Problem # 1

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Nursing Diagnosis

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Objectives

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Intervention

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Evaluation

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06 1530 July 2024

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Fluid volume deficit related to compromised regulatory mechanisms secondary to disease process

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Subjective:

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● “Dalawang araw na ako suka ng suka, kalahating baso bawat suka ko, 5 beses, nahinto lang ito ung na admit na ako sa V
Luna Hospital.”

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● “Nauuhaw at medyo nahihilo ako.”

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Objective:

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● Vital signs:

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⮚ T-35.8oC

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⮚ PR-102 bpm, with weak pulse

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⮚ RR- 20 cpm

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⮚ BP- 90/60 mmhg

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⮚ O2 Sat: 97%

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● With dry, cracked lips and dry mucous membrane

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● With yellowish and dry skin.

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● Poor skin turgor (2 to 3 seconds)

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● Skin cold to touch

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● Pale fingernails and decreased capillary refill (2 to 3 seconds)

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● (+) sunken eyeballs

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● With IFC connected to urine bag with dark yellow 100 ml urine output

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● Blood Chemistry (pre-HD) taken 05 Jul 24:

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Creatinine-867 mmol/L

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BUN-31.66 mmol/L

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At the end of two-hour nursing management, EPR will improve body fluid volume balance of as evidenced by:

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1) Verbalization of decreased feeling of dizziness with decreased episodes of vomiting

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2) Vital signs within acceptable limits:

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● T: 36.5oC - 37.3oC

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● PR: 60-100 bpm, with regular and full pulse

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● RR: 16-20 cpm

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● BP: 110/70mmHg

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● O2 sat: 96% to 100%

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3) Lips and mucous membranes are moist

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4) Skin is warm to touch

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5) Capillary refill within three (3) seconds

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6) Increase in urine output to more than 100 ml with lighter color

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7) Verbalization of decrease in feeling of thirst

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8) Verbalization of ways to enhance his fluid management (increased hydration)

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9) Decrease in creatinine and BUN levels

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Independent:

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● Established rapport with the patient to gain trust and cooperation of the patient.

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● Performed hemodialysis assessment such as pre, HD/post HD weight, vital signs, and physical examination.

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● Monitored vital signs every 30 minutes.

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● Monitored for complications during hemodialysis such as hypotension, difficulty of breathing, desaturation, and muscle cramps.

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● Placed in semi-Fowler position and elevated lower extremities to promote venous return

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● Monitored intake and output during HD to include appearance and quality of urine output.

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● Encouraged to increase oral fluid intake.

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Collaborative/Dependent:

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● Hooked to HD machine aseptically and started hemodialysis following the HD prescription:

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■ UF volume goal: 500mL

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■ Qd: 300 ml/min

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■ Qb: 150 ml/min.

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■ Flushing every 30 minutes

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● Fast drip of PNSS 1000 ml done during hemodialysis as ordered to enhance hydration.

06 1730 July 2024

Nursing care goal met

At the end of two-hour nursing management, EPR had improved body fluid volume balance as evidenced by:

1) “Nabawasan ang pagkahilo ko” as verbalized by EPR.

2) No episodes of vomiting during HD

3) Vital signs within acceptable limits for hemodialysis patient:

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 T: 36.7oC

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 PR: 82 bpm, with regular and full pulse

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 RR: 18 cpm

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 BP: 110/70mmHg

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  O2 sat: 99%

4) Lips and mucous membranes were moist

5) Skin was warm to touch

6) Capillary refill within two (2) seconds

7) Increased urine output (300 ml drained in urine bag) with lighter color

8) Verbalized decrease of thirst as he was able to hydrate with 200 ml of water while on HD

9) Verbalized ways to enhance his fluid management (increased hydration) such as avoidance of caffeinated drinks and following
a hydration schedule/plan

10) Blood Chemistry (taken 08 Jul 24 pre-HD):

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Creatinine-499 mmol/L

BUN-43.79 mmol/L

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Problem # 2

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Nursing Diagnosis

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Objectives

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Intervention

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Evaluation

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06 1530 July 2024

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Activity Intolerance, Level III Functional Classification, Gordon, 1987 (See Appendix) related to anemia, metabolic waste product
retention, and disease process

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Subjective:

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● “Nanghihina talaga ako ma’am kahit na tumayo lang ako”

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● “Nahihilo din po ako ma’am lalo kapag bumabangon”.

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Objective:

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● Vital signs:

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⮚ T-35.8oC

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⮚ PR-102 bpm, with weak pulse

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⮚ RR- 20 cpm; (+) exertional dyspnea

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⮚ BP- 90/60 mmHg

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⮚ O2 Sat: 97%

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● With generalized body weakness and easy fatigability

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● Pale conjunctivae and icteric sclerae noted

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● Required assistance during transfer from wheelchair to HD chair

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● Laboratory results (05 Jul 24):

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CBC:

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Hgb: 124 gms/L
↓Hct: 34.9

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Blood Chemistry:

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Creatinine-867 mmol/L

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BUN-31.66 mmol/L

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At the end of two (2)-hour nursing management, the patient will manifest an increased tolerance in performing ADLs (activities of
daily living) as evidenced by:

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1) Vital signs within normal limits

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● T: 36.5oC - 37.3oC

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● PR: 60-100 bpm, with regular and full pulse

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● RR: 16-20 cpm, without exertional dyspnea

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● BP: 110/70mmHg

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● O2 sat: 96% to 100%

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2) Reduction in generalized body weakness and dizziness

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3) Verbalization of increased energy levels and being rested/relaxed

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4) Performance or verbalization of at least three (3) ways or techniques to increase activity tolerance

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5) Decrease in creatinine and BUN levels

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Independent:

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● Established rapport with the patient to build a positive nurse-patient relationship.

