotonous lifestyle, cultural beliefs.


6. Inefektif Individual Coping related to situational crisis / maturasional, the support system is inadequate, ineffective coping methods.


7. Deficient Knowledge related to lack of information about the disease process and self-care.

Nursing Intervention Nursing Care Plan for Hypertension

Risk for Excess Fluid Volume | Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for excess Fluid Volume

Risk factors may include
Rapid and excessive fluid intake—IV, blood, plasma expanders, saline given to support BP during dialysis

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

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Maintain “dry weight” within client’s normal range; be free of edema; and have clear breath sounds and serum sodium levels within normal limits.

Nursing intervention with rationale:
1. Measure all sources of I&O. Weigh routinely.
Rationale: Aids in evaluating fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg or approximately 1 lb/day.

2. Monitor BP and pulse.
Rationale: Hypertension and tachycardia between hemodialysis runs may result from fluid overload and heart failure (HF).

3. Note presence of peripheral or sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, and electrocardiogram (ECG) changes indicative of ventricular hypertrophy.
Rationale: Fluid volume excess due to inefficient dialysis or repeated hypervolemia between dialysis treatments may cause or exacerbate HF, as indicated by signs and symptoms of respiratory and systemic venous congestion.

4. Note changes in mentation. (Refer to CP: Renal Dialysis; ND: risk for disturbed Thought Processes.)
Rationale: Fluid overload or hypervolemia may potentiate disequilibrium syndrome.

5. Monitor serum sodium levels. Restrict sodium intake, as indicated.
Rationale: High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.

6. Restrict fluid intake as indicated, spacing allowed fluids throughout a 24-hour period.
Rationale: The intermittent nature of hemodialysis results in fluid retention and volume overload between procedures and may require fluid restriction. Spacing fluids helps reduce thirst.

Risk for Deficient Fluid Volume | Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Ultrafiltration
Fluid restrictions, actual blood loss—systemic heparinization or disconnection of the shunt

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

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membranes, absence of bleeding, and appropriate weight.

Nursing intervention with rationale:
1. Measure all sources of intake and output (I&O). Have client keep diary.
Rationale: Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis clients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.

2. Weigh daily as well as before and after dialysis run.
Rationale: Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal. Dry weight determines how much excess fluid has been removed and serves as a guide for subsequent dialysis run time and solution.

3. Monitor BP, pulse, and hemodynamic pressures, if available, during dialysis.
Rationale: Hypotension, tachycardia, and falling hemodynamic pressures suggest volume depletion.

4. Ascertain whether diuretics and antihypertensives are to be withheld.
Rationale: Dialysis potentiates hypotensive effects if these drugs have been administered.

5. Verify continuity of shunt or access catheter.
Rationale: Disconnected shunt or open access permits exsanguination.

6. Apply external shunt dressing. Permit no puncture of shunt.
Rationale: Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.

7. Place client in a supine or Trendelenburg position, as necessary.
Rationale: Maximizes venous return if hypotension occurs.

8. Assess for oozing or frank bleeding at access site, mucous membranes, or incisions and wounds. Hematest stools or any drainage.
Rationale: Systemic heparinization during dialysis prolongs clotting times and places client at risk for bleeding, especially during the first 4 hours after procedure.

9. Monitor laboratory studies, as indicated, such as the following: Hemoglobin/hematocrit (Hgb/Hct)
Rationale: May be reduced because of anemia, hemodilution, or actual blood loss.

10. Reduce rate of ultrafiltration during dialysis, as indicated.
Rationale: Reduces the amount of water being removed and may correct hypotension or hypovolemia.

Risk for Injury | Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for Injury

Risk factors may include
Clotting, hemorrhage related to accidental disconnection, infection

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

Desired Outcomes/Evaluation Criteria—Client Will
Hemodialysis Access
Maintain patent vascular access.
Be free of infection.

Nursing intervention with rationale:
1. Assess client’s pulse and tissue color distal to shunt.
Rationale: Determines general circulatory status of limb.

2. Monitor internal AV fistula or graft patency at frequent intervals.
Rationale: Clotting (thrombosis) of the AV access is the most common complication.

3. Palpate for thrill.
Rationale: Should be palpable above venous exit site. If the thrill stops, or even feels different, this could indicate clotting. With early intervention, many clots can be dissolved or removed.

4. Auscultate for a bruit.
Rationale: Bruit is the sound caused by the turbulence of arterial blood entering the venous system and should be audible by stethoscope, although may be very faint. If the bruit gets higher in pitch, it could mean narrowing of the blood vessels; if it stops, clot may have formed.

5. Note color of blood and obvious separation of cells and serum.
Rationale: Change of color from uniform medium red to dark purplish red suggests sluggish blood flow and early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation. Note: Prior to insertion of an AV fistula or graft, client may have a temporary or permanent central catheter, which is maintained with heparin to inhibit clot formation. Because heparin remains active in the body for 4 to 6 hours, the client is at risk for hemorrhage during and immediately after dialysis (Leydig 2005).

