Nursing Care Plan


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Medical Diagnoses: Excess fluid volume related to compromised regulatory mechanisms, Activity intolerance, and Impaired physical mobility

1.Nursing dx: Excess fluid volume related to compromised regulatory mechanisms as evidenced by dyspnea, orthopnea, abnormal breath sounds, edema, and decreased hemoglobin and hematocrit lab values.

Data:  Patient diagnosed with end stage renal failure, CHF

Patient 2+ pitting edema on tops of feet and ankles

Patient often short of breath, becomes very anxious and labored breathing if head of bed not elevated

Lab values Hgb 8.7, 9.0, 9.2, Hct 26.0, 26.7, 27.8 

Patient hospitalized because became lethargic after 10lbs fluid removal during dialysis

Patient received blood transfusion

r/t # 2, 4, 8

2.Nursing dx: Activity intolerance related to imbalance between oxygen supply and demand and immobility as evidenced by exertional discomfort, exertional dyspnea, verbal report of fatigue and weakness, oxygen saturation dropping when not laying still.                                                          Data: Patient O2 sat dropped to 60s range when trying to turn in bed                                                                      Patient coughing and reported feeling short of air during bath when had to turn on side                                   Patient unable to bear any weight or walk              Patient diagnosed with COPD, CHF, anemia                     r/t # 2, 4

3.Nursing dx: Impaired physical mobility related to intolerance to activity and decreased strength and endurance as evidence by patient unable to bear weight, get out of bed, limited ability to move lower extremities, movement induced shortness of breath and drop in O2 sat, and unable to turn to side in bed without assistance.

Data: Patient unable to bear weight or walk        Patient had to be moved to chair with 3 ppl       Patient unable to turn to side in bed on own        Patient barely able to move lower extremities     Patient short of breath when turned in bed, O2 sat dropped to 60 range when being moved in bed                                                                     Patient unable to perform self care activities 

r/t # 2, 3,4

4.Nursing dx: Ineffective breathing pattern related to decreased energy, respiratory muscle fatigue, and fluid overload as evidenced by use of accessory muscles to breath, nasal flaring, dyspnea, and orthopnea.                                                                 Data:  Patient diagnosed with COPD, CHF                   Patient hospitalized because could not catch breath after becoming lethargic after dialysis; did not improve significantly so taking to ER                       Patient uses belly to breath at all times, frequent nasal flaring, use of accessory muscles                       Patient short of air at most times; patient especially short of air if not sitting up                                          Patient having large amounts of fluid removed during dialysis; 10pds day admitted, schedule is MWF                                                                                       r/t # 2

Current Illness: Weakness, anemia, shortness of breath

Previous History: Hypertension, hyperlipidemia, COPD, CHF, dementia, type 1 DM, ataxia, end stage renal disease, Parkinson’s disease, obstructive sleep apnea, cor pulmonale

Assessments: Monitor vital signs

Monitor fluid balance

Monitor blood glucose

Monitor O2 sat

Monitor lab values especially hemoglobin and hematocrit

Monitor I&O

Skin Turgor

Heart, lung, breath sounds every 2 hours

Assess skin, body alignment

Assess anxiety

Daily weight

5.Nursing dx: Self care defecit related to weakness, neuromuscular impairment and anxiety as evidenced by inability to open containers, limited ability to handle objects and utensils inability to wash body, inability to get to bathroom, and inability to put on clothing.                                                       Data: Patient unable to open juice, milk, unsteady with utensils, food often ends up on him, in bed, or in chair                                   Patient unable to bath self, or get to restroom, briefs used                                                        Patient unable to dress self, put on socks                             Patient diagnosed with Parkinson’s disease, dementia                                                                 r/t # 2,3,4,5

6.Nursing dx: Anxiety related to situational crises and threat of death as evidenced by restlessness, feelings of being scared, increased respiration, fatigue and weakness.           Data:  Patient often feels anxious when feeling short of air or coughing                                                                           Patient has dialysis MWF and admitted to hospital because became lethargic and unable to recover                                           Patient ask ‘do I have a bad heart?’, seemed very concerned and unaware of his past and present medical diagnoses         

 Patient easily fatigued and weak                                           Patient RR over 30

r/t # 4

7.Nursing dx: Impaired skin integrity related to physical immobilization, altered metabolic state, and altered fluid status as evidenced by edema, altered sensation, redness on sacrum and scrotum, chaffing, open sores in perineal area.                                                                Data: Patient 2+ pitting edema feet/ankles                

Patient sacrum red, scrotum enlarged, red                         Perineal area chaffed with open sores                             Patient could not feel light touch in lower extremities, no report or any sore areas that were reddened              

Patient diagnosed with Type 1 DM, CHF                          Patient unable to bear weight, walk, or rotate in bed

r/t # 1,3,5,6


NANDA Diagnostic Statement: Excess fluid volume related to compromised regulatory mechanisms as evidenced by dyspnea, orthopnea, abnormal breath sounds, edema, and decreased hemoglobin and hematocrit lab values.

Behavioral Outcome / Goal: Patient’s fluid and electrolyte balance will be stabilized and intake and output will reach an approximate balance over a span of 72 hours; target date third day after admission as evidenced by decreased peripheral edema, decreased signs of dyspnea, and patient verbalizing doesn’t feel breathlessness.   Patient’s complications will be prevented or minimized by discharge date.  Patient will demonstrate reduced extracellular fluid volume as evidenced weight loss, decreased peripheral edema, clear lung sounds, and normal heart sounds each day until discharge. 



Nursing Interventions:

 

1. Take vital signs every 4 hours including apical pulse.                             

2 .Check lung, heart, and breath sounds every 4 hours.             

 

3. Elevate head of bed 30 degrees if not contraindicated.         

4. Measure and record intake and output every shift.

5. Monitor skin turgor at least every 4 hours while awake.        

6. Monitor electrolytes, hemoglobin, and hematocrit. Collaborate with health care team regarding frequency of laboratory tests.

7. Weigh daily at same time each day in same weight clothing.

8. Administer medication as prescribed. Monitor medication side effects.

9. Prepare for dialysis. Patient scheduled Monday, Wednesday, Friday.                

 

10. Teach patient to monitor his intake and output if able.  Teach patient about heart healthy renal diet and diabetic diet.

Rationale:

1 .Permits monitoring of cardiovascular response to illness state and therapy (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

2. Essential monitoring for fluid collection in lungs and cardiac overload due to edema (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

3. Facilitates respiration  (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

4. Determines extent of fluid balance, need for dieresis, or progress of therapy  (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

5. Essential monitoring for fluid and electrolyte imbalance  (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

6. Essential monitoring for fluid and electrolyte imbalance (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

7. Monitoring for fluid replacement.  Allows consistent comparison of weight (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

8. Diuretics help to maintain fluid balance (Potter & Perry, 2009).

 

9. Reduction of uremic toxins and correction of electrolyte imbalances and fluid overload may limit/prevent cardiac manifestations, including hypertension and pericardial effusion (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

 

10. Supports the patient’s self care by pointing out measures he can use to control fluid imbalance.  Adequate intake and early intervention will prevent undesirable outcomes (Newfield, Hinz, Tilley, Sridaromont, &Maramba, 2007).

Client Response:

1. Patient tolerated frequent check of vital signs very well.  Patient did not mind at all.

2. Patient tolerated frequent assessment of lung, heart, and breath sounds very well.  Patient would ask results.

3.  Patient was much more comfortable when sitting up in bed.  Preferred semi fowlers and high fowlers.  Patient tolerated sitting in chair but did not prefer.  Asked several times to be put back into bed. 

4. Patients intake was measured easily.  Breakfast drank/ate 100% meal/fluids.  Lunch did not like food, asked for peanut butter and jelly instead. Ate jelly sandwich.  Patient was satisfied.

5. Patient tolerated measurement of skin turgor well.  Patient very easy to work with.

6. I was not there when blood was taken to do lab work so I am unsure of how patient tolerated procedure, however lab values were obtained each day patient has been in hospital.

