Plan of Nursing Care The Patient With Chronic Renal Failure

Nursing Diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water Goal: Maintenance of ideal body weight without excess fluid
Nursing Interventions 1. Assess fluid status: a. Daily weight b. nta!e and out"ut balance Rationale 1. Assess$ent "ro%ides baseline and ongoing database for $onitoring changes and e%aluating inter%entions. (. Fluid restriction will be deter$ined on basis of weight' urine out"ut' and res"onse to thera"y. *. 2nrecogni3ed sources of e.cess fluids $ay be identified. ,. 2nderstanding "ro$otes "atient and fa$ily coo"eration with fluid restriction. /. ncreasing "atient co$fort "ro$otes co$"liance with dietary restrictions. 0. 4ral hygiene $ini$i3es dryness of oral $ucous $e$branes. Expected Outcomes De$onstrates no ra"id weight changes

c. #!in turgor and "resence of ede$a d. Distention of nec! %eins e. &lood "ressure' "ulse rate' and rhyth$ f. Res"iratory rate and effort

+aintains dietary and fluid restrictions -.hibits nor$al s!in turgor without ede$a -.hibits nor$al %ital signs -.hibits no nec! %ein distention Re"orts no difficulty breathing or shortness of breath Perfor$s oral hygiene fre1uently Re"orts decreased thirst Re"orts decreased dryness of oral $ucous $e$branes

(. )i$it fluid inta!e to "rescribed %olu$e. *. dentify "otential sources of fluid: a. +edications and fluids used to ta!e or ad$inister $edications: oral and intra%enous b. Foods ,. -."lain to "atient and fa$ily rationale for fluid restriction. /. Assist "atient to co"e with the disco$forts resulting fro$ fluid restriction. 0. Pro%ide or encourage fre1uent oral hygiene.

Nursing Diagnosis: Imbalanced nutrition less than body re!uirements related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous membranes Goal: Maintenance of ade!uate nutritional inta"e
1. Assess nutritional status: a. Weight changes 1. &aseline data allow for $onitoring of changes and e%aluating

Consu$es "rotein of high biologic %alue

b. )aboratory %alues 5seru$ electrolyte' &2N' creatinine' "rotein' transferrin' and iron le%els6 (. Assess "atient7s nutritional dietary "atterns: a. Diet history b. Food "references c. Calorie counts *. Assess for factors contributing to altered nutritional inta!e: a. Anore.ia' nausea' or %o$iting b. Diet un"alatable to "atient c. De"ression d. )ac! of understanding of dietary restrictions e. #to$atitis ,. Pro%ide "atient7s food "references within dietary restrictions. /. Pro$ote inta!e of high biologic %alue "rotein foods: eggs' dairy "roducts' $eats. 0. -ncourage high8calorie' low8 "rotein' low8sodiu$' and low8 "otassiu$ snac!s between $eals. 9. Alter schedule of $edications so that they are not gi%en i$$ediately before $eals. :. -."lain rationale for dietary restrictions and relationshi" to !idney disease and increased urea and creatinine le%els. ;. Pro%ide written lists of foods

effecti%eness of inter%entions. (. Past and "resent dietary "atterns are considered in "lanning $eals. *. nfor$ation about other factors that $ay be altered or eli$inated to "ro$ote ade1uate dietary inta!e is "ro%ided. ncreased dietary inta!e is encouraged.

Chooses foods within dietary restrictions that are a""ealing Consu$es high8 calorie foods within dietary restrictions -."lains in own words rationale for dietary restrictions and relationshi" to urea and creatinine le%els Ta!es $edications on schedule that does not "roduce anore.ia or feeling of fullness Consults written lists of acce"table foods Re"orts increased a""etite at $eals -.hibits no ra"id increases or decreases in weight De$onstrates nor$al s!in turgor without ede$a> wound healing and acce"table "las$a albu$in le%els

,.

/. Co$"lete "roteins are "ro%ided for "ositi%e nitrogen balance needed for growth and healing. 0. Reduces source of restricted foods and "roteins and "ro%ides calories for energy' s"aring "rotein for tissue growth and healing. 9. ngestion of $edications <ust before $eals $ay "roduce anore.ia and feeling of fullness.

:. Pro$otes "atient understanding of relationshi"s between diet and urea and creatinine le%els to renal disease. ;. )ists "ro%ide a "ositi%e a""roach to dietary restrictions and a reference for "atient and fa$ily to use when at ho$e. 1=. 2n"leasant factors

allowed and suggestions for i$"ro%ing their taste without use of sodiu$ or "otassiu$. 1=. Pro%ide "leasant surroundings at $eal8ti$es. 11. Weigh "atient daily. 1(. Assess for e%idence of inade1uate "rotein inta!e: a. -de$a for$ation b. Delayed wound healing c. Decreased seru$ albu$in le%els

that contribute to "atient7s anore.ia are eli$inated. 11. Allows $onitoring of fluid and nutritional status. 1(. nade1uate "rotein inta!e can lead to decreased albu$in and other "roteins' ede$a for$ation' and delay in wound healing.