6. Palpate skin around shunt for warmth.
Rationale: Diminished blood flow results in “coolness” of shunt.

7. Notify physician and initiate declotting procedure if there is evidence of loss of shunt patency.
Rationale: Rapid intervention may save access; however, declotting must be done by experienced personnel.

8. Evaluate reports of pain, numbness, and tingling; note extremity swelling distal to access.
Rationale: May indicate inadequate blood supply.

9. Avoid trauma to shunt; for example, handle tubing gently and maintain cannula alignment. Limit activity of extremity. Avoid taking blood pressure (BP) or drawing blood samples in shunt extremity. Instruct client not to sleep on side with shunt or carry packages, books, or purse on affected extremity.
Rationale: Decreases risks of clotting and disconnection. It is critical that the catheter be used only for dialysis as it is the client’s lifeline (Leydig, 2005).

10. Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulae separate, clamp the arterial cannula first, then the venous. If tubing comes out of vessel, clamp cannula that is still in place and apply direct pressure to bleeding site. Place tourniquet above site or inflate BP cuff to pressure just above client’s systolic BP.
Rationale: Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.

Risk for Ineffective Breathing Pattern | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for ineffective Breathing Pattern

Risk factors may include
Abdominal pressure, restricted diaphragmatic excursion, rapid infusion of dialysate, pain
Inflammatory process, such as atelectasis and pneumonia

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

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Display an effective respiratory pattern with clear breath sounds and arterial blood gases (ABGs) within client’s normal range.
Experience no signs of dyspnea or cyanosis.

Nursing intervention with rationale:
1. Monitor respiratory rate and effort. Reduce infusion rate if dyspnea is present.
Rationale: Tachypnea, dyspnea, shortness of breath, and shallow breathing during dialysis suggest diaphragmatic pressure from distended peritoneal cavity or may indicate developing complications.

2. Auscultate lungs, noting decreased, absent, or adventitious breath sounds, such as crackles, wheezes, and rhonchi.
Rationale: Decreased areas of ventilation suggest presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection.

3. Note character, amount, and color of secretions.
Rationale: Client is susceptible to pulmonary infections as a result of depressed cough reflex and respiratory effort, increased viscosity of secretions, as well as altered immune response and chronic, debilitating disease.

4. Elevate head of bed or have client sit up in chair. Promote deep-breathing exercises and coughing.
Rationale: Facilitates chest expansion and ventilation and mobilization of secretions.

5. Review ABGs, pulse oximetry, and serial chest x-rays.
Rationale: Changes in PaO2 and PaCO2 and appearance of infiltrates and congestion on chest x-ray suggest developing pulmonary problems.

6. Administer supplemental oxygen, as indicated.
Rationale: Maximizes oxygen for vascular uptake, thus preventing or lessening hypoxia.

7. Administer analgesics, as indicated.
Rationale: Alleviates pain and promotes comfortable breathing and maximal cough effort.

Risk for Infection | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for Infection

Risk factors may include
Contamination of the catheter during insertion, periodic changing of tubing and bags
Skin contaminants at catheter insertion site
Sterile peritonitis (response to the composition of dialysate)

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

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Identify interventions to prevent or reduce risk of infection.
Experience no signs or symptoms of infection.

Nursing intervention with rationale:
1. Observe meticulous aseptic technique and wear masks during catheter insertion, dressing changes, and whenever the system is opened. Change tubing per protocol.
Rationale: Prevents the introduction of organisms and airborne contamination that may cause infection, the most common complication of PD.

2. Change dressings as indicated, being careful not to dislodge the catheter. Note character, color, odor, or drainage from insertion site.
Rationale: Moist environment promotes bacterial growth. Purulent drainage at insertion site suggests presence of local infection, often involving skin organisms, which can be difficult to treat and sometimes require catheter removal and temporary HD. Note: Polyurethane adhesive film (e.g., blister film) dressings have been found to decrease amount of pressure on catheter and exit site as well as incidence of site infections.

3. Observe color and clarity of effluent.
Rationale: Cloudy effluent is suggestive of peritoneal infection.

4. Apply povidone-iodine (Betadine) barrier in distal, clamped portion of catheter when intermittent dialysis therapy used.
Rationale: Reduces risk of bacterial entry through catheter between dialysis treatments when catheter is disconnected from closed system.

5. Investigate reports of nausea or vomiting, increased or severe abdominal pain, rebound tenderness, or fever.
Rationale: Signs and symptoms suggesting peritonitis, requiring prompt intervention.

6. Monitor white blood cell (WBC) count of effluent.
Rationale: Presence of WBCs initially may reflect normal response to a foreign substance; however, continued or new elevation of WBCs suggests developing infection.

7. Obtain specimens of blood, effluent, and drainage from insertion site, as indicated, for culture and sensitivity.
Rationale: Identifies types of organism(s) present and influences choice of interventions.

8. Monitor renal blood urea nitrogen (BUN) and creatinine (Cr) clearance.
Rationale: Choice and dosage of antibiotics are influenced by level of clearance.

