Islamic University of Gaza



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 |Rationale |Expected Outcomes |

|Assess fluid status: |Assessment provides baseline and ongoing |Demonstrates no rapid weight changes |

|Daily weight |database for monitoring changes and evaluating|Maintains dietary and fluid |

|Intake and output balance |interventions. |restrictions |

|Skin turgor and presence of edema |Fluid restriction will be determined on basis |Exhibits normal skin turgor without |

|Distention of neck veins |of weight, urine output, and response to |edema |

|Blood pressure, pulse rate, and rhythm |therapy. |Exhibits normal vital signs |

|Respiratory rate and effort |Unrecognized sources of excess fluids may be |Exhibits no neck vein distention |

|Limit fluid intake to prescribed volume. |identified. |Reports no difficulty breathing or |

|Identify potential sources of fluid: |Understanding promotes patient and family |shortness of breath |

|Medications and fluids used to take or administer |cooperation with fluid restriction. |Performs oral hygiene frequently |

|medications: oral and intravenous |Increasing patient comfort promotes compliance|Reports decreased thirst |

|Foods |with dietary restrictions. |Reports decreased dryness of oral |

|Explain to patient and family rationale for fluid |Oral hygiene minimizes dryness of oral mucous |mucous membranes |

|restriction. |membranes. | |

|Assist patient to cope with the discomforts resulting from | | |

|fluid restriction. | | |

|Provide or encourage frequent oral hygiene. | | |

|Nursing Diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, and altered |

|oral mucous membranes |

|Goal: Maintenance of adequate nutritional intake |

|Assess nutritional status: |Baseline data allow for monitoring of changes |Consumes protein of high biologic |

|Weight changes |and evaluating effectiveness of interventions.|value |

|Laboratory values (serum electrolyte, BUN, creatinine, | |Chooses foods within dietary |

|protein, transferrin, and iron levels) |Past and present dietary patterns are |restrictions that are appealing |

|Assess patient's nutritional dietary patterns: |considered in planning meals. |Consumes high-calorie foods within |

|Diet history |Information about other factors that may be |dietary restrictions |

|Food preferences |altered or eliminated to promote adequate |Explains in own words rationale for |

|Calorie counts |dietary intake is provided. |dietary restrictions and relationship|

|Assess for factors contributing to altered nutritional |Increased dietary intake is encouraged. |to urea and creatinine levels |

|intake: |Complete proteins are provided for positive |Takes medications on schedule that |

|Anorexia, nausea, or vomiting |nitrogen balance needed for growth and |does not produce anorexia or feeling |

|Diet unpalatable to patient |healing. |of fullness |

|Depression |Reduces source of restricted foods and |Consults written lists of acceptable |

|Lack of understanding of dietary restrictions |proteins and provides calories for energy, |foods |

|Stomatitis |sparing protein for tissue growth and healing.|Reports increased appetite at meals |

|Provide patient's food preferences within dietary | |Exhibits no rapid increases or |

|restrictions. |Ingestion of medications just before meals may|decreases in weight |

|Promote intake of high biologic value protein foods: eggs, |produce anorexia and feeling of fullness. |Demonstrates normal skin turgor |

|dairy products, meats. |Promotes patient understanding of |without edema; wound healing and |

|Encourage high-calorie, low-protein, low-sodium, and |relationships between diet and urea and |acceptable plasma albumin levels |

|low-potassium snacks between meals. |creatinine levels to renal disease. | |

|Alter schedule of medications so that they are not given |Lists provide a positive approach to dietary | |

|immediately before meals. |restrictions and a reference for patient and | |

|Explain rationale for dietary restrictions and relationship |family to use when at home. | |

|to kidney disease and increased urea and creatinine levels. |Unpleasant factors that contribute to | |

|Provide written lists of foods allowed and suggestions for |patient's anorexia are eliminated. | |

|improving their taste without use of sodium or potassium. |Allows monitoring of fluid and nutritional | |

|Provide pleasant surroundings at meal-times. |status. | |

|Weigh patient daily. |Inadequate protein intake can lead to | |

|Assess for evidence of inadequate protein intake: |decreased albumin and other proteins, edema | |

|Edema formation |formation, and delay in wound healing. | |

|Delayed wound healing | | |

|Decreased serum albumin levels | | |

|Nursing Diagnosis: Deficient knowledge regarding condition and treatment |

|Goal: Increased knowledge about condition and related treatment |

|Assess understanding of cause of renal failure, consequences|Provides baseline for further explanations and|Verbalizes relationship of cause of |

