NURSING CARE PLAN

Actual Problem

Systemic Infection

CUES Nursing Inference Goal/ Plan Nursing Rationale Evaluation

Diagnosis Intervention
 BP 160/90 Risk for Frequent IV At the end of the  Promoted  Reduces Goal met-
mmHg systemic cannnula will shift, patient will good hand risk of cross- Patient had
 Restlessness infection introduce experience no washing by contaminatio experienced
 Oliguria related to microorganism signs/symptoms client and n no signs of
 Hct.level 0.25 hemodialysis in the blood of infection. staff. infection.
 Na level 134 procedure as circulation that  Use  Reduces
 Hb. 0.83gm/l manifested would trigger aseptic bacterial
by fatigue, systemic technique colonization
weakness and infection. when and risk of
low Hb., manipulating ascending
Hct.level IV/invasive UTI.
lines.  Prevents
atelectasis
 Encourage and mobilizes
d deep secretions to
breathing, redue risk of
coughing, pulmonary
frequent infections.
position
changes.

 Excoriatio
ns from
scratching
 Assessed may become
 skin integrity secondarily
infected.

 Fever with
increased
 Monitored pulse and a
vital signs respiration is
typical of
increase
metabolic
rate resulting
from
inflammatory
process,
although
sepsis can
occur without
a febrile
response.

Decreased Tissue Perfusion

CUES Nursing Inference Goal/ Nursing Intervention Rationale Evaluation

Diagnosis Plan
 Oliguria Decreased Constriction At the  . Measure and  Provides Goal not
 Hypertensive tissue perfusion of the end of recorded blood objective data for met.
 Restlessness related to peripheral my pressure as indicated monitoring. Patient’s
 Cold and peripheral blood shift, blood
clammy skin vasoconstriction vessels will patient  Observed skin pressure
as manifested alter the will color, moisture,  Presence of remained
by high blood flow of decreas temperature, and pallor: cool, 160/90.
pressure blood to e blood capillary refill time. moist skin; and
perfuse the pressure delays capillary
different from refill time may
cells of the 160/90 be due to
body. to peripheral
130/90 vasoconstriction.
 Noted  May indicate
dependent/gener heart or renal
al edema failure

 Helps reduce
sympathetic
 Provided calm, stimulation;
restful promotes
surroundings, relaxation.
minimize  Reduces
environmental physical stress
activity/noise. and tension
Limit the that affect
number of blood
visitors and pressure and
length of stay. the course of
hypertension.
 Maintain activity  Decreases
restrictions; such discomfort
as bed rest/chair and may
rest; schedule reduce
periods of sympathetic
 uninterrupted stimulation
rest; assisted
client with self-
care activities as
needed.

 Provided
comfort measure
such back
massage,  Antihypert
elevation of ensive
head. medications
play a key
 Administered role in
antihypertensive treatment of
medications as hypertension
prescribed associated
with chronic
renal failure.

 Adherence to
diet and fluid
restrictions
 Encouraged and dialysis
compliance with schedule
dietary and fluid prevents
restriction excess fluid
therapy. and sodium
accumulation.
Oliguria

CUES Nursing Inference Goal/ Nursing Intervention Rationale Evaluation

Diagnosis Plan
 Decreased of Oliguria The After 1  Assess the cause  To be able to After 1
urine output related to production week if of decrease apply the proper week of
380cc End Stage of an nursing urinary output therapeutic nursing
 Dribbling of Renal abnormally interventio regimen. intervention
urine Disease small n the  Encourage client the patient’s
 Potassium- volume of patient to void every 2-4  May minimize urine output
7.47 urine. This will hrs & when urge urinary increased
increased may be a demonstrat is noted retention/overdist
(3.5- 5.0 mg/dl) result of e an  Determine the ention of the
copious increase in initial fluids and bladder
 Sodium- 134 sweating, amount of electrolytes level  Serve as baseline
decreased kidney urine for progress.
(135-145 mg/dl) disease, loss voided  Monitor intake &
of blood each time. output hourly
 Percuss/palpate  To determine the
suprapubic area. progress of the
disease
 A distended
 Observe Signs and bladder can be
symptoms of felt in the
fluids & suprapubic area.
electrolytes
imbalance such as  To be able to
dyspnea changes prevent further
in ECG and complication and
restlessness. administer proper
therapeutic agents
  Ensure clients as prescribed.
compliance on
hemodialysis  To promote
procedure continuous
elimination of
fluids and waste
products.

Potential Problem

Anxiety

CUES Nursing Inference Goal/ Plan Nursing Rationale Evaluation

Diagnosis Intervention

 Body malaise Anxiety Anxiety is a After 1 hour  Assessed  Helps Patient

related to normal of nursing level of fear determine verbalized
 Blurred in chronic experience. intervention, of client. the kind of acceptance of
vision intervention self in
illness w/ Moderate or the patient
s required. situation.
changes in high level of will verbalize
 Restlessness  Explained  Fear of
roles/ body anxiety can awareness of procedures/ unknown is
image. increase feelings of care as lessened by
alertness and anxiety. delivered. information
performance Repeated & may
in particular explanation’s enhance
situations. frequently as acceptance
needed. of
However,
permanence
people who of ESRD
experience and
 continues or necessity
recurring for dialysis.
fears or
episodes of  Creates
 Provided feeling of
intense fear
opportunities openness &
can feel for client to cooperation
powerless to ask questions & provides
manage their & information
symptoms verbalization that will
and their of concern. assist in
lives can problem
identificatio
become n/ solving.
severely
restricted.

Lack of Sleep

CUES Nursing Inference Goal/ Plan Nursing Rationale Evaluation

Diagnosis Intervention
 Restlessness Sleep pattern The client is At the end of Goal partially
 Dark circles disturbance r/t Unable to sleep my shift, the  Assess the  To met.
under eyes urinary because she clients will cause of determine Patient’s
 Irritable frequency frequent urge to increase the inability to the proper sleeping pattern
empty urinary sleeping hours sleep. increased from
bladder. Thus from 5 hrs. to 8  Assist  To 5-7 hrs.
her sleeping hrs. patient in promote
pattern is observing relaxation.
disrupted. any
previous b
Bedtime
 ritual.

 Advised  To
daytime promote
physical urinary
activities as eliminati
indicated. on thus
reducing
bladder
distentio
n to
promote
 Limit fluids sleep
before during
bedtime. night
time.

 To
prevent
urinary
bladder
retention
causing
dribbling
of urine.