9. Administer antibiotics systemically or in dialysate, as indicated.
Rationale: Treats infection and prevents sepsis.

Acute Pain | Nursing Diagnosis Peritoneal Dialysis

Nursing diagnosis: acute Pain related to insertion of catheter through abdominal wall, catheter irritation, improper catheter placement, irritation, infection within the peritoneal cavity, infusion of cold or acidic dialysate, abdominal distention, rapid infusion of dialysate

Possibly evidenced by
Reports of pain
Self-focusing
Guarding, distraction behaviors, restlessness

Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Verbalize decrease of pain and discomfort.
Demonstrate relaxed posture and facial expression; be able to sleep and rest appropriately.

Nursing intervention with rationale:
1. Investigate client’s reports of pain; note intensity (0 to 10), location, and precipitating factors.
Rationale: Assists in identification of source of pain and appropriate interventions.

2. Explain that initial discomfort usually subsides after the first few exchanges.
Rationale: Information may reduce anxiety and promote relaxation during procedure.

3. Monitor for pain that begins during inflow and continues during equilibration phase. Slow infusion rate, as indicated.
Rationale: Pain will occur if acidic dialysate causes chemical irritation of peritoneal membrane.

4. Note reports of discomfort that are most pronounced near the end of inflow, and instill no more than 2,000 mL of solution at a single time.
Rationale: Likely the result of abdominal distention from dialysate. Amount of infusion may have to be decreased initially.

5. Prevent air from entering peritoneal cavity during infusion. Note report of pain in area of shoulder blade.
Rationale: Inadvertent introduction of air into the abdomen irritates the diaphragm and results in referred pain to shoulder blade. This type of discomfort may also be reported during initiation of therapy or during infusions and usually is related to stretching or irritation of the diaphragm with abdominal distention. Smaller exchange volumes may be required until client adjusts.

6. Elevate head of bed at intervals. Turn client from side to side. Provide back care and tissue massage.
Rationale: Position changes and gentle massage may relieve abdominal and general muscle discomfort.

7. Warm dialysate to body temperature before infusing.
Rationale: Warming the solution increases the rate of urea removal by dilating peritoneal vessels. Cold dialysate causes vasoconstriction, which can cause discomfort and excessively lower the core body temperature, precipitating cardiac arrest.

8. Monitor for severe or continuous abdominal pain and temperature elevation, especially after dialysis has been discontinued.
Rationale: May indicate developing peritonitis.

9. Encourage use of relaxation techniques, such as deepbreathing exercises, guided imagery, and visualization. Provide diversional activities.
Rationale: Redirects attention and promotes sense of control.

10. Add sodium hydroxide to dialysate, if indicated.
Rationale: Occasionally used to alter pH if client is not tolerating acidic dialysate.

Nursing Care Plan for COPD

Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)

Nursing Assessment for COPD (Chronic Obstructive Pulmonary Disease)

1. The Identity of the Client
   Name, place and date of birth, age, sex, the responsible include: name, address, relationship with the client.


2. Perception of Health and Health Maintenance.
   Review the status of a medical history of having experienced the client, what efforts and where clients get medical help, then what makes the client's health status declined.


3. Metabolic Nutrition
   Ask the client about the type, frequency, and amount of food and drink clients in a day. Assess excessive or decreased appetite, nausea, vomiting or a review of the intravenous therapy, use of enteric tube, measuring weight, height measurement.


4. Elimination
   Review of rekuensi, characteristics, difficulties / problems and also the use of assistive devices such as catheters, also measuring intake and output.
   Elimination process, review the frequency, characteristics, difficulties / problems defecation and also the use of tools / interventions in defecation.


5. Activity and Exercise
   Assess the ability of activities both before illness or condition now and also the use of assistive devices such as canes, wheel chairs and others. Ask the client about the use of leisure time. Are there any complaints on your breathing, such as the beating heart, chest pain, weak body.


6. Sleep and Rest
   Ask the client's daily sleep habits. How to sleep atmosphere client whether light or dark. Often wake up during sleep caused by pain, itching, urination, difficulty and others.


7. Cognitive Perception
   Ask the client whether to use vision aids, hearing. Is there any client trouble remembering things, how clients cope with discomfort: pain. Is there a perception of sensory disturbances such as blurred vision, hearing impaired. Assess the level of orientation to time place and person.


8. Perception and Self-Concept
   Assess the behavior of the self, whether the client has experienced despair / frustration / stress, and how according to clients about themselves.


9. Role Relationships
   What is the role of clients in the community and family, how client relationships in the community, family and coworkers. Assess whether there is disruption and disturbance of verbal communication in interactions with family members and others.


10. Sexual Production
    Ask the client about the use of contraception and the problems that arise. How many children of clients and client's marital status.


11. Coping Mechanisms and Tolerance to Stress.
    Assess the factors that make the client angry, where clients exchange opinions and coping mechanisms that are used for this. Assess client's current situation against conformity, expression, denial / rejection of self.


