Student Nurses Community

NURSING CARE PLAN Hemodialysis

ASSESSMENT

SUBJECTIVE:
I feel very
weak as
verbalized by
the patient.
OBJECTIVE:
Loss of
weight
Restlessness
Weakness
V/S taken as
follows:
T: 36.8 C
P: 73
R: 18
BP: 110/80

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

Risk for
deficient fluid
volume. Risk
factor may
include
ultrafiltration,
fluid
restriction
and actual
blood loss
such as
systemic
heparinizatio
n or
disconnection
of the shunt.

Hemodialysis
is one of
several renal
replacement
therapies used
for the
treatment of
dialysis
removes
excess fluid
and restores
chemical and
electrolyte
balance.
Hemodialysis
involves
passing the
patients blood
through an
artificial
semipermeabl
e membrane
to perform the
filtering and
excretion
functions of
the kidney.

After 8
hours of
nursing
intervention
s, the
patient will:

Independent:

Maintain
fluid
balance
as
evidenced
by stable
vital
signs.
Moist
mucous
membran
e
Absence
of
bleeding.
Appropria
te weight

RATIONALE

Aids in
evaluating
Measure all
status,
sources of
especially when
intake and
compared with
output. Have
weight.
patient to
Weight loss over
keep a diary.
precisely
Weigh daily as
measured time
well as before
is a measure of
and after
ultrafiltration
dialysis run.
and fluid
removal.
Monitor vital
Hypotension,
signs during
dialysis.
tachycardia, and
falling
As certain
hemodynamic
whether
pressures
diuretics and
suggests volume
antihypertensi
depletion.
ves are to be

Dialysis
withheld.
potentiates
Verify
hypotensive
continuity of
effects if these
shunt or
drugs have been
access
administered.
catheter.
Apply external Disconnected
shunt or open
shunt
access permits
dressing.
exsanguination.
Permit to

EVALUATIO
N
After 8 hours
of nursing
intervention
s, the
patient was
able to:
Maintain
fluid
balance as
evidenced
by stable
vital signs.
Have
Good skin
turgor.
Moist
mucous
membran
e
Absence
of
bleeding.
Appropriat
e weight

Student Nurses Community

puncture of
shunt.
Place patient
in a supine or
trendelenburg
position, as
necessary.
Collaborative:
Monitor
laboratory
studies as
indicated.
Reduce rate
of
ultrafiltration
during
dialysis, as
indicated.

Minimizes stress
on cannula
insertion site to
reduce
inadvertent
dislodgement
and bleeding
from site.
Maximizes
venous return if
hypotension
occurs.
To monitor
closely to
prevent future
complications.
Reduces the
amount of water
being removed
and may correct
hypotension or
hypovolemia.