|of renal failure, and its treatment: |teaching. |renal failure to consequences |

|Cause of patient's renal failure |Patient can learn about renal failure and |Explains fluid and dietary |

|Meaning of renal failure |treatment as he or she becomes ready to |restrictions as they relate to |

|Understanding of renal function |understand and accept the diagnosis and |failure of kidney's regulatory |

|Relationship of fluid and dietary restrictions to renal |consequences. |functions |

|failure |Patient can see that his or her life does not |States in own words relationship of |

|Rationale for treatment (hemodialysis, peritoneal dialysis, |have to revolve around the disease. |renal failure and need for treatment |

|transplantation) |Provides patient with information that can be |Asks questions about treatment |

|Provide explanation of renal function and consequences of |used for further clarification at home. |options, indicating readiness to |

|renal failure at patient's level of understanding and guided| |learn |

|by patient's readiness to learn. | |Verbalizes plans to continue as |

|Assist patient to identify ways to incorporate changes | |normal a life as possible |

|related to illness and its treatment into lifestyle. | |Uses written information and |

|Provide oral and written information as appropriate about: | |instructions to clarify questions and|

|Renal function and failure | |seek additional information |

|Fluid and dietary restrictions | | |

|Medications | | |

|Reportable problems, signs, and symptoms | | |

|Follow-up schedule | | |

|Community resources | | |

|Treatment options | | |

|Nursing Diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure |

|Goal: Participation in activity within tolerance |

|Assess factors contributing to activity intolerance: |Indicates factors contributing to severity of |Participates in increasing levels of |

|Fatigue |fatigue. |activity and exercise |

|Anemia |Promotes improved self-esteem |Reports increased sense of well-being|

|Fluid and electrolyte imbalances |Promotes activity and exercise within limits | |

|Retention of waste products |and adequate rest. |Alternates rest and activity |

|Depression |Adequate rest is encouraged after dialysis |Participates in selected self-care |

|Promote independence in self-care activities as tolerated; |treatments, which are exhausting to many |activities |

|assist if fatigued. |patients. | |

|Encourage alternating activity with rest. | | |

|Encourage patient to rest after dialysis treatments. | | |

|Nursing Diagnosis: Risk for situational low self-esteem related to dependency, role changes, change in body image, and change in sexual function |

|Goal: Improved self-esteem |

|Assess patient's and family's responses and reactions to |Provides data about problems encountered by |Identifies previously used coping |

|illness and treatment. |patient and family in coping with changes in |styles that have been effective and |

|Assess relationship of patient and significant family |life. |those no longer possible due to |

|members. |Identifies strengths and supports of patient |disease and treatment (alcohol or |

|Assess usual coping patterns of patient and family members. |and family. |drug use; extreme physical exertion) |

|Encourage open discussion of concerns about changes produced|Coping patterns that may have been effective |Patient and family identify and |

|by disease and treatment: |in past may be harmful in view of restrictions|verbalize feelings and reactions to |

|Role changes |imposed by disease and treatment. |disease and necessary changes in |

|Changes in lifestyle |Encourages patient to identify concerns and |their lives |

|Changes in occupation |steps necessary to deal with them. |Seeks professional counseling, if |

|Sexual changes |Alternative forms of sexual expression may be |necessary, to cope with changes |

|Dependence on health care team |acceptable. |resulting from renal failure |

|Explore alternate ways of sexual expression other than |Sexuality means different things to different |Reports satisfaction with method of |

|sexual intercourse. |people, depending on stage of maturity. |sexual expression |

|Discuss role of giving and receiving love, warmth, and | | |

|affection. | | |

|Collaborative Problems: Hyperkalemia; pericarditis, pericardial effusion, and pericardial tamponade; hypertension; anemia; bone disease and |

|metastatic calcifications |

|Goal: Absence of complications |

|Hyperkalemia |

|Monitor serum potassium levels. Notify physician if level |Hyperkalemia causes potentially |Patient has normal potassium level |

|greater than 5.5 mEq/L, and prepare to treat hyperkalemia. |life-threatening changes in the body. |Experiences no muscle weakness or |

|Assess patient for muscle weakness, diarrhea, ECG changes |Cardiovascular signs and symptoms are |diarrhea. |

