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.