Nursing Diagnosis: Deficient "nowledge regarding condition and treatment Goal: Increased "nowledge about condition and related treatment
1. Assess understanding of cause of renal failure' conse1uences of renal failure' and its treat$ent: a. Cause of "atient7s renal failure b. +eaning of renal failure c. 2nderstanding of renal function d. Relationshi" of fluid and dietary restrictions to renal failure e. Rationale for treat$ent 5he$odialysis' "eritoneal dialysis' trans"lantation6 (. Pro%ide e."lanation of renal function and conse1uences of renal failure at "atient7s le%el of understanding and guided by "atient7s readiness to learn. *. Assist "atient to identify ways to incor"orate changes related to illness and its treat$ent into lifestyle. 1. Pro%ides baseline for further e."lanations and teaching. (. Patient can learn about renal failure and treat$ent as he or she beco$es ready to understand and acce"t the diagnosis and conse1uences. *. Patient can see that his or her life does not ha%e to re%ol%e around the disease. ,. Pro%ides "atient with infor$ation that can be used for further clarification at ho$e.

?erbali3es relationshi" of cause of renal failure to conse1uences -."lains fluid and dietary restrictions as they relate to failure of !idney7s regulatory functions #tates in own words relationshi" of renal failure and need for treat$ent As!s 1uestions about treat$ent o"tions' indicating readiness to learn ?erbali3es "lans to continue as nor$al a life as

,. Pro%ide oral and written infor$ation as a""ro"riate about: a. Renal function and failure b. Fluid and dietary restrictions c. +edications d. Re"ortable "roble$s' signs' and sy$"to$s e. Follow8u" schedule f. Co$$unity resources

"ossible

2ses written infor$ation and instructions to clarify 1uestions and see! additional infor$ation

g. Treat$ent o"tions

Nursing Diagnosis: #ctivity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure Goal: $articipation in activity within tolerance
1. Assess factors contributing to acti%ity intolerance: a. Fatigue b. Ane$ia c. Fluid and electrolyte i$balances d. Retention of waste "roducts e. De"ression (. Pro$ote inde"endence in self8 care acti%ities as tolerated> assist if fatigued. *. -ncourage alternating acti%ity with rest. ,. -ncourage "atient to rest after dialysis treat$ents. 1. ndicates factors contributing to se%erity of fatigue.

(. Pro$otes i$"ro%ed self8estee$ *. Pro$otes acti%ity and e.ercise within li$its and ade1uate rest. ,. Ade1uate rest is encouraged after dialysis treat$ents' which are e.hausting to $any "atients.

Partici"ates in increasing le%els of acti%ity and e.ercise Re"orts increased sense of well8being Alternates rest and acti%ity Partici"ates in selected self8 care acti%ities

Nursing Diagnosis: %is" for situational low self&esteem related to dependency, role changes, change in body image, and change in sexual function Goal: Improved self&esteem
1. Assess "atient7s and fa$ily7s res"onses and reactions to 1. Pro%ides data about "roble$s encountered

dentifies "re%iously used

illness and treat$ent. (. Assess relationshi" of "atient and significant fa$ily $e$bers. *. Assess usual co"ing "atterns of "atient and fa$ily $e$bers. ,. -ncourage o"en discussion of concerns about changes "roduced by disease and treat$ent: a. Role changes b. Changes in lifestyle c. Changes in occu"ation d. #e.ual changes e. De"endence on health care tea$ /. -."lore alternate ways of se.ual e."ression other than se.ual intercourse. 0. Discuss role of gi%ing and recei%ing lo%e' war$th' and affection. (.

by "atient and fa$ily in co"ing with changes in life. dentifies strengths and su""orts of "atient and fa$ily.

*. Co"ing "atterns that $ay ha%e been effecti%e in "ast $ay be har$ful in %iew of restrictions i$"osed by disease and treat$ent. ,. -ncourages "atient to identify concerns and ste"s necessary to deal with the$. /. Alternati%e for$s of se.ual e."ression $ay be acce"table. 0. #e.uality $eans different things to different "eo"le' de"ending on stage of $aturity.

co"ing styles that ha%e been effecti%e and those no longer "ossible due to disease and treat$ent 5alcohol or drug use> e.tre$e "hysical e.ertion6

Patient and fa$ily identify and %erbali3e feelings and reactions to disease and necessary changes in their li%es #ee!s "rofessional counseling' if necessary' to co"e with changes resulting fro$ renal failure Re"orts satisfaction with $ethod of se.ual e."ression

'ollaborative $roblems: (yper"alemia pericarditis, pericardial effusion, and pericardial tamponade hypertension anemia bone disease and metastatic calcifications Goal: #bsence of complications
Hyperkalemia 1. +onitor seru$ "otassiu$ le%els. Notify "hysician if le%el greater than /./ $-1@)' and "re"are to treat hy"er!ale$ia. (. Assess "atient for $uscle wea!ness' diarrhea' -CA changes 5tall8tented T wa%es and widened BR#6. 1. Cy"er!ale$ia causes "otentially life8 threatening changes in the body. (. Cardio%ascular signs and sy$"to$s are characteristic of hy"er!ale$ia.