|(tall-tented T waves and widened QRS). |characteristic of hyperkalemia. |Exhibits normal ECG pattern |

| | |Vital signs are within normal limits |

|Pericarditis, Pericardial Effusion, and Pericardial Tamponade |

|Assess patient for fever, chest pain, and a pericardial |About 30%–50% of chronic renal failure |Has strong and equal peripheral |

|friction rub (signs of pericarditis) and, if present, notify|patients develop pericarditis due to uremia; |pulses |

|physician. |fever, chest pain, and a pericardial friction |Absence of a paradoxical pulse |

|If patient has pericarditis, assess for the following every |rub are classic signs. |Absence of pericardial effusion or |

|4 hours: |Pericardial effusion is a common fatal sequela|tamponade on cardiac ultrasound |

|Paradoxical pulse > 10 mm Hg |of pericarditis. Signs of an effusion include |Patient has normal heart sounds |

|Extreme hypotension |a paradoxical pulse (> 10 mm Hg drop in blood | |

|Weak or absent peripheral pulses |pressure during inspiration) and signs of | |

|Altered level of consciousness |shock due to compression of the heart by a | |

|Bulging neck veins |large effusion. Cardiac tamponade exists when | |

|Prepare patient for cardiac ultrasound to aid in diagnosis |the patient is severely compromised | |

|of pericardial effusion and cardiac tamponade. |hemodynamically. | |

|If cardiac tamponade develops, prepare patient for emergency|Cardiac ultrasound is useful in visualizing | |

|pericardiocentesis. |pericardial effusions and cardiac tamponade. | |

| |Cardiac tamponade is a life-threatening | |

| |condition, with a high mortality rate. | |

| |Immediate aspiration of fluid from the | |

| |pericardial space is essential. | |

|Hypertension |

|Monitor and record blood pressure as indicated. |Provides objective data for monitoring. |Blood pressure within normal limits |

|Administer antihypertensive medications as prescribed. |Elevated levels may indicate non-adherence to |Reports no headaches, visual |

|Encourage compliance with dietary and fluid restriction |the treatment regimen. |problems, or seizures |

|therapy. |Antihypertensive medications play a key role |Edema is absent |

|Teach patient to report signs of fluid overload, vision |in treatment of hypertension associated with |Demonstrates compliance with dietary |

|changes, headaches, edema, or seizures. |chronic renal failure. |and fluid restrictions |

| |Adherence to diet and fluid restrictions and | |

| |dialysis schedule prevents excess fluid and | |

| |sodium accumulation. | |

| |These are indications of in-adequate control | |

| |of hypertension and the need to alter therapy.| |

|Anemia |

|Monitor RBC count, hemoglobin, and hematocrit levels as |Provides assessment of degree of anemia. |Patient has a normal skin color |

|indicated. |RBCs need iron, folic acid, and vitamins to be|without pallor |

|Administer medications as prescribed, including iron and |produced. Epogen stimulates the bone marrow to|Exhibits hematology values within |

|folic acid supplements, Epogen, and multivitamins. |produce RBC. |acceptable limits |

|Avoid drawing unnecessary blood specimens. |Anemia is worsened by drawing numerous |Experiences no bleeding from any site|

|Teach patient to prevent bleeding: avoid vigorous nose |specimens. | |

|blowing and contact sports, and use a soft toothbrush. |Bleeding from anywhere in the body worsens | |

|Administer blood component therapy as indicated. |anemia. | |

| |Blood component therapy may be needed if the | |

| |patient has symptoms. | |

|Bone Disease and Metastatic Calcifications |

|Administer the following medications as prescribed: |Chronic renal failure causes numerous |Exhibits serum calcium, phosphorus, |

|phosphate binders, calcium supplements, vitamin D |physiologic changes affecting calcium, |and aluminum levels within acceptable|

|supplements. |phosphorus, and vitamin D metabolism. |ranges |

|Monitor serum lab values as indicated (calcium, phosphorus, |Hyperphosphatemia, hypocalcemia, and excess |Exhibits no symptoms of hypocalcemia |

|aluminum levels) and report abnormal findings to physician. |aluminum accumulation are common in chronic |Has no bone demineralization on bone |

|Assist patient with an exercise program. |renal failure. |scan |

| |Bone demineralization increases with |Discusses importance of maintaining |

| |immobility. |activity level and exercise program |

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