Nursing care plan:

Nursing Nursing Diagnosis Planning Implementation Rational Evaluation

Assessment
(1)Objective (1)Exess fluid (1)Monitoring of (1)This was not possible (1) (1)
Data: He has volume related to weight daily because his GC was poor.
Oedema over kidneys inability to -Monitoring of -Vitals were monitored. -Blood pressure -He maintained blood
lower excrete water vital signs He had high blood changes reflect fluid pressure with anti
extremities, pressure, SPO2 volume. hypertensive drugs and
high blood maintained with maintained other vitals.
pressure and ventilator support and
mild pulmonary tachycardia was there.
effusion. -Monitoring of -He had Oedema over -Oedema is a -Oedema reduced.
Oedema lower extremities, ascites symptom of fluid
was there. Inj. Frusemide overload
was given 20mg iv twice a
day to reduce Oedema.

-Monitoring of -He had low serum -Low serum protein -He maintained serum
serum protein protein and albumin and albumin levels protein level
and albumin levels. He received extra contribute to
levels protein diet as he was on Oedema
dialysis.

-Maintain fluid -Blood investigation -Fluid intake was -He had positive balance
and sodium showed that he had high adjusted so that in output. Maintained
restriction serum sodium level for weight gains are no weight as he was on
which only 1000ml of more than 1-3 kg dialysis.
Ryles tube feeding was between dialysis
advised and also have to session.
maintain positive balance
 .Ryles tube feeding was
given 200 ml 4 hourly.
Intake and output was
1100ml/600ml.

(2) Objective (2)Impaired skin (2)Skin to be (2) His skin was observed (2)It detects early (2)He maintained intact
data: integrity related to observed for open areas and signs signs of problems skin and did not report
He had itching dryness,excess fluid of infection itching and dryness
and dry skin & crystal deposits. -Sponging to be -Sponging was done with -Bath regularly
done with tepid water and oil. Body reduce crystals with
moisturizer lotion is applied to skin non-drying items to
after bath reduce itching and
dryness and
promote comfort.

(3)Objective (3)Risk for infection (3)Signs of (3)WBC count was high (3)High WBC count (3)WBC count reduce
Data: Blood related to impaired infections to be i.e.12000 with high body and high slightly
investigation immune system monitored temperature. temperature are the Body temperature within
showed high function. signs of infection. normal range
WBC count with -Patient to be -Dialysis line care was -He had dialysis line -No sign of infections in
high grade protected from done by using aseptic in situ and this route this route
temperature any source of measures and Oral care is the source of
i.e.1010f infection. was done with infections .Handling
chlorhexidine solution of this route with
four hourly. Antibiotic inj sterile way reduce
ceftriaxone and infection.
tazobactum iv given twice
a day
 -Aseptic measures were
taken during dialysis.
-Skin integrity to -Regular bathing with -Regular bathing -Maintain intact skin
be maintained moisturizer was used to prevents deposition
prevent skin becoming dry of crystals and
and itching. maintain skin
integrity.
-Culture to be -Blood from dialysis line -Culture test can - Culture test showed no
done of any was send for culture test evaluate the growth of any organisms
suspected site of to rule out whether there presence of
infection was any growth of microorganisms
microorganism or not.

(4)Subjective (4)Imbalanced (4)Weight and (4)Blood investigations (4)These blood

Data: Nutrition:Less than serum protein were done for serum reports provides
He had taken body requirements and albumin albumin and protein information about
less amount of related to restricted levels to be levels. The result showed nutrition status of
food diet,anorexia,nausea checked. lower value than normal the patient
Objective Data: and vomiting range. Supplimentary
He had low protein(because he was
appetite,nausea on dialysis) and albumin
and vomiting. were given in the form of
powder protein and
inj.human albumin.

-Diet planning -Low sodium,potassium -Although the

restricted diet were patient was advised
 advised and that diet was to take restricted
according to the patients renal diet if we give
choice was chosen. him scope to
Supplementary calcium identify foods that
tablets along with iron are palatable yet
and folic acid and within this diet plan
multivitamins were choose he may eat it
advised and given. with interest.
Because restrictions
are complex ,the
diet may be a source
of frustration for
him.

-Oral care to be -Frequent small feeding -Smaller feeding are -He is tolerating small
given and dietary supplements better tolerated and feedings
was Provided. reduces risk of
nausea.
-Medication for -Oral care was given every -Oral care enhances -Oral care enhances
nausea and four hourly with appetite and appetite
vomiting to be chlorhexidine solution to reduces urine taste
given enhance the appetite. in mouth

-Maintaining the -Inj Ondansetron 8mg IV -Nausea reduces -Emetics are effective
the bowel was given along with Inj appetite and it must
movement Pantoprazole 40mg IV to be controlled.
reduce nausea and
vomiting
 -Duphalac 15 ml was given -Constipation can -His bowel function is
to soften the stool. interfere with normal
appetite.

(5)Subjective (5)Activity (5)Mucous (5)His body skin colour (5)These are signs (5)He showed the sign
Data: He said Intolerance related membranes and was pale .He had chest and symptoms of and symptoms of anemia
he feel to anemia secondary skin colour is to pain. anemia
weakness to do to impaired assess for sign of
his daily synthesis of anemia
activities like erythropoietin by -Monitoring of -His Hb% value was -Low haemoglobin -He had lower
brushing, and the kidneys. Hb% 6.8mg/dl which was lower and hematocrit haemoglobin value
eating by self. than normal range. 1 unit indicate anemia.
Objective Data: PRBC was advised and
He was unable given .
to do daily
activities. -Signs of bleeding -He had hemoptysis. -Bleeding will -Signs of bleeding
to be watched worsen anemia present

-Administration -Inj Erythropoietin (Eposis -Erythropoietin -Haemoglobin rise with

of inj 4000IU) SC given once stimulates use of inj. erythropoietin
Erythropoietin weekly. production of RBCs
by bone marrow