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● Performed hemodialysis assessment such as pre, HD/post HD weight, vital signs, and physical examination.

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● Monitored vital signs every 30 minutes.

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● Monitored for complications during hemodialysis such as hypotension, difficulty of breathing, desaturation, and muscle cramps.

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● Assessed and monitored extent of body weakness, fatigability, and dizziness and in relation to performance of ADLs.

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● Assessed characteristics of body weakness and consequential limitations on the activities of the patient.

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● Promoted rest and maintained maximum comfort during HD.

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● Facilitated and encouraged to do range-of-motion (ROM) exercises while on HD as tolerated.

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● Instructed and encouraged to perform deep-breathing exercises.

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● Conducted health teaching on activity and rest such as progression of activities and incorporating rest periods as well as on nu -
trition emphasizing on consumption of food with high iron content such as fish which provides elemental iron for the formation of
hemoglobin.

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Collaborative/Dependent:

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● Hooked to HD machine aseptically and started hemodialysis following the HD prescription:

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■ UF volume goal: 500mL

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■ Qd: 300 ml/min

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■ Qb: 150 ml/min.

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■ Flushing every 30 minutes

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 Fast drip of PNSS 1000 ml done during hemodialysis as ordered to enhance hydration.

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● Instructed patient to verbalize need for oxygen support while on HD.

06 1730 July 2024

Nursing care goal partially met

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At the end of the two (2)-hour nursing management, the patient manifested an increased tolerance in performing ADLs as evi-
denced by:

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1) Vital signs within normal limits

● T: 36.7oC
● PR: 82 bpm, with regular and full pulse
● RR: 18 cpm, no exertional dyspnea noted
● BP: 110/70mmHg
● O2 sat: 99%

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2) Reduction in generalized body weakness and dizziness as claimed

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3) Verbalized “Mas maganda na po ang pakiramdam ko ngayon, ma’am. Medyo mas nagagalaw ko na ng maayos ang mga paa
ko.”

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4) Performed regular deep-breathing exercises and observed response of body during performance of ADLs and able to stop or
solicit assistance when needed

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-Performed progressive range of motion exercises on arms and legs.

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5) Blood Chemistry (taken 08 Jul 24):

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Creatinine-499 mmol/L

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BUN-43.79 mmol/L

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Problem # 3

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Nursing Diagnosis

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Objectives

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Intervention

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 Evaluation

Knowledge deficit related to At the end of two (2)-hour Independent: At the end of two (2)-hour nurs-
present illness and its treat- nursing management, the  Evaluated understanding of the ing management, the patient
ment regimen related to lack of patient will express ade- disease condition and the expressed adequate under-
sufficient information and learn- quate understanding of hemodialysis procedure. standing of his illness and its
ing resources his illness and its treat-  Offered information about the treatment regimen translated
ment regimen translated causes, signs and symptoms, and into:
Subjective Data: into: complications of his illness and why 1) Was able to discuss his ill-
 “Gagaling na kaya ako kapag 1) Discussion of his ill- hemodialysis treatment was indi- ness in own words and stated
na-dialysis ako?” ness in own words and cated. that he would be more cautious
concepts (e.g the reason  Provided learning resources re- next time when he wades in
Objective Data: why he was infected with garding the hemodialysis procedure flood water and in general take
 Inquires repeatedly about his leptospirosis and corre- through a printed material with in- care of his health
health condition sponding symptoms and teractive health teachings such as 2) Verbalized the importance of
 Seeks more information on management). fluid intake and output monitoring, adherence to his management
the course of his manage- 2) Verbalization on the im- deep breathing exercises, caring for and treatment in order for him
ment in Renal Unit and his portance of adherence to IJ catheter as HD access, healthy to optimally recover
treatment his management and diet, activity and exercise (activities 3) Discussed health practices
 Displays apprehension on treatment in order for him with rest periods), and care of HD related to treatment his man-
the information and details to optimally recover access (IJ cathether). agement such as:

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provided by nurses 3) Discussion of health  Advised the patient and relative  Adherence to fluid hy-
practices related to treat- (sister) regarding diet plan and im- dration plan to prevent de-
ment his management portance of OFI. hydration
such as ch as:  Kept updated on his HD monitoring  Avoidance of high salt,
 Adherence to fluid parameters. high cholesterol, and high
hydration plan  Encouraged patient to ask ques- potassium containing food
 Avoidance of high tions or express clarifications not  Progressive perfor-
salt, high cholesterol, only during health teachings but mance of passive and ac-
and high potassium also during nurse-patient interac- tive ROM exercise to in-
containing food tion. crease tolerance of ADLs
 Progressive perfor-  Caring for IJ catheter as
mance of passive HD access
and active ROM ex-  Following medications
ercise to increase tol- and other instructions from
erance of ADLs healthcare providers
 Caring for IJ catheter
as HD access
 Following medica-
tions and other in-
structions from
healthcare providers

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