Student Nurses Community

NURSING CARE PLAN Hemodialysis ASSESSMENT SUBJECTIVE: Nanghihina ako (I feel very weak) as verbalized by the patient. DIAGNOSIS Risk for deficient fluid volume. Risk factor may include ultrafiltration, fluid restriction and actual blood loss such as systemic heparinization or disconnection of the shunt. INFERENCE Hemodialysis is one of several renal replacement therapies used for the treatment of renal failure. Dialysis removes excess fluid and waste products and restores chemical and electrolyte balance. Hemodialysis involves passing the patients blood through an artificial semipermeable membrane to perform the filtering and excretion functions of the kidney. PLANNING After 8 hours of nursing interventions, the patient will maintain fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membranes, absence of bleeding, and appropriate weight. INTERVENTION Independent Measure all sources of intake and output. Have patient to keep a diary. Weigh daily as well as before and after dialysis run. RATIONALE Aids in evaluating status, especially when compared with weight. Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal. Hypotension, tachycardia, and falling hemodynamic pressures suggests volume depletion. Dialysis potentiates hypotensive effects if these drugs have been administered. Disconnected shunt or open access permits exsanguination. Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and EVALUATION After 8 hours of nursing interventions, the patient was able to maintain fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membranes, absence of bleeding, and appropriate weight.

OBJECTIVE: Loss of weight Restlessness Weakness V/S taken as follows T: 36.8C P: 73 R: 18 BP: 110/ 80

Monitor vital signs during dialysis.

Ascertain whether diuretics and antihypertensives are to be withheld. Verify continuity of shunt or access catheter. Apply external shunt dressing. Permit no puncture of shunt.

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bleeding from site. Maximizes venous return if hypotension occurs.

Place patient in a supine or trendelenburg position, as necessary.

Collaborative Monitor laboratory studies as indicated. Reduce rate of ultrafiltration during dialysis, as indicated.

To monitor closely to prevent future complications. Reduces the amount of water being removed and may correct hypotension or hypovolemia.