Care Plan for Dialysis Patient

Category / Primary Body System

• Renal / Urinary System

Problem

• Resident is a dialysis patient with potential for complications.

Goal

• Resident will not experience any complications from dialysis for 90 days.

Plan/Approach

1. Dialysis Management

   • Attend dialysis as scheduled
   • Communicate through dialysis communication book/form

2. Access Site Care

   • Assess bruit/thrill every shift as ordered
   • Assess shunt for signs of infection
   • Monitor shunt for bleeding

3. Fluid and Medication Management

   • Adhere to fluid restrictions as ordered
   • Administer medications at optimal times

4. Patient and Family Education

   • Educate patient and family on signs of complications and proper care of dialysis access site

Rationale

1. Dialysis Management

   • Regularly attending dialysis sessions ensures adequate removal of waste products and fluid, which is critical for managing end-stage renal disease (ESRD).
   • Using a communication book/form facilitates effective communication between the dialysis center and other healthcare providers, ensuring continuity of care.

2. Access Site Care

   • Assessing the bruit/thrill ensures the vascular access is functioning properly.
   • Monitoring the shunt for signs of infection and bleeding helps in early detection and prompt intervention to prevent complications.

3. Fluid and Medication Management

   • Adhering to fluid restrictions helps prevent fluid overload, which can lead to complications such as hypertension and heart failure.
   • Administering medications at optimal times maximizes their effectiveness and reduces the risk of interactions and side effects.

4. Patient and Family Education

   • Educating the patient and family empowers them to recognize early signs of complications and take appropriate actions to manage them.

Actions

1. Dialysis Management

   • Ensure the patient attends all scheduled dialysis sessions, documenting attendance and any issues that arise.
   • Use a dialysis communication book/form to relay information between the dialysis center and healthcare providers, ensuring all relevant details are communicated.

2. Access Site Care

   • Assess the bruit/thrill of the dialysis access site every shift, documenting findings and reporting any abnormalities.
   • Examine the shunt site for signs of infection (redness, warmth, swelling, discharge) and report any concerns to the healthcare provider immediately.
   • Monitor for bleeding at the shunt site and take appropriate action if bleeding occurs, including applying pressure and notifying the healthcare provider.

3. Fluid and Medication Management

   • Adhere to prescribed fluid restrictions, educating the patient on the importance of limiting fluid intake.
   • Administer medications at optimal times, ensuring they are taken as prescribed and monitoring for any adverse effects.

4. Patient and Family Education

   • Provide education to the patient and family on the signs and symptoms of potential complications (e.g., infection, clotting, bleeding) and proper care of the dialysis access site.
   • Offer written and verbal instructions on managing fluid restrictions and adhering to medication schedules.