12. Belief System
    Assess whether the client worship, clients follow a religion? Assess whether there are values ​​on which clients embrace religion contrary to health.

Nursing Diagnosis Nursing Care Plan for COPD

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.


2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.


3. Impaired Gas Exchange related to ventilation perfusion inequality.


4. Activity Intolerance related to imbalance between supply with oxygen demand.


5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.


6. Disturbed Sleep Pattern related to discomfort, the setting position.


7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.


8. Anxiety related to threat to self-concept, the threat of death, unmet needs.


9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.


10. Knowledge Deficit related to lack of information, do not know the source of information.

Source : http://nandanursingdiagnosis.blogspot.com



Nursing Intervention Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)


Nursing Diagnosis for COPD

Ineffective Airway Clearance related to bronchoconstriction, Increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

Goal:
Achieving client airway clearance


Nursing Intervention for COPD

1. Give the patient 6 to 8 glasses of fluid per day unless there is Cor pulmonale.
2. Teach and give the use of diaphragmatic breathing and coughing techniques.
3. Assist in the provision of a nebulizer action, measured dose inhalers.
4. Perform postural drainage with percussion and vibration in the morning and at night as required.
5. Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
6. Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in color of sputum, sputum viscosity, increased shortness of breath, chest tightness, fatigue.
7. Give antibiotics as required.
8. Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

Nursing Diagnosis for COPD

Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway Irritants.

Goal:
Improvement of breathing patterns

Nursing Intervention for COPD

1. Teach client diaphragmatic breathing exercises and breathing lips sealed.
2. Give encouragement to intersperse activity with periods of rest. Let the patient make decisions about treatment based on patient tolerance level.
3. Give encouragement to use the muscles of breathing exercises if required.

Source : http://nursinginterventions-diagnosis.blogspot.com

Risk for Trauma | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for Trauma

Risk factors may include
Catheter inserted into peritoneal cavity
Site near the bowel and bladder with potential for perforation during insertion or manipulation of the catheter

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

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Experience no injury to bowel or bladder.

Nursing intervention with rationale:
1. Have client empty bladder before peritoneal catheter insertion if indwelling catheter not present.
Rationale: An empty bladder is more distant from insertion site and reduces likelihood of being punctured during catheter insertion.

2. Anchor catheter and tubing with tape. Stress importance of client avoiding pulling or pushing on catheter. Restrain hands if indicated.
Rationale: Reduces risk of trauma by manipulation of the catheter.

3. Note presence of fecal material in dialysate effluent or strong urge to defecate, accompanied by severe, watery diarrhea.
Rationale: Suggests bowel perforation with mixing of dialysate and bowel contents.

4. Note reports of intense urge to void or large urine output following initiation of dialysis run. Test urine for sugar, as indicated.
Rationale: Suggests bladder perforation with dialysate leaking into bladder. Presence of glucose-containing dialysate in the bladder will elevate glucose level of urine.

5. Stop dialysis if there is evidence of bowel or bladder perforation, leaving peritoneal catheter in place.
Rationale: Prompt action will prevent further injury. Immediate surgical repair may be required. Leaving catheter in place facilitates diagnosing and locating the perforation.

Risk for Deficient Fluid Volume | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Use of hypertonic dialysate with excessive removal of fluid from circulating volume

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

Desired Outcomes/Evaluation Criteria—Client Will
Systemic Toxin Clearance: Dialysis
Achieve desired alteration in fluid volume and weight with BP and electrolyte levels within acceptable range.
Experience no symptoms of dehydration.

Nursing intervention with rationale:
1. Maintain record of inflow and outflow volumes and individual and cumulative fluid balance.
Rationale: Provides information about the status of client’s loss or gain at the end of each exchange.

2. Adhere to schedule for draining dialysate from abdomen.
Rationale: Prolonged dwell times, especially when 4.5% glucose solution is used, may cause excessive fluid loss.

3. Weigh when abdomen is empty, following initial 6 to 10 runs, then as indicated.
Rationale: Detects rate of fluid removal by comparison with baseline body weight.

4. Monitor BP lying and sitting and pulse. Note level of jugular pulsation.
Rationale: Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia.

5. Note reports of dizziness, nausea, and increasing thirst.
Rationale: May indicate hypovolemia or hyperosmolar syndrome.

6. Inspect mucous membranes, evaluate skin turgor, peripheral pulses, and capillary refill.
Rationale: Dry mucous membranes, poor skin turgor, and diminished pulses and capillary refill are indicators of dehydration and need for increased intake or changes in strength of dialysate.

7. Monitor laboratory studies, as indicated, such as: Serum sodium and glucose levels
Rationale: Hypertonic solutions may cause hypernatremia by removing more water than sodium. In addition, dextrose may be absorbed from the dialysate, thereby elevating serum glucose.

8. Monitor laboratory studies, as indicated, such as: Serum potassium levels
Rationale: Hypokalemia may occur and can cause cardiac dysrhythmias.

