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Nursing Fundamentals study notes.pdf
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Nursing 101 Fundamentals of Nursing Practice Exam 1 With Verified Questions And Answers
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Peritoneal Dialysis Nursing Care PlansNursing Diagnosis
▪ Risk for Deficient Fluid Volume
Risk Factors
▪ Use of hypertonic dialysate with excessive removal of fluid from
circulating volume
Desired Outcomes
▪ Will achieve desired alteration in fluid volume and weight with BP and
electrolyte levels within acceptable range.
▪ Will experience no symptoms of dehydration.
Nursing Interventions
▪ Measure and record intake and output, including all body fluids, such
as wound drainage, nasogastric output, and diarrhoea.
▪ Rationale: Provides information about the status of patient’s loss
or gain at the end of each exchange.
▪ Maintain record of inflow and outflow volumes and individual and
cumulative fluid balance.
▪ Rationale: Provides information about the status of patient’s loss
or gain at the end of each exchange.
▪ Assess hb and hct and replace blood components, as indicated.
▪ Rationale: This is important in view of under dialysis in patients of
normal or near normal haematocrit and suggests the need for
modification of dialysis prescription in such situations.
▪ Adhere to schedule for draining dialysate from abdomen.
▪ Rationale: Prolonged dwell times, especially when 4.5% glucose
solution is used, may cause excessive fluid loss.
▪ Weigh when abdomen is empty, following initial 6–10 runs, then as
indicated
▪ Rationale: Detects rate of fluid removal by comparison with
baseline body weight.
▪ Monitor vital signs. watch and report any signs of pericarditis (pleuritic
chest pain, tachycardia, pericardial friction, rub), inadequate renal
perfusion (hypotension), and acidosis.
▪ Rationale: Patients with end-stage renal disease (ESRD) may
develop pericardial disease.
▪ Monitor BP (lying and sitting) and pulse. Note level of jugular pulsation
▪ Rationale: Decreased BP, postural hypotension, and tachycardia
are early signs of hypovolemia
▪ Note reports of dizziness, nausea, increasing thirst.
▪ Rationale: May indicate hypovolemia and hyperosmolar syndrome.
, ▪ Inspect mucous membranes, evaluate skin turgor, peripheral pulses,
capillary refill
▪ Rationale: Dry mucous membranes, poor skin turgor and
diminished pulses and capillary refill are indicators of dehydration
and need for increased intake and changes in strength of dialysate.
▪ Monitor laboratory studies as indicated: Serum sodium and glucose
levels;
▪ Rationale: Hypertonic solutions may cause hypernatremia
by removing more water than sodium. In addition, dextrose may be
absorbed from the dialysate, thereby elevating serum glucose.
▪ Maintain proper electrolyte balance. Serum potassium levels. Watch for
symptoms of hyperkalaemia (malaise, anorexia, paraesthesia, or
muscle weakness) and electrocardiogram changes (tall peaked T
waves, widening QRS segment, and disappearing P waves), and report
them immediately.
▪ Rationale: Although a small percent of patients are chronically
hypokalaemia, hyperkalaemia is by far the most common
abnormality in dialysis patients.
▪ Assess patient frequently, especially during emergency treatment to
lower potassium levels. If the patient receives hypertonic glucose and
insulin infusions, monitor potassium levels. If you give sodium
polystyrene sulfonate rectally, make sure the patient doesn’t retain it
and become constipated.
▪ Rationale: To prevent bowel perforation.
▪ Maintain nutritional status. Provide a high-calorie, low-protein, low-
sodium, and low-potassium diet, with vitamin supplements.
▪ Rationale: To balance nutritional intake.
▪ Aggressively restore fluid volume after major surgery or trauma.
▪ Rationale: Dialysis disequilibrium syndrome is a frequent
complication of renal replacement therapy and seems to be related
to changes in fluid balance.
Nursing Diagnosis
▪ Risk for Ineffective Breathing Pattern
Risk factors may include
▪ Abdominal pressure/restricted diaphragmatic excursion; rapid infusion
of dialysate; pain
▪ Inflammatory process (e.g., atelectasis/pneumonia)
Desired Outcomes
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