Chronic renal

failure
Raghad Nahar 442500236
 Nursing diagnosis
1- Disturbed thought
processes related to
physiological changes,
accumulation of toxins,
such as urea, ammonia;
metabolic acidosis;
hypoxia; electrolyte
imbalances; calcification in
the brain as evidenced by
disorientation to person,
place, time.
Planning/expected intervention Rational Evaluation
outcome
Client will regain or 1 Assess extent of 1 Uremic syndrome’s effect can begin Client has maintained optimal level of
maintain optimal level of impairment in thinking with minor confusion or mentation, identified ways for
mentation, identify ways ability, memory, and irritability and progress to altered compensate for cognitive impairment
to compensate for orientation. Note personality, inability to assimilate and memory deficits.
cognitive impairment and attention span. information or participate in care.
memory deficits. Awareness of changes provides
opportunity for evaluation and
intervention.
2 Ascertain from 2 Provides comparison to evaluate
significant other (SO) progression or resolution of
client’s usual level of impairment.
mentation.
3Provide SO with 3 Some improvement in mentation
information about client’s may be expected with restoration of
status. more normal levels of BUN,
electrolytes, and serum pH.
4Provide quiet, calm 4 Minimizes environmental stimuli to
environment and reduce sensory overload and
judicious use of TV, radio, confusion while preventing sensory
and visitation. deprivation.
5Promote adequate rest 5 Sleep deprivation may further
and undisturbed periods impair cognitive abilities.
for sleep.
 Nursing diagnosis
Risk for impaired skin
integrity related to 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.
Planning/expected
outcome
Client will maintain intact
skin, demonstrate behaviors
and techniques to prevent
skin breakdown or injury.
Intervention
1Inspect skin for changes in
color, turgor, and vascularity. circulation and early breakdown
Note redness and excoriation.
Observe for ecchymosis and
purpura.
2Monitor fluid intake and
hydration of skin and mucous
membranes.
3Inspect dependent areas
for edema. Elevate legs, as
indicated.
4Change position frequently,
move client carefully, pad
bony prominences with
sheepskin, and use elbow and
heel protectors.
5Provide soothing skin care,
restrict use of soaps, and
apply ointments or creams
such as lanolin or Aquaphor.
Rational Evaluation
1Indicates areas of poor Client has maintained intact skin,
demonstrated behaviors and
that may lead to decubitus techniques to prevent skin
formation and infection. breakdown or injury.
2Detects presence of dehydration
or overhydration that affects
circulation and tissue integrity at
the cellular level.
3Edematous tissues are more
prone to breakdown. Elevation
promotes venous return, limiting
venous stasis and edema
formation.
4Decreases pressure on
edematous, poorly perfused
tissues to reduce ischemia.
5Baking soda and cornstarch
baths decrease itching and are
less drying than soaps. Lotions
and ointments may be
desired to relieve dry, cracked
skin.
Deep vein thrombosis
Raghad Nahar 442500236
 Nursing diagnosis
Ineffective peripheral tissue
perfusion related to decreased
blood flow and venous states
as evidenced by tissue edema,
pain, diminished peripheral
pulses, slow or diminished
capillary refill, skin color
changes
Planning/expected
outcome
Client will demonstrate
improved perfusion as
evidenced by peripheral pulses
present, equal skin color, and
temperature normal and
absence of edema
Intervention
1Promote early
ambulation.
2Caution client to avoid
crossing legs or hyperflex at
knee, such as seated
position with legs dangling
or lying in jackknife
position.
3Instruct client to avoid
rubbing or massaging the
affected extremity.
4Encourage deep-breathing
exercises.
5Increase fluid intake to at
least 1,500 to 2,000 mL/day,
within cardiac tolerance.
Rational Evaluation
1- Short, frequent walks are Client has improved perfusion
better for extremities and as evidenced by peripheral
prevention of pulmonary pulses present, equal skin
complications than one long color and temperature normal
walk. If client is confined to and absence of edema.
bed, ensure range-of-motion.
2- Physical restriction of
circulation impairs blood flow
and increases venous stasis in
pelvic, popliteal, and leg
vessels, thus increasing
swelling and discomfort.
3This activity potentiates risk
of fragmenting and dislodging
thrombus, causing
embolization, and increasing
risk of complications.
4Increases negative pressure in
thorax, which assists in
emptying large veins.
5Dehydration increases blood
viscosity and venous stasis,
pre- disposing to thrombus
formation.
 Nursing diagnosis
Acute pain\impaired comfort
related to diminished arterial
circulation and oxygenation of
tissues with production and
accumulation of lactic acid in
tissue inflammatory process as
evidenced by report of pain,
tenderness, aching or burning
guarding of affected limb,
restlessness, distraction
behavior
Planning\ expected
outcome
Client will report that pain or
discomfort is alleviated or
controlled Verbalize methods
that provide relief. Display
relaxed manner; be able to
sleep or rest and engage in
desired activity.
Intervention Rational Evaluation
1Maintain bedrest during 1- Reduces discomfort Client has reported that pain
acute phase. associated with muscle or discomfort is alleviated or
contraction and movement. controlled with verbalize
2 Elevate affected 2- Encourages venous return methods that provide relief
extremity. to facilitate circulation,
reducing stasis and edema
formation.
3Cradle keeps pressure of
bedclothes off the affected leg,
3 Provide foot cradle. thereby reducing pressure
discomfort.
4Reduces muscle fatigue, helps
minimize muscle spasm, and
4Encourage client to change maximizes circulation to
position frequently. tissues.
5Elevations in heart rate may
indicate increased discomfort
5Monitor vital signs, noting or may occur in response to
elevated temperature. fever and inflammatory
process. Fever can also
increase client’s discomfort.