Risk for Excess Fluid Volume | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for excess Fluid Volume

Risk factors may include
Inadequate osmotic gradient of dialysate
Fluid retention—malpositioned, kinked or clotted catheter; bowel distention, peritonitis, scarring of peritoneum
Excessive oral (PO) or intravenous (IV) intake

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

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Demonstrate dialysate outflow exceeding or approximating infusion.
Experience no rapid weight gain, edema, or pulmonary congestion.

Nursing intervention with rationale:
1. Maintain a record of inflow and outflow volumes and cumulative fluid balance.
Rationale: In most cases, the amount drained should equal or exceed the amount instilled. A positive balance with more fluid in than out indicates need for further evaluation.

2. Record serial weights, compare with intake and output (I&O) balance. Weigh client when abdomen is empty of dialysate providing a consistent reference point.
Rationale: Serial body weights are an accurate indicator of fluid volume status. A positive fluid balance with an increase in weight indicates fluid retention.

3. Assess patency of catheter, noting difficulty in draining. Note presence of fibrin strings or plugs.
Rationale: Slowing of flow rate or presence of fibrin suggests partial catheter occlusion requiring further evaluation or possible intervention.

4. Check tubing for kinks; note placement of bags. Anchor catheter so that adequate inflow and outflow is achieved.
Rationale: Improper functioning of equipment may result in retained fluid in abdomen and insufficient clearance of toxins.

5. Turn from side to side, elevate the head of the bed, and apply gentle pressure to the abdomen.
Rationale: May enhance outflow of fluid when catheter is malpositioned or obstructed by the omentum.

6. Note abdominal distention associated with decreased bowel sounds, changes in stool consistency, and reports of constipation.
Rationale: Bowel distention or constipation may impede outflow of effluent. (Refer to CP: Renal Dialysis; ND: risk for Constipation.)

7. Monitor blood pressure (BP) and pulse, noting hypertension, bounding pulses, neck vein distention, and peripheral edema; measure central venous pressure (CVP), if available.
Rationale: Elevations indicate hypervolemia. Assess heart and breath sounds, noting S3 and crackles and rhonchi. Fluid overload may potentiate heart failure (HF) or pulmonary edema.

8. Evaluate development of tachypnea, dyspnea, and increased respiratory effort. Drain dialysate and notify physician.
Rationale: Abdominal distention or diaphragmatic elevation may cause respiratory distress.

9. Assess for headache, muscle cramps, mental confusion, and disorientation.
Rationale: Symptoms suggest hyponatremia or water intoxication.

10. Add heparin to initial dialysis runs; assist with irrigation of catheter with heparinized saline.
Rationale: May be useful in preventing fibrin clot formation, which can obstruct peritoneal catheter.

Anxiety | Nursing Care Plan for Renal Dialysis

Nursing diagnosis: Anxiety related to situational crisis, threat to self-concept, change in health status, role functioning, socioeconomic status, threat of death, unknown consequences or outcome

Possibly evidenced by
Increased tension, apprehension, uncertainty, fear
Expressed concerns
Sympathetic stimulation, focus on self

Desired Outcomes/Evaluation Criteria—Client Will
Anxiety [or] Fear Self-Control
Verbalize awareness of feelings and reduction of anxiety or fear to a manageable level.
Demonstrate problem-solving skills and effective use of resources.
Appear relaxed and able to rest and sleep appropriately.

Nursing intervention with rationale:
1. Assess level of fear of both client and SO. Note signs of denial, depression, or narrowed focus of attention.
Rationale: Helps determine the kind of interventions required.

2. Explain procedures and care as delivered. Repeat explanations frequently, as needed. Provide information in multiple formats, including pamphlets and films.
Rationale: Fear of unknown is lessened by information and knowledge and may enhance acceptance of permanence of ESRD and necessity for dialysis. Alteration in thought processes and high levels of anxiety or fear may reduce comprehension, requiring repetition of important information. Note: Uremia can impair short-term memory, requiring repetition or reinforcement of information provided.

3. Acknowledge normalcy of feelings in this situation.
Rationale: Knowing feelings are normal can allay fear that client is losing control.

4. Provide opportunities for client and SO to ask questions and verbalize concerns.
Rationale: Creates feeling of openness and cooperation and provides information that will assist in problem identification and solving.

5. Encourage SO to participate in care, as able and desired.
Rationale: Involvement promotes sense of sharing, strengthens feelings of usefulness, provides opportunity to acknowledge individual capabilities, and may lessen fear of the unknown.

6. Acknowledge concerns of client and SO.
Rationale: Prognosis and possibility of need for long-term dialysis and resultant lifestyle changes are major concerns for this client and those who may be involved in future care.

7. Point out positive indicators of treatment—improvement in laboratory values, stable BP, and lessened fatigue.
Rationale: Promotes sense of progress in an otherwise chronic process that seems endless while client still is experiencing physical deterioration and depression.

8. Arrange for visit to dialysis center and meeting with another dialysis client, as appropriate.
Rationale: Interaction with others who have encountered similar problems may assist client and SO to work toward acceptance of chronic condition and focus on problem-solving activities.

