Implementation Phase

Table 19. Nursing Care Implementation

Identified Problems Objectives of Care Implementation Evaluation

Imbalanced nutrition: less than After 10 days of nursing Substitutive Role: Client has demonstrated signs of
body requirements related to intervention, the client will 1. Note presence of nausea/anorexia. sufficient nutritional intake as
dietary restrictions be able to: manifested by the absence of anorexia
2. Recommend small, frequent meals. and improvement in the patient’s
Subjective Cues: Schedule meals according to dialysis appetite.
“May oras na minsan wala akong  Demonstrate adequate needs.
ganang kumain, at ang daming nutritional intake. The client showed enthusiasm in trying
hindi ko na pwedeng kainin. (I have 3. Encouraged frequent mouth care. out meals with alternative flavorings
a lot of food restrictions and such as garlic, onions, and lemon in
oftentimes I experience loss of Supplementary Role: place of salt and soy sauce. In addition
appetite)” as verbalized by the client. 1. Encourage patient to participate in menu the client adhered to eating small,
planning. frequent meals throughout the day
Objective Cues: instead of taking three full meals a day
 Anemia (Hgb: 98 g/L) 2. Encourage use of herbs/spices, e.g., garlic, and consumes his dialysis meals
 Fatigue onion, pepper, parsley, cilantro, and lemon. during the hour of treatment.
 Poor Muscle tone
 Initial weight upon entry 3. Suggest socialization during meals.
into dialysis unit: 57.5kg
 Present weight 51-54kg Complementary Role:
 BMI: 19.9 (underweight) 1. Provide a balance diet of complex
carbohydrates and ordered amount of high-
quality protein and essential amino acids.

2. Restrict sodium/potassium as indicated,

e.g., avoid processed meats and foods,
orange juice, tomato soup.

3. Administered multivitamins as indicated.

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 Identified Problems Objectives of Care Implementation Evaluation

Fluid Volume , excess related to After 10 days of nursing Substitutive Role: The client was able to demonstrate no
Compromised Regulatory intervention, the client will 1. Asses fluid status: rapid weight gain.
Mechanisms (Chronic Kidney be able to: a. Daily weight
Disease) b. Intake and output balance Maintains dietary and fluid
c. Skin turgor and presence of edema restrictions. Exhibits normal skin
Subjective Cues: d. Distention of neck veins turgor without edema. Client’s vital
“Alam ko na may limit ako sa pag- e. Blood pressure, pulse rate and signs within normal range. Reports no
inom ng tubig pero minsan  Display stable weight, rhythm difficulty of breathing or shortness of
napaparami ang inom ko ng tubig vital signs within f. Respiratory rate and effort breath.
lalo na pag mainit ang panahon. (I patient’s normal range,
know that I have fluid intake and absence of edema. 2. Identify potential sources of fluid:
limitations but sometimes I tend to a. Medications and fluids used to
drink a lot most especially during a take or administer medications oral
hot weather)” as verbalized by the and intravenous
client. b. Foods

Objective Cues: Supplementary Role:

 Oliguria 1. Limit fluid intake to prescribed volume.
 Mild bipedal edema
 Fluid intake 2-2.5 liters per 2. Explain to patient and significant others
day. rationale for fluid restriction.
 BP changes: elevated BP
3. Assist patient to cope with the discomforts
especially pre HD (180/100 resulting from fluid restriction.
mmhg)
Complementary Role:
1. Establish guidelines and goals of activity
with the client and caregiver.

