Table 5

Nursing Diagnosis: Excess fluid volume related to failure of kidney to eliminate excess body fluid

Scientific Basis: Renal disorder impairs glomerular filtration that resulted to fluid overload. Since fluid is not reabsorbed at the venous, fluid volume
overload the lymph system resulting of occurrence of edema, weight gain, pulmonary congestion and hypertension. (Brunner & Suddarth, 2016)
DEFINING EXPECTED
NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS OUTCOME
Subjective Cues: Short Term: Short Term:
Safe and Quality Nursing Care
“Akong BP usahay After 4 hours of After 4 hours of
maabot na sa 140/90 nurse-patient 1. Establish rapport To gain trust to patient and the SO. nurse-patient
usahay sa 150/90 tapos interaction, the patient 2. Monitor and record V/S To obtain baseline data. interaction, the patient
panagsa nalang ko will be able to 3. Assess the patient’s appetite To note for presence of nausea and was able to maintain a
mangihe.” demonstrate behaviors vomiting. fluid balance as
to maintain fluid 4. Note amount or rate of fluid To prevent fluid overload and evidenced by normal
balance. intake from all sources monitor intake and output. vital signs, stable
5. Compare current weight gain To monitor fluid retention and weight, and free from
with admission or previous stated evaluate degree of excess. signs of edema.
Objective Cues: Long Term: weight
• BP-140/80 to 140/90 After 3 days of 6. Auscultate breath sounds For presence of crackles or Long Term:
mmHg nurse-patient congestion. After 3 days of
• Weight gain from interaction, the patient 7. Record occurrence of dyspnea To evaluate degree of excess. nurse-patient
previous weight 61.75 will prevent from any 8. Note presence of edema To determine fluid retention. interaction, the patient
kg to 63.45 kg from complications of fluid 9. Measure abdominal girth for May indicate increase in fluid shows no signs of
pre-HD overload such as changes retention. complication of fluid
• Urine output of 240 ml delayed wound 10. Observe skin mucous To evaluate degree of fluid excess. overload.
per day healing, edema, membrane Weight gain indicates fluid retention
• Non-pitting edema headache, high blood 11. Weight patient or edema.
noted on right hand pressure, and stomach Health Education
bloating.
1. Instruct patient to restrict To lessen fluid retention and
sodium and fluid intake if indicated overload.
2. Encourage quiet, restful To conserve energy and lower
atmosphere tissue oxygen demand.
Records Management
1. Record I/O accurately and To monitor kidney function and fluid
calculate fluid volume balance retention.

Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span.
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 Table 6
Nursing Diagnosis: Ineffective renal tissue perfusion related to decreased hemoglobin concentration in blood
Scientific Basis: Chronic renal disease is a progressive loss in renal function over a period of months or years. Because of this disease, the kidney
cannot adequately produce erythropoietin hormone that leads to decrease in hemoglobin and hematocrit count. Thus, resulting to anemia because of
this manifests palpebral conjunctiva and paleness. (Brunner & Suddarth, 2016)
DEFINING EXPECTED
NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS OUTCOME
Subjective Cues: Short Term: Short Term:
“Dali kayo ko magluya After 4 hours of Safe and Quality Nursing Care After 4 hours of
kung naa koy buhaton nurse-patient nurse-patient
sa balay unya kabantay interaction, the patient 1. Establish rapport To gain trust and cooperation. interaction, the patient
ko manghupong na will demonstrate 2. Monitor vital signs To obtain baseline data was able to
akong kamot o dili gali behaviors or lifestyle 3. Assess patient’s general To obtain baseline data and note demonstrate behaviors
akong tiil.” changes to improve condition any abnormal findings. or lifestyle changes to
circulation. 4. Note characteristic of urine: To assess for hematuria and improve circulation.
measure specific gravity proteinuria and renal impairment
5. Ascertain usual voiding pattern To compare with current situation
Objective Cues: Long Term: 6. Monitor blood pressure GFR may increase renin and Long Term:
• BP-140/80 to 140/90 After 3 days of raise blood pressure. After 3 days of
mmHg nurse-patient 7. Observed for dependent To note impairment of renal nurse-patient
• Non-pitting edema interaction, the patient generalized edema function. interaction, the patient
noted on the right will be able to show 8. Measure capillary refill time To provide information on was able to increase
hand signs of increase perfusion. perfusion as evidenced
• Restlessness noted perfusion such as CRT Quality Improvement by decrease capillary
• CRT >3 secs. < 3 seconds, improve refill time, improve
fatigability and no signs 1. Review laboratory To note degree of impairment or fatigability with no signs
of dyspnea. studies/BUN/serum electrolytes organ involvement. of dyspnea noted.
Laboratory Results: 2. Administer medications like To maximize tissue perfusion.
•  Hemoglobin level of Epoetin
11g/dL Health Education
•  Hematocrit level of
39.3% 1. Encourage patient to have rest To conserve energy or lowers
periods between activities tissue oxygen demand.
2. Provide for diet restrictions, as Restriction of protein helps limit
indicated while providing Bun.
adequate calories to meet the
body’s need
Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span.
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 Table 7
Nursing Diagnosis: Activity intolerance related to muscle weakness
Scientific Basis: Erythropoietin production is at the kidneys but due chronic renal insufficiency, there is a decrease in erythropoietin production and
profound anemia due to lack of hemoglobin which results to decrease in oxygen to tissues that would lead to weakness and fatigue. (Brunner &
Suddarth, 2016)
DEFINING EXPECTED
NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS OUTCOME
Subjective: Short Term: Safe and Quality Nursing Care Short Term:
“Medyo magluya sad After 4 hours of After 4 hours of nursing
ko, murag kulang ra nurse-patient 1. Assess the factors contributing Indicates factors contributing to intervention, the patient
akong kusog if naa koy interaction, the patient to activity intolerance: severity of fatigue. was able to participate
buhaton.” will be able to a. Fatigue in increase level of
participate in increase b. Anemia activity and exercise.
level of activity and c. Fluid and electrolyte
exercise. imbalances
d. Retention of waste
products
Objective: Long Term: e. Depression Long Term:
• Restlessness noted After 3 days of 2. Monitor laboratory results such To identify the extent of After 3 days of
• Pale skin noted nurse-patient as hemoglobin and hematocrit deficiency. nurse-patient
• Unable to lift minimal interaction, the patient interaction, the patient
weight objects such will be able to report Health Education was able to report
as chair or her increase in sense of 1. Encourage alternating activity Promotes activity and exercise increase in sense of
handbang well-being, with rest. within limits and adequate rest. well-being, demonstrate
demonstrate 2. Plan care with rest periods To reduce fatigue. independency on
independence, and between activities self-care activities.
Laboratory Results: participates in selected 3. Encourage increase intake of To increase iron supplement of
•  Hemoglobin level of self-care activities. iron-rich foods the body.
11g/dL 4. Encourage quiet play, reading, Provides relaxation and
•  Hematocrit level of watching tv and restful promote rest and comfort.
39.3% atmosphere. Requires minimal energy only.