9. Address financial considerations. Refer to appropriate resources.
Rationale: Treatment for kidney failure is expensive, although Medicare and other health insurance programs pay much of the cost.

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.

Risk for Constipation | Nursing Care Plan for Renal Dialysis

Nursing diagnosis: risk for Constipation

Risk factors may include
Decreased fluid intake, altered dietary pattern
Reduced intestinal motility, compression of bowel (peritoneal dialysate), electrolyte imbalances, decreased mobility

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

Desired Outcomes/Evaluation Criteria—Client Will
Bowel Elimination
Maintain usual or improved bowel function.

Nursing intervention with rationale:
1. Auscultate bowel sounds. Note consistency and frequency of bowel movements (BMs) and presence of abdominal distention.
Rationale: Decreased bowel sounds; passage of hard-formed or dry stools suggests constipation and requires ongoing intervention to manage.

2. Review current medication regimen.
Rationale: Side effects of some drugs, such as iron products and some antacids, may compound problem.

3. Ascertain usual dietary pattern and food choices.
Rationale: Although restrictions may be present, thoughtful consideration of menu choices can aid in controlling problem.

4. Suggest adding fresh fruits, vegetables, and fiber to diet within restrictions, when indicated.
Rationale: Provides bulk, which improves stool consistency.

5. Encourage or assist with ambulation, when able.
Rationale: Activity may stimulate peristalsis, promoting return to normal bowel activity.

6. Provide privacy at bedside commode and bathroom.
Rationale: Promotes psychological comfort needed for elimination.

7. Administer stool softeners, such as Colace or bulk-forming laxatives, such as Metamucil, as appropriate.
Rationale: Produces a softer, more easily evacuated stool.

8. Keep client nothing by mouth (NPO) status; insert NG tube, as indicated.
Rationale: Decompresses stomach when recurrent episodes of unrelieved vomiting occur. Large gastric output suggests ileus, a common early complication of PD, with accumulation of gas and intestinal fluid that cannot be passed rectally.

Self-Care Deficit | Nursing Care Plan for Renal Dialysis

Nursing diagnosis: Self-Care Deficit related to intolerance to activity, decreased strength and endurance, pain or discomfort, perceptual or cognitive impairment (accumulated toxins)

Possibly evidenced by
Reported inability to carry out ADLs
Disheveled and unkempt appearance, strong body odor

Desired Outcomes/Evaluation Criteria—Client Will
Self-Care: Activities of Daily Living (ADLs)
Participate in ADLs within level of own ability and constraints of the illness.

Nursing intervention with rationale:
1. Determine client’s ability to participate in self-care activities (scale of 0 to 4).
Rationale: Underlying condition dictates level of deficit, affecting choice of interventions. Note: Psychological factors, such as depression, motivation, and degree of support, also have a major impact on the client’s abilities.

2. Provide assistance with activities as necessary.
Rationale: Meets needs while supporting client participation and independence.

3. Encourage use of energy-saving techniques: sitting, not standing; using shower chair; and doing tasks in small increments.
Rationale: Conserves energy, reduces fatigue, and enhances client’s ability to perform tasks.

4. Recommend scheduling activities to allow client sufficient time to accomplish tasks to fullest extent of ability.
Rationale: Unhurried approach reduces frustration and promotes client participation, enhancing self-esteem.

Impaired physical Mobility | Nursing Care Plan for Renal Dialysis

Nursing diagnosis: impaired physical Mobility related to restrictive therapies—lengthy dialysis procedure, fear of or real danger of dislodging dialysis lines or catheter, decreased strength and endurance; musculoskeletal impairment, perceptual or cognitive impairment

Possibly evidenced by
Reluctance to attempt movement
Inability to move within physical environment
Decreased muscle mass, tone, and strength
Impaired coordination
Pain, discomfort

Desired Outcomes/Evaluation Criteria—Client Will
Mobility
Maintain optimal mobility and function.
Display increased strength and be free of associated complications—contractures and decubitus ulcers.

Nursing intervention with rationale:
1. Assess activity limitations, noting presence and degree of restriction or ability.
Rationale: Influences choice of interventions.

2. Encourage frequent change of position when on bedrest or chair rest; support affected body parts and joints with pillows, rolls, sheepskin, and elbow and heel pads, as indicated.
Rationale: Decreases discomfort, maintains muscle strength and joint mobility, enhances circulation, and prevents skin breakdown.

3. Provide gentle massage. Keep skin clean and dry. Keep linens dry and wrinkle free.
Rationale: Stimulates circulation; prevents skin irritation.

4. Encourage deep breathing and coughing. Elevate head of bed, as appropriate.
Rationale: Mobilizes secretions, improves lung expansion, and reduces risk of respiratory complications, such as atelectasis or pneumonia.

5. Suggest and provide diversion as appropriate to client’s condition—visitors, radio or TV, and books. Take time to interact with client, showing interest in client’s life.
Rationale: Decreases boredom; promotes relaxation.

