TOP 3 NURSING CARE PLAN

1st Priority

Assessment Diagnosis Planning Implementation Rationale Evaluation

Objective: Risk for bleeding At the end of 4 hours of Independent: Independent: After 4 hours of nurse-
nurse-client intervention,
1. Assess vital signs, 1. To establish baseline client intervention the
• Patient is undergoing data
the client will be able to: including BP and PR client:
Hemodialysis 2. Changes in these signs
2. Assess skin color and
• Patient is getting low 1. Be free of signs of moisture, urinary may indicative of blood 1. Is free of signs of
loss affecting systemic
dose of Heparin active bleeding as output, and level of active bleeding as
circulation or local organ
during Hemodialysis evidenced by stable consciousness function such as the evidenced by stable
vital signs, skin and 3. Avoid trauma to fistula kidneys or brain vital signs, skin and
mucous membranes by handling tubing 3. Avoiding trauma mucous membranes
free of pallor gently, maintaining decreases risk of free of pallor
2. Identify individual cannula alignment, clotting and 2. Identified individual
risks to bleeding limiting activity of disconnection, resulting risks to bleeding
3. Engage in extremity, and not in bleeding 3. Engaged in
appropriate behaviors taking the BP on 4. The use of medications appropriate behaviors
to prevent bleeding fistula side such as NSAIDs, to prevent bleeding
episodes 4. Evaluate the client’s anticoagulants, and episodes
corticosteriods
medication regimen
predispose the client for
5. Provide health bleeding
teachings about 5. To allow patient to be
techniques to prevent involved and aware that
bleeding and educate a decrease in blood
patient of its volume due for bleeding
importance may compromise health
Dependent:
1. Review laboratory Dependent:
data such as CBC, 1. To evaluate bleeding
PT and PTT risk
 TOP 3 NURSING CARE PLAN

2nd Priority

Assessment Diagnosis Planning Implementation Rationale Evaluation

Objective: Risk for infection At the end of 4 hours of Independent: Independent: After 4 hours of nurse-
related to foreign object nurse-client 1. Practice and emphasize 1. Minimizes client intervention the
• Dialysis tubing constant and proper contamination of hands
access to the fistula intervention, the client handwashing by all and acts as first-line of
client:
accessing the
will be able to: caregivers between defense against
fistula therapies and clients. healthcare-associated
1. Identify Wear gloves and mask. infections. (HAIs) 1. Identified
interventions to 2. Assess patient’s vital 2. To establish baseline interventions to
signs data and to look for
prevent or reduce 3. Observe at-risk client for signs of infection
prevent or reduce
risk of infection changes in skin color through a high risk of infection
2. Demonstrate and warmth at temperature 2. Demonstrated
techniques to injection/fistula sites 3. These symptoms could techniques to
promote safe 4. Avoid contamination of be signs of localized promote safe
access site by using infection
environment aseptic technique and 4. Prevents introduction of
environment
masks when giving microorganisms that can
fistula care. cause infection
5. Teach the patient about 5. Encouraging proper skin
techniques to protect care and prevention of
the integrity of the skin, infection reduces the
care for fistula, and risk
prevention of spread of
infection Dependent:
Dependent: 1. Determines presence of
1. Obtain blood samples of pathogens
site culture, as
indicated.
 TOP 3 NURSING CARE PLAN

3rd Priority

Assessment Diagnosis Planning Implentation Rationale Evaluation

Subjective: Activity intolerance At the end of 4 hours of Independent: Independent: After 4 hours of nurse-
related to history of nurse-client intervention, 1. Evaluate the actual and 1. Provides a comparative client intervention, the
• Patient verbalized “I perceived limitations and baseline and
stroke the client will be able to: severity of deficit in light of
client:
am unable move or information about
usual status.
feel my right arm" 1. Participate in 2. Note client's reports of
needed education or 1. Participated in
weakness, fatigue, pain, interventions regarding
conditioning/rehabilita conditioning/rehabilita
Objective: difficulty, and quality of life
tion program to 2. Symptoms can tion program to
accomplishing tasks.
• Patient has history of enhance ability to 3. Reduce intensity levels or contribute to intolerance enhance ability to
right-sided weakness perform activities discontinue activities that of activity perform activities
due to stroke 20 2. Identify alternative cause undesired 3. To prevent overexertion 2. Identify alternative
ways to maintain physiological changes 4. To reduce fatigue and ways to maintain
years ago 4. Involve patient in planning encourage participation
desired activity level desired activity level
• Patient uses care to carefully balance on the patient’s part
rest periods with activities
cane/walking stick to 5. To prevent and limit
5. Develop alternative ways
deterioration
assist with walking to remain active within the
limits of the disabling 6. To prevent injuries and
• Upon taking blood condition Promote wellness
pressure, right arm 6. Teach client and family
has no range of about appropriate safety Dependent:
measures 1. To develop individually
motion [needs appropriate therapeutic
assistance with lifting Dependent: regimens
arm] 1. Provide referral to other 2. Aid in sustaining activity
disciplines such as
level
physical therapists, as
indicated
2. Refer patients to
appropriate resources for
assistance and/or
equipment, as needed