Collaboration and Teamwork

1. Promote independence in Promotes improved
self-care activities, assist if self-esteem.
needed.
2. Promote or implement To prevent to limit deterioration.
conditioning program and
support inclusion in exercise
Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span.
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 Table 8
Nursing Diagnosis: Impaired Skin Integrity of lower and upper extremities related to dry skin and itching
Scientific Basis: Skin involvement in chronic renal failure is characterized by a multitude of different aspects. Often pruritus, xerosis cutis,
hyperpigmentation, and actinic elastosis occur. These symptoms tend to alter and are aggravated relatively quickly when chronic renal insufficiency
leads to compulsory dialysis treatment. (Brunner & Suddarth, 2016)
DEFINING EXPECTED
NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS OUTCOMES
Subjective Cues: Short Term: Safe and Quality Nursing Care Short Term:
“Tungod sa ka dryness After 4 hours of After 4 hours of
sakong panit, maabot nurse-patient interaction, 1. Note changes in skin color, Indicates areas of poor nurse-patient interaction,
na siya sa punto nga the patient will be able to texture, and turgor. Assess areas circulation or breakdown. the patient was able to
mangatol ko unya demonstrate behaviors of pigmentation for color changes. demonstrate behaviors or
kabantay sad ko nga or techniques to prevent 2. Monitor fluid intake and Detects presence of techniques in preventing
nangitom ang uban part skin breakdown and hydration of skin and mucous dehydration or overhydration skin breakdown and injury
sakong panit.” injury. membranes. that affects circulation and
tissue integrity.
Objective Cues: Long Term: 3. Inspect dependent areas for Edematous tissues are more Long Term:
• Slightly saggy, pale After 3 days of edema. prone to breakdown. After 3 days of
skin noted nurse-patient interaction, 4. Keep bed clothes dry and free Reduces prolonged pressure nurse-patient interaction,
• Dry and itchy on lower the patient will be able to of wrinkles, crumbs, and so forth. on tissues. the patient was able to
and upper extremities maintain an intact skin, 5 Investigate reports of itching. To assess the extent of maintain an intact skin
• Poor skin turgor and displays timely itching tendencies. without developing any
• Mild pigmentation healing without Health Education complications such as
noted complications. itching and dryness.
• Urine output of 240 ml 1. Encourage patient to apply Lotions and ointments may
per day soothing skin care, restrict use of be desired to relieve dry,
• Nails are light pink in soaps. Apply ointments or cracked skin.
tone creams.
2. Suggest wearing loose-fitting Prevents direct dermal
Laboratory Results: cotton garments. irritation.
•  Hemoglobin level of 3. Recommended keeping nails Reduce risk of dermal injury
11g/dL short or wearing gloves. when severe itching present.
•  Hematocrit level of 4. Emphasize importance of To aid in healing and
39.3% optimum nutrition and increased maintain general good health
protein intake. and skin turgor.
5. Promote patient to learn stress To control feelings of
reduction and alternative therapy helplessness in a situation.
Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span.
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 Table 9
Nursing Diagnosis: Disturbed Sleep Pattern related to inadequate sleep hygiene
Scientific Basis: Sleep disorders are common among patients undergoing dialysis in end stage renal disease (ESRD). Insomnia is the most
common sleep disorder in different populations including patients on dialysis. It is defined as the subjective sensation of short and/or unsatisfying
sleep or trouble falling asleep and/or to nighttime waking. (Brunner & Suddarth, 2016)
DEFINING EXPECTED
NURSING INTERVENTIONS RATIONALE EVALUATION
CHARACTERISTICS OUTCOMES
Subjective Cues: Short Term: Safe and Quality Nursing Care Short Term:
“Putol-putol na akong After 4 hours of After 4 hours of
pahuway og katog, nurse-patient interaction, 1. Determine patterns of sleep in Provides baselin data for nurse-patient interaction,
unya kalit lang ko the patient will be able to the past in a normal environment: evaluating means to improve the patient was able to
makamata was a oras obtain optimal amounts amount, bedtime routines, depth, the patient’s sleep. obtain optimal amounts of
then if ganahan sad ko of sleep and relaxation length, positions and aids. sleep by displaying
matog balik, dugay techniques or behavior. 2. Take note observations of Provides baseline data for relaxation techniques or
nasad ko makapiyong.” sleep-wake behaviors. the evaluation of insomnia behavior.
3. Observe and evaluate the Medications may affect the
timing or effects of medications sleeping pattern of the
Objective Cues: Long Term: that can affect sleep. patient.
• Restlessness noted After 3 days of 4. Introduce relaxing activities Provides relaxation and Long Term:
• Taking a nap when nurse-patient interaction such as warm bath, calm music, distraction to prepare mind After 3 days of
there is a chance or if the patient will be able to reading a book, and relaxation and body for sleep. nurse-patient interaction,
free time have an improvement in exercises before bedtime. the patient was able to
• Yawning or dozing off sleep pattern. Health Education display improvement in
• Irritability noted sleep pattern as
• Sudden awakening at 1. Educate the patient on the This may interfere with the evidenced by decrease
night proper food and fluid intake such patient’s ability to relax and usual yawning, well
as avoiding heavy meals, alcohol, fall asleep. rested appearance, and
caffeine or smoking before verbalization of feeling
bedtime. rested.
2. Encourage patient to take milk.
L-tryptophan is a component
of milk promotes sleep.
3. Remind to avoid taking an This will refrain the patient
amount of fluids before bedtime. from going to the bathroom.
4. Instruct patient to inhibit Napping can disrupt normal
daytime naps unless needed. sleep pattern
5. Suggest an environment A lot of people sleep better in
conducive to rest or sleep. cool, dark, quiet
environment.
Source: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span.
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