6. Instruct in and assist with active and passive range-of-motion (ROM) exercises.
Rationale: Maintains joint flexibility, prevents contractures, and aids in reducing muscle tension. Note: A high level of phosphorus may cause calcium-phosphorus crystals to build up in the joints, muscles, and other body organs, leading to bone and joint pain. To avoid these risks, client may be prescribed a phosphate binder such as Basalgel or Renagel (Leydig, 2005).

7. Institute a planned activity or exercise program as appropriate, with client’s input.
Rationale: Increases client’s energy and sense of well-being. Studies have shown that regular exercise programs have benefited clients with ESRD, both physically and emotionally. Stable clients have not been shown to have adverse effects (Goodman & Ballou, 2004).

8. Provide foam, water, or air flotation mattress or soft chair cushion.
Rationale: Reduces tissue pressure and may enhance circulation, thereby reducing risk of dermal ischemia and breakdown.

Imbalanced Nutrition: Less than Body Requirements | Nursing Diagnosis for Renal Dialysis

Nursing diagnosis: imbalanced Nutrition: Less than Body Requirements related to gastrointestinal (GI) disturbances (result of uremia or medication side effects)—anorexia, nausea, vomiting, and stomatitis, sensation of feeling full—abdominal distention during continuous ambulatory peritoneal dialysis (CAPD), dietary restrictions—bland, tasteless food; lack of interest in food, loss of peptides and amino acids (building blocks for proteins) during dialysis

Possibly evidenced by
Inadequate food intake, aversion to eating, altered taste sensation
Poor muscle tone, weakness
Sore, inflamed buccal cavity; pale conjunctiva and mucous membranes

Desired Outcomes/Evaluation Criteria—Client Will
Nutritional Status
Demonstrate stable weight or gain toward goal with normalization of laboratory values and no signs of malnutrition.

Nursing intervention with rationale:
1. Monitor food and fluid ingested and calculate daily caloric intake.
Rationale: Identifies nutritional deficits and therapy needs, which are extremely variable, depending on client’s age, stage of renal disease, other coexisting conditions, and the type of dialysis being planned.

2. Recommend client/significant other (SO) keep a food diary, including estimation of ingested calories, protein, and electrolytes of individual concern—sodium, potassium, chloride, magnesium, and phosphorus.
Rationale: Helps client realize “big picture” and allows opportunity to alter dietary choices to meet individual desires within identified restriction.

3. Note presence of nausea and anorexia.
Rationale: Symptoms accompany accumulation of endogenous toxins that can alter or reduce intake and require intervention.

4. Encourage client to participate in menu planning.
Rationale: May enhance oral intake and promote sense of control.

5. Recommend small, frequent meals. Schedule meals according to dialysis needs.
Rationale: Smaller portions may enhance intake. Type of dialysis influences meal patterns; for instance, clients receiving HD might not be fed directly before or during procedure because this can alter fluid removal, and clients undergoing PD may be unable to ingest food while abdomen is distended with dialysate.

6. Encourage use of herbs and spices such as garlic, onion, pepper, parsley, cilantro, and lemon.
Rationale: Adds zest to food to help reduce boredom with diet, while reducing potential for ingesting too much potassium and sodium.

7. Suggest socialization during meals.
Rationale: Provides diversion and promotes social aspects of eating.

8. Encourage frequent mouth care.
Rationale: Reduces discomfort of oral stomatitis and metallic taste in mouth associated with uremia, which can interfere with food intake.

9. Refer to nutritionist or dietitian to develop diet appropriate to client’s needs.
Rationale: Necessary to develop complex and highly individual dietary program to meet cultural and lifestyle needs within specific kilocalorie and protein restrictions while controlling phosphorus, sodium, and potassium.

10. Provide a balanced diet, usually of 2,000 to 2,200 calories/day of complex carbohydrates and ordered amount of high-quality protein and essential amino acids.
Rationale: Provides sufficient nutrients to improve energy and prevent muscle wasting (catabolism); promotes tissue regeneration and healing and electrolyte balance. Although client with kidney disease is often advised to limit protein intake, that changes with the start of dialysis. Protein-rich foods, such as fresh meats, poultry, fish and other seafood, eggs and egg whites, and small servings of dairy products are needed for building muscles, repairing tissue, and fighting infection. However, some protein-rich foods may contain a high level of phosphorus, so a dietitian’s input is essential in determining the right amount to eat (Paton, 2007).

Risk for Impaired Oral Mucous Membrane

Nursing diagnosis: risk for impaired Oral Mucous Membrane

Risk factors may include
Lack of or decreased salivation, fluid restrictions
Chemical irritation, conversion of urea in saliva to ammonia

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

Desired Outcomes/Evaluation Criteria—Client Will
Oral Health
Maintain integrity of mucous membranes.
Identify and initiate specific interventions to promote healthy oral mucosa.

