NURSING CARE PLAN ASSESSMENT : A + O X 1 (name), restrained to left arm and right leg for restlessness and confusion.

Pt. is on haemodialysis (Mon/ Tues/ Wed). V/S: B.P. 136/65 mmHg, Pulse 65 beats/min, O2Sat 95%, Temp. 360 C, Resp. 18 resp/min. NURSING DIAGNOSIS : Urosepsis Focus Area Confusion Goal To decrease probability of injury due to confusion Interventions Rational 1) Evaluate the safety of the 1. To reduce risk of injury immediate environment. Have mats by bedside in case patient does decide to come out of bed when unsupervised. 2) Assess LOO, VS (hypotension, changes in temperature) and Blood sugar( hypoglycaemia) and monitor lab tests. 2. Altered in LOO, VS , Decreased Blood sugar level, low mental status exam score, electrolyte imbalance, High WBC may contribute to confusion . 3.To prevent aspiration and choking risks 4. If restrained cuff will be too tight skin break down can occur. 5.Oxygen helps to maintain perfusion to the tissues. Evaluation *Pt. calm and restrains removed *Cont. to monitor q 1-2 hrs.

3) Assess Patients LOC before meals 4) If patient is restrained, monitor skin under restrain cuff q 30mins 5) If patients experience low oxygen saturation administer with supplemental oxygen as per physicians order. 6) Administer antibiotics and any PRN medication(if

6.Antibiotics helps to control infection and PRN

restless) to patient as per doctors order 7) Dont reinforce the hallucination, maintain reality through reorientation and focus on real situation. Hypertension To maintain B.P. within the normal range 1.Monitor BP every 1-2 hours before and after administering medication. Assess for S&S for hypertension 2. Change position of patient q 1-2 hr

meds helps to calm the patient 7.Reality orientation decreases falls , sensory perceptions and enhances patients sense of self worth and personal dignity. 1.Changes in BP may indicates changes in patient status requiring prompt attention 2. It may decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. 3. Peripheral vasoconstriction may result in pale, cool, clammy skin, with prolonged capillary refill time due to cardiac dysfunction and decreased cardiac output. After 4-6 hrs of nursing interventions, blood pressure maintained within set parameters for the client

3. Observe skin color, temperature, capillary refill time and diaphoresis.

4. Administer medicines as 4. To promote wellness. prescribed by the physician. 5. Encourage patient to decrease intake of caffeine 5. Caffeine is a cardiac stimulant and may adversely affect cardiac function 1.It shows high pressure Pt. is free from infection

Haemodialysis

To prevent clotting and

1. Monitor AVF by palpate

infection after patient came from haemodialysis AV Fistula intact

for distal thrill. 2. Palpate skin around AVF for warmth. 3. Assess the patient for pain, numbness, tingling, extremity swelling. 4. Monitor temperature, fever, chills and hypotension after haemodialysis.

arterial blood flow entering ,edema, and AVF is thrill low pressure venous system to palpate adequately. 2. Diminished blood flow results in coolness of shunt. 3. It may indicate inadequate blood supply 4. Signs of infection/ sepsis require immediate medical intervention.

5. Provides information 5.Monitor PT, aPTT, results about coagulation status, of blood culture presence of pathogens. 6. Administer medications (anticoagulant, antibiotics) as per physicians order. 6. Helps to prevent blood clotting and infection after haemodialysis.