Assessment Diagnosis Planning Intervention Rationale Outcome

Objective- Risk for After 6 hours Independent At the end of

scaly dry skin impaired of nursing -Assess skin -This may be 6 hours, client
observed skin care, client routinely indication of was able to
integrity as will verbalize noting color, particular verbalize
manifested understanding moisture and vulnerability. understanding
by scaly of treatment elasticity. of treatment
skin. regimen and -Emphasize -To maintain regimen and
demonstrate importance general good demonstrate
behaviors to of adequate health and behaviors to
prevent nutritional skin turgor. prevent
impaired skin. and fluid impaired skin
intake.
-Advise To keep skin
regular use moisturized
of skin and
moisturizers hydrated.
like vase
lines, or
moisturizers.
Collaborative
-Refer to To identify
dietician as nutritional
appropriate. needs.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Patient Non After 8 hours Independent After 8 hours
verbalized compliance of nursing -develop Provides of nursing
not taking r/t deficient intervention, therapeutic atmosphere intervention,
medications knowledge client will nurse-client for which client
because she relevant to verbalize relationship. client can verbalized
thinks she regimen accurate easily accurate
doesnt behavior as knowledge of express knowledge of
need them. evidenced by condition and views and condition and
subjective understanding concerns. understanding
verbalization of treatment of treatment
of not taking plans. -determine -to assess plans.
medication. -client will whether if clients -client also
also verbalize client knows knowledge verbalized
commitment what the and educate commitment
to mutually medications about her to mutually
agreed upon are and why medication. agreed upon
goals and they are goals and
treatment prescribed. treatment
plans. -establish -encourages plans.
goals or progression
modified to more
regimen as advanced
necessary. goal.
-stress -improves
importance of clients
clients adherence
knowledge by a
and significant
understanding percentage.
of the need
for treatment
or
medication.

Collaborative
-Refer to Helps
counselling encourage
therapy client to
adhere to
take
medications
Assessment Diagnosis Planning Intervention Rationale Evaluation
Client was Disturbed After 8 hours -Determine -there is After 8 hours
being body image of nursing whether always of nursing
conscious r/t bulgy intervention, condition is something intervention,
about her arm made client should permanent. that can be client was
arm. by fistula be able to done to able to
verbalize enhance verbalize
understanding acceptance. understanding
of body -evaluate -may of body
changes and clients indicate changes and
acceptance of knowledge of acceptance acceptance of
self in and anxiety or non self in
situation. related to acceptance situation.
situation. of situation.
-discuss
meaning of -a change in
the body function may
change to be different
client. for some to
deal with
than a
change in
-encourage appearance.
client to -helps to
look/touch incorporate
body part. changes into
-help client body image.
to select - to minimize
clothing. body
changes and
enhance
appearance.
PROBLEM LIST
POSSIBLE RISK FACTORS
Excess fluid volume
Imbalanced nutrition
Altered renal tissue perfusion
Due to hemodialysis treatment.
NURSING DIAGNOSIS
Risk for excess fluid volume
Imbalanced nutrition less than body
requirement
Altered Renal Perfusion RT glomerular
malfunction
Risk for nausea.