Nursing intervention with rationale:
1. Inspect oral cavity: note moistness, character of saliva, presence of inflammation, ulcerations, and leukoplakia.
Rationale: Provides opportunity for prompt intervention and prevention of infection.

2. Provide fluids throughout 24-hour period within prescribed limit.
Rationale: Prevents excessive oral dryness from prolonged period without oral intake.

3. Offer frequent mouth care or rinse with 0.25% acetic acid solution. Provide gum, hard candy, or breath mints between meals.
Rationale: Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.

4. Encourage good dental hygiene after meals and at bedtime. Recommend avoidance of dental floss.
Rationale: Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding.

5. Recommend client stop smoking and avoid lemon and glycerin products or mouthwash containing alcohol.
Rationale: These substances are irritating to the mucosa and have a drying effect, potentiating discomfort.

6. Provide artificial saliva as needed, such as Ora-Lube.]
Rationale: Prevents dryness, buffers acids, and promotes comfort.

Risk for Impaired Skin Integrity | Nursing Diagnosis for Chronic Renal Failure

Nursing diagnosis: risk for impaired Skin Integrity

Risk factors may include
Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy)
Changes in fluid status; alterations in skin turgor—edema
Reduced activity, immobility
Accumulation of toxins in the skin

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

Desired Outcomes/Evaluation Criteria—Client Will
Tissue Integrity: Skin and Mucous Membranes
Maintain intact skin.
Risk Management
Demonstrate behaviors and techniques to prevent skin breakdown or injury.

Nursing intervention with rationale:
1. Inspect skin for changes in color, turgor, and vascularity. Note redness and excoriation. Observe for ecchymosis and purpura.
Rationale: Indicates areas of poor circulation and early breakdown that may lead to decubitus formation and infection.

2. Monitor fluid intake and hydration of skin and mucous membranes.
Rationale: Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level.

3. Inspect dependent areas for edema. Elevate legs, as indicated.
Rationale: Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation.

4. Change position frequently, move client carefully, pad bony prominences with sheepskin, and use elbow and heel protectors.
Rationale: Decreases pressure on edematous, poorly perfused tissues to reduce ischemia.

5. Provide soothing skin care, restrict use of soaps, and apply ointments or creams such as lanolin or Aquaphor.
Rationale: Baking soda and cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin.

6. Keep linens dry and wrinkle free.
Rationale: Reduces dermal irritation and risk of skin breakdown.

7. Investigate reports of itching.
Rationale: Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products, such as phosphate crystals associated with hyperparathyroidism in ESRD.

8. Recommend client use cool, moist compresses to apply pressure to, rather than scratch, pruritic areas. Keep fingernails short; encourage use of gloves during sleep, if needed.
Rationale: Alleviates discomfort and reduces risk of dermal injury.

9. Suggest wearing loose-fitting cotton garments.
Rationale: Prevents direct dermal irritation and promotes evaporation of moisture on the skin.

10. Provide foam or flotation mattress.
Rationale: Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis.

Disturbed Thought Processes | Nursing Diagnosis for Renal Failure

Nursing diagnosis: Disturbed Thought Process related to physiological changes—accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances;
calcifications in the brain

Possibly evidenced by
Disorientation to person, place, time, situation
Memory deficit, altered attention span, decreased ability to grasp ideas
Impaired ability to make decisions, problem-solve
Changes in sensorium—somnolence, stupor, coma
Changes in behavior—irritability, withdrawal, depression, psychosis

Desired Outcomes/Evaluation Criteria—Client Will
Cognition
Regain or maintain optimal level of mentation.
Identify ways to compensate for cognitive impairment and memory deficits.

Nursing intervention with rationale:
1. Assess extent of impairment in thinking ability, memory, and orientation. Note attention span.
Rationale: Uremic syndrome’s effect can begin with minor confusion or irritability and progress to altered personality, inability to assimilate information or participate in care. Awareness of changes provides opportunity for evaluation and intervention.

2. Ascertain from significant other (SO) client’s usual level of mentation.
Rationale: Provides comparison to evaluate progression or resolution of impairment.

3. Provide SO with information about client’s status.
Rationale: Some improvement in mentation may be expected with restoration of more normal levels of BUN, electrolytes, and serum pH.

4. Provide quiet, calm environment and judicious use of TV, radio, and visitation.
Rationale: Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation.

5. Reorient to surroundings, person, and so forth. Provide calendars, clocks, and outside window.
Rationale: Provides clues to aid in recognition of reality.

6. Present reality concisely and briefly, and do not challenge illogical thinking.
Rationale: Confrontation potentiates defensive reactions and may lead to client mistrust and heightened denial of reality.

7. Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary.
Rationale: May aid in reducing confusion and increases possibility that communications will be understood and remembered.

8. Establish a regular schedule for expected activities.
Rationale: Aids in maintaining reality orientation and may reduce fear and confusion.

9. Promote adequate rest and undisturbed periods for sleep.
Rationale: Sleep deprivation may further impair cognitive abilities.

10. Prepare for dialysis.
Rationale: Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis.