Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020

(Nur 458 )

Nursing care plan

Patient's name:
Medical diagnosis: MI

Nursing diagnosis Expected outcomes Implementation Rationale Evaluation

 Risk for Injury  Maintain Notify physician and/or initiate Rapid intervention Goal is met
related to patent vascular declotting procedure if there is may save access;
infection access evidence of loss of shunt however, declotting
 Be free of patency. must be done by
infection experienced personnel.
Evaluate reports of pain, May indicate Goal is met
numbness or tingling; note inadequate blood
extremity swelling distal to supply.
access.
Attach two cannula clamps to Prevents massive
shunt dressing. Have tourniquet blood loss while
available. If cannulas separate, awaiting medical
clamp the arterial cannula first, assistance if cannula
then the venous. If tubing separates or shunt is
comes out of vessel, clamp dislodged.
cannula that is still in place and
apply direct pressure to
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
bleeding site. Place tourniquet
above site or inflate BP cuff to
pressure just above patient’s
systolic BP.
Assess skin around vascular Signs of local infection,
access, noting redness, swelling, which can progress
local warmth, exudate, to sepsis if untreated.
tenderness.
 Excess Fluid  Maintain “dry 1. Measure all sources of
Volume R/T weight” within I&O. Weigh routinely. Aids in evaluating fluid
saline given to patient’s normal status, especially when
support BP range compared with weight.
during dialysis Weight gain between
treatments should not
exceed 0.5 kg/day.

Note presence of Fluid volume excess GAOL IS MET

peripheral or sacral due to inefficient
edema, respiratory rales, dialysis or
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
dyspnea, orthopnea, repeated hypervolemia 
distended neck veins, ECG between dialysis
changes indicative of treatments may cause
ventricular hypertrophy. or exacerbate HF, as
indicated by signs and
symptoms of
respiratory and/or
systemic venous
congestion.
 Impaired Urinary  Patient will 1. Establish rapport. 1. To get the
Elimination R/T verbalize cooperation of
failing understanding of the patient and
glomerular condition SO.
filtration AEB 2. To obtain
Impaired baseline
excretion of 2. Monitor and record vital signs. data.
nitrogenous
products
secondary 3. To know what
to Renal Failure 3. Assess pt’s general condition problem and
interventions
should be
prioritize.

4. Review for laboratory test for changes in 4. To assess for

contributing or
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
renal function. causative factors.
 Risk for Impaired  Maintain intact 1. Inspect skin for changes in color, turgor, 1. Indicates areas of
Skin Integrity R/T skin. vascularity. Note redness, excoriation. poor circulation
Accumulation of Observe for ecchymosis, purpura. or breakdown
toxins in the skin that may lead to
decubitus
formation and
infection.

2. Detects presence
2. Monitor fluid intake and hydration of skin of dehydration or
and mucous membranes. overhydration
that affect
circulation and
tissue integrity at
the cellular level.

3. Inspect dependent areas for edema. 3. Edematous

Elevate legs as indicated. tissues are more
prone to
breakdown.
Elevation
promotes venous
return, limiting
venous stasis and
edema
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
formation.

4. Change position frequently; move patient 4. Decreases

carefully; pad bony prominences with pressure on
sheepskin, elbow or heel protectors. edematous,
poorly perfused
tissues to reduce
ischemia.

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