ESRD careplan help - risk of infection

eCCU · Oct 24, 2012

The careplan I am having to complete is for an ESRD patient.
She just underwent hemodialysis catheter placement surgery two weeks ago. I am in need of help regarding the "planning" and "interventions" section of my care plan.
Does anyone have any good NANDA information.

There are a lot of Nursing dx for patients with ESRD, just provide your patient assessment. For example what are the lab values to determine electrolyte imbalance, what does the skin assessment state? Most esrd pts are also uremic hence impaired skin integrity, respiratory assessment?, mental status? Most definitely they have impaired tissue perfusion, renal what's the patients volume status?.......just provide your pt assessment so that the nurses can help with some input! We are more than happy to assist:-)

DSCCnsg14 · Oct 24, 2012

[TABLE]

[TR]

[TD]Creatinine

[/TD]

[TD]0.8 – 1.3

[/TD]

[TD]3.8 MG/L

[/TD]

[TD]H

[/TD]

[/TR]

[TR]

[TD]BUN

[/TD]

[TD]7 – 18

[/TD]

[TD]42 MG/L

[/TD]

[TD]H

[/TD]

[/TR]

[TR]

[TD]Glucose

[/TD]

[TD]74 – 106

[/TD]

[TD]153 MG/L

[/TD]

[TD]H

[/TD]

[/TR]

[/TABLE]

[TABLE=width: 813]

[TR]

[TD=colspan: 5]Capillary refill:

[/TD]

[TD=colspan: 3]

[/TD]

[TD=colspan: 3]X

[/TD]

[TD=colspan: 3] > 3 sec.

[/TD]

[TD=colspan: 3]

[/TD]

[TD=colspan: 7]

[/TD]

[/TR]

[TR]

[TD]Skin:

[/TD]

[TD=colspan: 2]Color:

[/TD]

[TD=colspan: 6]Appropriate for race

[/TD]

[TD=colspan: 3]Temp:

[/TD]

[TD=colspan: 6]Warm to touch

[/TD]

[TD=colspan: 2]Turgor:

[/TD]

[TD=colspan: 3]Recoil > 4 seconds

[/TD]

[TD]

[/TD]

[/TR]

[TR]

[TD=colspan: 6] Mucous membranes:

[/TD]

[TD]

[/TD]

[TD=colspan: 3]Color

[/TD]

[TD=colspan: 5]Pink - yellow

[/TD]

[TD=colspan: 4] Lips:

[/TD]

[TD=colspan: 3]Color

[/TD]

[TD]Appropriate for race

[/TD]

[TD]

[/TD]

[/TR]

[TR]

[TD=colspan: 2]Edema:

[/TD]

[TD=colspan: 2]Present

[/TD]

[TD=colspan: 6]

[/TD]

[TD=colspan: 3]Absent

[/TD]

[TD=colspan: 3] X

[/TD]

[TD=colspan: 5]

[/TD]

[TD=colspan: 3]

[/TD]

[/TR]

[/TABLE]

[TABLE=width: 813]

[TR]

[TD] Rate:

[/TD]

[TD=colspan: 2]RR 16

[/TD]

[TD=colspan: 2]Rhythm:

[/TD]

[TD=colspan: 3]Regular

[/TD]

[TD]Character:

[/TD]

[TD=colspan: 4]Unlabored

[/TD]

[/TR]

[TR]

[TD=colspan: 2] Breath Sounds:

[/TD]

[TD=colspan: 2] Clear

[/TD]

[TD=colspan: 2] X

[/TD]

[TD]Wheeze

[/TD]

[TD]

[/TD]

[TD=colspan: 2]Crackles/rales

[/TD]

[TD]

[/TD]

[TD]Rhonchi

[/TD]

[TD]

[/TD]

[/TR]

[/TABLE]

[TABLE=width: 813]

[TR]

[TD=colspan: 3]

Urinary Pattern:

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3]

Several times through

[/TD]

[TD=colspan: 2]

out the

[/TD]

[TD=colspan: 2]

day

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[TR]

[TD=colspan: 2] Nocturia:

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3] X

[/TD]

[TD=colspan: 2]Pain:

[/TD]

[TD=colspan: 2]Denies

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]Incontinence:

[/TD]

[TD=colspan: 2]Denies

[/TD]

[TD]

[/TD]

[/TR]

[TR]

[TD=colspan: 2] Retention:

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3]Denies

[/TD]

[TD=colspan: 2]Frequency:

[/TD]

[TD=colspan: 2]5x daily

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]Burning:

[/TD]

[TD=colspan: 2]Denies

[/TD]

[TD]

[/TD]

[/TR]

[TR]

[TD=colspan: 2] Blood:

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3]Denies

[/TD]

[TD=colspan: 2]Distention:

[/TD]

[TD=colspan: 2]N/A

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD]

[/TD]

[/TR]

[TR]

[TD][/TD]

[TD=colspan: 5][/TD]

[TD][/TD]

[TD=colspan: 2][/TD]

[TD][/TD]

[/TR]

[/TABLE]

[TABLE=width: 813]

[TR]

[TD=colspan: 3] Eating habits:

[/TD]

[TD=colspan: 3]3

[/TD]

[TD]meal

[/TD]

[TD=colspan: 2]s daily

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3]

[/TD]

[TD]

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[TR]

[TD=colspan: 8] Food preferences/Intolerances:

[/TD]

[TD=colspan: 3]Likes: bake

[/TD]

[TD=colspan: 2]d be

[/TD]

[TD=colspan: 2]dns, potato

[/TD]

[TD=colspan: 2]salad, and chopp

[/TD]

[TD=colspan: 3]ed BB

[/TD]

[TD]Q; no d

[/TD]

[TD=colspan: 2]islikes.

[/TD]

[/TR]

[TR]

[TD=colspan: 5] Fluid/food intake:

[/TD]

[TD=colspan: 6]75% total daily fluid intak

[/TD]

[TD=colspan: 2]e an

[/TD]

[TD=colspan: 2]d 100% tot

[/TD]

[TD=colspan: 2]al daily food inta

[/TD]

[TD=colspan: 3]ke.

[/TD]

[TD]

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[TR]

[TD=colspan: 5]

[/TD]

[TD=colspan: 6]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3]

[/TD]

[TD]

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[TR]

[TD=colspan: 2] Current diet:

[/TD]

[TD=colspan: 9]ADA, thin liquid consistency

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 2]

[/TD]

[TD=colspan: 3]

[/TD]

[TD]

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[TR]

[TD=colspan: 2] Dentures:

[/TD]

[TD=colspan: 8]N/A

[/TD]

[TD=colspan: 2]Nausea:

[/TD]

[TD=colspan: 4]Denies

[/TD]

[TD=colspan: 2]Vomiting:

[/TD]

[TD=colspan: 3]Denies

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[TR]

[TD=colspan: 4] Current weight:

[/TD]

[TD=colspan: 6]200 lbs.

[/TD]

[TD=colspan: 4]Current height:

[/TD]

[TD=colspan: 2]66”

[/TD]

[TD=colspan: 3]Weight change:

[/TD]

[TD=colspan: 3]Weight ↑

[/TD]

[TD]

[/TD]

[/TR]

[TR]

[TD]Comments:

[/TD]

[TD=colspan: 9]Patient eats independently;

[/TD]

[TD=colspan: 2]no supple

[/TD]

[TD=colspan: 4]ments; no added salt; n

[/TD]

[TD=colspan: 2]o fried food

[/TD]

[TD=colspan: 3]s. Weight ↑

[/TD]

[TD=colspan: 2]of lbs.

[/TD]

[/TR]

[TR]

[TD=colspan: 4]since 07-25-12; n

[/TD]

[TD=colspan: 6]o difficulty chewing.

[/TD]

[TD=colspan: 2]Patient d

[/TD]

[TD=colspan: 4]enies any N/V but PRN

[/TD]

[TD=colspan: 2]meds

[/TD]

[TD=colspan: 3]

[/TD]

[TD=colspan: 2]

[/TD]

[/TR]

[/TABLE]

Esme12, ASN, BSN, RN · Oct 24, 2012

With the information I gave you just the other day......what do you think? What is the patient assessment? What is their main complaint? What is YOUR assessment of the patient?

The information you provided.....

BUN 42

Cr 3.8

Glu 153

Turgor 4 secs

She had nocturia and voids frequently

No edema....but recent weight gain

What does this tell you about this patient? What other information do you have about this patient. Remember a care plan is all about what the patient needs........

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.
What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)
The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

What else could cause this patient to have an elevated BUN/Cr with and elevated glucose, poor skin turgor indicating dehydration but complains of frequent voiding. What is this patients story? Is this a real patient?

What care plan/nursing diagnosis book are you using?

nurseprnRN, BSN, RN · Oct 24, 2012

I'm starting to feel like a broken record here, but I hope that people will take it to heart. THE definitive book for your nursing plans of care is the NANDA-I (2012-2014 is the current edition). It has every approved nursing diagnosis WITH every defining characteristic, so you can look to see if your assessment justifies a given diagnosis. Because it gives you the defining characteristics, you can almost always determine how to solve the patient problem...which is the core of care planning.

Amazon has this book for free two-day shipping, and you need it as fast as they can send it to you. Please, please, please, students, you owe it to yourselves to get the definitive, clear, understandable, unimpeachable source for nursing diagnosis and planning. Do it now!