Nursing Assessment & Diagnosis | Planning & patient centered goals | Nursing Interventions | Scientific Rationale | Evaluation | 1) Diagnosis: Excess fluid volume r/t decreased urinary output Assessment: B.K is an 88 year-old female presented with acute renal failure with urinary retention. Patient was admitted into Lehigh Regional on July 5th, 2013.Previous history: Diabetes, HTN, UTI, skin cancer, TIA. Subjective: Patient states, “I feel a bit fatigued in the evenings. My doctor said it is a side effect of my dialysis sessions. I don’t like going to dialysis but I know that I have to”.Objective: Patient alert and oriented x4. Vitals signs: BP: 119/72, Temperature: 98.9, Pulse: 82 bpm, respiratory rate: 18, and displays no pain at this time. Breath sounds clear, gag and cough reflexes intact. Bowel sounds present in all four quadrants. Eyes: PERRLA. Skin integrity is not intact; stage 1 pressure ulcer located in right posterior upper thigh, below buttock. Minor bruising on both upper extremities, No signs of DVT. Patient PICC line placement in right upper arm. Patient is easily fatigued primarily after dialysis sessions. Chooses to ambulate by wheelchair due to occasional dizziness. 1 assist when walking.Diagnostic test: Recent CBC done on 07/11/13 showed an elevated WBC count with a result of 14.0.Progress notes: “ Patient readmitted to facility due to noncompliance with dialysis sessions. Experiencing fatigue and occasional anxiety between dialysis sessions. Recent elevated WBC count may be sign of infection. Will continue to monitor”.2) Diagnosis: Risk for infection r/t altered immune functioning3) Diagnosis: Fatigue r/t effects of chronic uremia | Short term goals: 1) Patient will maintain daily urine output within 500 mL of intake through next week July 18th, 2013.2) Patient will remain free of edema through next week July 18th, 2013.3) Patient will comply with 2 scheduled days of dialysis therapy through next week July 18th, 2013.4) Patient will remain free from symptoms of infection through next week July 18th, 2013.Long-term goal: 1) Patient will experience normal fluid volume as evidenced by behavioral dialysis compliance, balanced intake and output, stable vital signs, weight, and clear lung sounds through August 11th, 2013.Expected outcomes:Patient will remain free of edemaPatient will comply with dialysis sessionsPatient will experience normal fluid volume | 1) Nurse will monitor daily intake of fluids and urine output.2) Nurse will monitor location and extent of edema, use the 1+ to 4+ scale to quantify edema. 3) Nurse will encourage patient to attend dialysis sessions and explain the importance of therapy.4) Nurse will observe and report signs of infection such as redness, warmth, discharge, increased body temperature, and abnormal lab values.1) Nurse will monitor daily weight for sudden increases, monitor lung sounds and vital signs. | 1) Generalized edema is associated with decreased oncotic pressure as a result of nephrotic syndrome. Heart failure and renal failure are usually associated with dependent edema because of increased hydrostatic pressure; dependent edema will cause swelling in the legs and feet of ambulatory clients. (Fauci et al, 2008)2) Body weight changes reflect changes in body fluid volume. A study demonstrated that body weight could safely be used to monitor for fluid overload when administering hyperhydration with high dose chemotherapy (Mank et al, 2003)3) The white blood cell count and the automated absolute neutrophil count are better diagnostic tests for adults (Cornbleet, 2002).Citation:Ackley, B., & Ladwig, G. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care. (9th ed., pp. 393-397, 492). Mosby elsevier. | Observed:1) Patient has had a minimum urine output of 250 mL daily. Patient states: “It is a bit difficult for me to urinate. Especially after a dialysis session”. Goal was met.2) Patient has remained free of edema as of July 18th, 2013. Patient states: “Nurse has been coming in my room every day to check my legs for any swelling”. Goal was met.3) Patient has complied with dialysis therapy as of July 18th, 2013. Patient stated, “The more sessions of dialysis therapy that I attend, the less anxiety I have. I may feel tired after but it makes me feel better”. Goal was met.4) In patient chart, recent CBC showed WBC count within limits. Goal was met.1) In physician progress notes, doctor states: “Patient remains WNL of fluid volume. Nurse will continue to monitor dialysis compliance, I&O, vital signs, weight, and lung sounds”. Goal was met-ongoing. |