7. Patient being weighed using bed scale so unaware of procedure.  Likes being in bed.

8. Patient tolerates medication administration very well.  Tolerates insulin shots with no complaint, and swallows all pills at once with water.  Diuretics increasing urine output.  Patient tolerates eye drops well.  Does both him a little bit because holds eye closed in between each drop and rubs eyes after, but has no complaints during procedure.

9. Patient was receiving dialysis when I was leaving for the day, however he knows his dialysis schedule and asked frequently if he was on schedule for today.

10. Although patient is hard of hearing, he is receptive to information and asks appropriate questions.  Patient is aware of what foods to avoid and what foods are best for him regarding diabetes.


 

Goal Evaluation (goal met, partially met, or unmet within timeframe as evidenced by…):  The goal of patient’s fluid and electrolyte balance will be stabilized and intake and output will reach an approximate balance over a span of 72 hours; target date third day after admission as evidenced by decreased peripheral edema, decreased signs of dyspnea, and patient verbalizing doesn’t feel breathlessness was not met.  The patient was admitted to the hospital on 8/20 and as of 8/24 early morning he had 2+ pitting edema in bilateral ankles and tops of feet, feelings of breathlessness, and dyspnea.  Patient was still on his normal dialysis schedule which is Monday, Wednesday, Friday.  He was back to his feeling of normal, which includes feeling short of air, deep breathing, and use of accessory muscles and belly to breathe, however is still retaining large volumes of fluid.  He was being considered for discharge back to Clark Rehab over the weekend.

The goal of patient’s complication will be prevented or minimized by discharge date was met.  The patient’s condition did not get any worse once he was admitted and he said he felt back to normal despite the fact that he was still short of air and unable perform any type of activity without feeling extremely breathless and his oxygen saturation dropping to the 60s range.  Patient stated he has felt short of breath for years and was feeling better since the day he came in.  He said he didn’t feel well at all 8/20, his day of admission.

The goal of patient will demonstrate reduced extracellular fluid volume as evidenced by weight loss, decreased peripheral edema, clear lung sounds, and normal heart sounds each day until discharge was partially met.  The patients lung sounds were clear, and heart regular rhythm despite rate being high at times.  His weight had decreased since his admission date.  The goal is only partially met because he does still have peripheral edema.  2t in ankles and tops of feet. 

The goal of patient will remain free of infection throughout course of hospitalization was partially met.  Until this point there has been no issues.  Patient is in isolation for prior MRSA of nares.  Goal is only partially met because patient has not yet been discharged.

 

 

Diagnosis Evaluation (Provide summary.  Include answers to the following questions: was this care plan effective in resolving, monitoring, management your patient’s diagnosis? If so, provide evidence. Is more time needed in order to evaluate effectiveness):  This care plan was effective in monitoring  and management of patient’s diagnosis because the patient experienced decreased signs of dyspnea, reported feeling less breathless than when he did on admission, and his edema and weight has not increased since his arrival.  His medical conditions are far from resolved but are being managed effectively.  The patient has been experiencing large fluid volume excess as of late and has been undergoing dialysis regularly.  His recent hospitalization was due to the extreme fluid volume lost and his inability to catch his breath afterward.  More time is needed to truly evaluate this plan of care and determine if all goals can be declared as met or unmet, especially goals relating to patient remaining free of infection, and fluid and electrolyte balance being stabilized because the patient is not yet at his discharge date. The patient still needs to be closely monitored because he is unable to move freely and had decreased sensitivity in his lower extremities.  The interventions were effective in monitoring his complications and were able to be accomplished.  Overall though, in terms of how he was feeling, he did state several times the day I worked with him that he felt fine, and felt as he remembers he normally feels.  He was looking forward to going home to Clark Nursing and Rehabilitation Center.

 

References

Newfield, S. A., Hinz, M. D., Tilley, D. S., Sridaromont, K. L., & Maramba, P. J. (2007). Cox's Clinical Applications of Nursing Diagnosis (5th ed.).                Philadelphia, PA, USA: F.A. Davis Company.

Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO, USA: Mosby Elsevier

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Textbook of Medical-Surgical Nursing (12th ed., Vol. 1). Philadelphia, PA, USA: Wolters Kluwer Lippincott Williams & Wilkins.


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