Patient has nor$al "otassiu$ le%el -."eriences no $uscle wea!ness or diarrhea. -.hibits nor$al

-CA "attern

?ital signs are within nor$al li$its Cas strong and e1ual "eri"heral "ulses Absence of a "arado.ical "ulse Absence of "ericardial effusion or ta$"onade on cardiac ultrasound Patient has nor$al heart sounds

Pericarditis, Pericardial Effusion, and Pericardial Tamponade 1. Assess "atient for fe%er' chest 1. About *=EF/=E of "ain' and a "ericardial friction chronic renal failure rub 5signs of "ericarditis6 and' if "atients de%elo" "resent' notify "hysician. "ericarditis due to ure$ia> fe%er' chest (. f "atient has "ericarditis' "ain' and a "ericardial assess for the following e%ery , friction rub are classic hours: signs. a. Parado.ical "ulse D 1= $$ Cg b. -.tre$e hy"otension c. Wea! or absent "eri"heral "ulses d. Altered le%el of consciousness e. &ulging nec! %eins *. Pre"are "atient for cardiac ultrasound to aid in diagnosis of "ericardial effusion and cardiac ta$"onade. ,. f cardiac ta$"onade de%elo"s' "re"are "atient for e$ergency "ericardiocentesis. (. Pericardial effusion is a co$$on fatal se1uela of "ericarditis. #igns of an effusion include a "arado.ical "ulse 5D 1= $$ Cg dro" in blood "ressure during ins"iration6 and signs of shoc! due to co$"ression of the heart by a large effusion. Cardiac ta$"onade e.ists when the "atient is se%erely co$"ro$ised he$odyna$ically. *. Cardiac ultrasound is useful in %isuali3ing "ericardial effusions and cardiac ta$"onade. ,. Cardiac ta$"onade is a life8threatening condition' with a high $ortality rate. $$ediate as"iration of fluid fro$ the "ericardial s"ace is essential. Hypertension 1. +onitor and record blood "ressure as indicated. (. Ad$inister antihy"ertensi%e 1. Pro%ides ob<ecti%e data for $onitoring. -le%ated le%els $ay indicate non8

&lood "ressure within nor$al li$its

$edications as "rescribed. *. -ncourage co$"liance with dietary and fluid restriction thera"y. ,. Teach "atient to re"ort signs of fluid o%erload' %ision changes' headaches' ede$a' or sei3ures.

adherence to the treat$ent regi$en. (. Antihy"ertensi%e $edications "lay a !ey role in treat$ent of hy"ertension associated with chronic renal failure. *. Adherence to diet and fluid restrictions and dialysis schedule "re%ents e.cess fluid and sodiu$ accu$ulation. ,. These are indications of in8ade1uate control of hy"ertension and the need to alter thera"y.

Re"orts no headaches' %isual "roble$s' or sei3ures -de$a is absent De$onstrates co$"liance with dietary and fluid restrictions

Anemia 1. +onitor R&C count' he$oglobin' and he$atocrit le%els as indicated. (. Ad$inister $edications as "rescribed' including iron and folic acid su""le$ents' -"ogen' and $ulti%ita$ins. *. A%oid drawing unnecessary blood s"eci$ens. ,. Teach "atient to "re%ent bleeding: a%oid %igorous nose blowing and contact s"orts' and use a soft toothbrush. /. Ad$inister blood co$"onent thera"y as indicated.

1. Pro%ides assess$ent of degree of ane$ia. (. R&Cs need iron' folic acid' and %ita$ins to be "roduced. -"ogen sti$ulates the bone $arrow to "roduce R&C. *. Ane$ia is worsened by drawing nu$erous s"eci$ens. ,. &leeding fro$ anywhere in the body worsens ane$ia.

Patient has a nor$al s!in color without "allor -.hibits he$atology %alues within acce"table li$its -."eriences no bleeding fro$ any site

/. &lood co$"onent thera"y $ay be needed if the "atient has sy$"to$s. one !isease and "etastatic #alcifications 1. Ad$inister the following 1. Chronic renal failure $edications as "rescribed: causes nu$erous "hos"hate binders' calciu$ "hysiologic changes su""le$ents' %ita$in D affecting calciu$' su""le$ents. "hos"horus' and

-.hibits seru$ calciu$' "hos"horus' and alu$inu$ le%els within

(. +onitor seru$ lab %alues as indicated 5calciu$' "hos"horus' alu$inu$ le%els6 and re"ort abnor$al findings to "hysician. *. Assist "atient with an e.ercise "rogra$.

%ita$in D $etabolis$. (. Cy"er"hos"hate$ia' hy"ocalce$ia' and e.cess alu$inu$ accu$ulation are co$$on in chronic renal failure. *. &one de$inerali3ation increases with i$$obility.

acce"table ranges -.hibits no sy$"to$s of hy"ocalce$ia Cas no bone de$inerali3ation on bone scan Discusses i$"ortance of $aintaining acti%ity le%el and e.ercise "rogra$