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 Identified Problems Objectives of Care Implementation Evaluation

Impaired physical mobility After 10 days of nursing Substitutive Role: The client attains highest degree of
related to pain on both knees intervention, the client will 1. Educate patient to promote self-care. mobility possible within confines of
be able to: disease and able to carry out mobility
Subjective Cues: 2. Give explanation about progressive regimen together with/without
“Minsan nahihirapan talaga akong activity to patient assistance of family members.
gumalaw lalo na pag masakit ang  Attain highest degree of
mga tuhud ko. (Sometimes I have mobility possible within 3. Implement measures to promote Mobility improved when performing
difficulty in doing physical confines of disease. independence, but intervene when the self-care activities.
activities because my knees are in  Maintain muscle patient cannot function.
pain)” as verbalized by the client. strength and joint ROM.
 Carry out mobility Supplementary Role:
Objective Cues: regimen together 1. Apply regular routines, and allow adequate
 Increased pulse with/without assistance time for the client to complete task.
 Elevated blood uric acid of family members.
 Mild swelling of both knees 2. Help client in moving affected part and
Barthel Index of ADL perform self-care activities such as
score: 75/100 (moderate feeding, bathing and dressing.
dependency)
3. Help client with the use of assistive device.

Complementary Role:
1. Educate patient about appropriate types of
exercise for his level of health in
collaboration with a primary care provider.

2. Urge patient for some physical activity and

exercise

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 Identified Problems Objectives of Care Implementation Evaluation

Fatigue related to anemia and After 10 days of nursing Substitutive Role: Client has been able to perform and
dialysis procedure intervention, the client will 1. Note daily patterns (i.e., peaks/valleys) participate in his desired activities and
be able to: verbalized improvements in his energy
Subjective Cues: 2. Alternate activity with periods of levels. Furthermore, patient expressed
“Lagi akong pagod. Nararamdaman rest/uninterrupted sleep. feeling rested after sleep. In addition,
ko rin ito pagkatapos ng dialysis ko.  Report improved sense the patient religiously complies with
Wala akong lakas, minsan gusto ko of energy. 3. Provide environment conductive to relief his medication as prescribed by his
ng matulog at magpahinga. (I get  Participate in desired of fatigue. nephrologist.
tired easily. I ‘am feeling weak activities at level of
after every dialysis session. I just ability. Supplementary Role:
feel like I just want to rest)” as 4. Discuss with patient the need for activity.
verbalized by the client. Plan schedule with patient and identify
activities that lead to fatigue.
Objective Cues:
 Anemia (Hgb: 98 g/L) 5. Assist patient to cope with fatigue and
 Falls asleep immediately manage within individual limits of ability.
after cannulation for
hemodialysis treatment Complementary Role:
 Fatigue Severity Scale 1. Administer medication as appropriate:
score: 46 ( suffering - Hormones and supplements as indicated,
fatigue) e.g., erythropoietin (EPO, epogen) and iron
supplements.

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 Identified Problems Objectives of Care Implementation Evaluation

Disturbed sleep pattern related to After 10 days of nursing Substitutive Role: The client has achieved optimal amount
unresolved psychological conflict intervention, the client will 1. Assessed past patterns of sleep in of sleep with the use of anxiety self-
be able to: normal environment. control measures as evidence by rested
Subjective Cues: 2. Assessed the client’s perception of cause appearance, verbalization of feeling
“Nahihirapan akong matulog, kasi of sleep difficulty and possible relief rested and improvement in sleep pattern.
minsan naiisip ko ang sakit ko, lalo  Achieve optimal measures to facilitate treatment.
na’t bata pa ang mga anak ko. (I amounts of sleep as Client’s number of hour sleep has
‘am experiencing trouble in evidence by rested Supplementary Role: increased from her typical 4-5 hour of
sleeping, maybe because I ‘am appearance, 1. Instructed the client to follow as sleep to 5-6 hour of sleep. Client was also
worried about my illness and how verbalization of feeling consistent a daily schedule for retiring able to take naps during the day.
it’s affecting my family)” as rested, and improvement and arising as possible.
verbalized by the client. in sleep pattern. 2. Instructed the client to avoid heavy
meals, alcohol, caffeine or smoking
Objective Cues: before eating.
 Frequent yawning 3. Instructed the client to avoid large fluid
 Fatigue intake before bedtime.
 Often sleeps late at night 4. Increased day time physical activities as
 Average sleeping time 4-5 indicated, but instruct the client to avoid
hours strenuous activity before bedtime.
 Insomnia Severity Index
score: 14/28 (Subthreshold Complementary Role:
insomnia) 1. Established appropriate short and long-
range goals.

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