CRF

CRF

A. Assessment

Basic Patient Assessment Data

- Activities

Symptoms: extreme fatigue, kalemahan, malaise

Sleep disturbance (insomnia / restless or somnolen)

Signs: muscle weakness, loss of tone, decreased range of motion.

- Circulation

Symptoms: A history of prolonged or severe hypertension

palpatasi, chest pain (angina)

Alert: Hypertension, DUJ, strong pulse, the public network and pitting edema in the feet, palms, hands.

Weak pulse, hypotension ortostatikmenunjukkan hypovolemia, which is rare in the late stages of disease.

Pale, greenish brown skin, yellow.

Bleeding tendency

- Ego Integrity

Symptoms: stress factors, eg financial, relationships and so forth.

Feeling helpless, hopeless, no power.

Signs: Refuse, anxiety, fear, anger, easily aroused, changes in personality.

- Elimination

Symptoms: Decreased urinary frequency, oliguria, anuria (at the advanced stage renal failure)

Abdominal bloating, diarrhea, or constipation

Signs: Changes in urine color, dark yellow example, red, brown, oliguria.

- Food / fluid

Symptoms: Weight gain was rapid (edema), weight loss (malnutrition).

Anorexia, heartburn, nausea / vomiting, unpleasant metallic taste in the mouth (breathing ammonia)

Usage diurotik

Signs: Abdominal distension / ascites, liver enlargement (final stage)

Changes in skin turgor / humidity

Edema (general, targantung)

Ulceration of the gums, bleeding gums / tongue.

Decrease in muscle, subcutaneous fat loss, no powerful appearance

- Neurosensori

Symptoms: Headache, blurred vision

Muscle cramps / spasms, syndrome "restless legs", a burning sensation on the soles of the feet, tingling and weakness, especially ekstremiras below.

Signs: Impaired mental status, decreased contah field of attention, inability to concentrate, memory loss, confusion, decreased level of consciousness, stupor.

Seizures, muscle fasciculation, seizures activity.

Thin hair, brittle nails and thin

- Pain / comfort

Symptoms: pelvic pain, headaches, muscle cramps / leg pain

Signs: Behavior careful / distraction, anxiety

- Respiratory

Symptoms: short breath, dyspnea, cough with or without sputum thicker and more

Signs: Tachypnoea, dyspnea, increased frequency / depth.

Cough with watery sputum (pulmonary edema)

- Security

Symptoms: Itchy skin

There is / recurrent infections

Signs: pruritis

Fever (sepsis, dehydration), normotermia can actually increase in patients with lower body temperature than normal

Ptekie, ekimosis areas on the skin

Bone fractures, limited motion of joints

- Sexuality

Symptoms: Decreased libido, amenorrhea, infertility

- Social interaction

Symptoms: Difficulty determining the conditions, eg unable to work, role, functions normally in the family.

- Extension / Learning

Symptoms: History of DM (high risk for kidney failure), polycystic disease, nephritis heredeter, calculus urenaria, maliganansi.

History terpejan the toxin, eg drugs, environmental toxins.

The use of nephrotoxic antibiotics current / recurrent.

B. Nursing Diagnosis

Nursing diagnosis is established on the basis of data from patients. Possible nursing diagnosis of people with chronic kidney failure are as follows:

- Excess fluid volume associated with decreased urine output, excessive dietary sodium and fluid retention as well.

- Changes in nutrition: less than body requirements related to anorexia, nausea and vomiting, diet restriction, and changes in oral mucous membranes.

- Activity intolerance related to fatigue, anemia, retention, product waste.

- High risk of cardiac-related penururnan fluid imbalances affect circulating volume, myocardial work, and systemic vascular resistance.

- High risk of damage to skin integrity related to the accumulation of toxins in the skin.

- Anxiety associated with less knowledge about the condition, diagnostic tests, the action plan, and prognosis.

D. Implementation

Nursing care for clients with chronic renal failure

1. Therapy Helps Achieve Objectives

a. Ensuring that people continue to pursue water restrictions that have been ordered.

b. Ensuring that people pursue high-carbohydrate diet accompanied by restrictions of sodium, potassium, phosphorus and protein.

c. Pursue food ingredient that binds phosphate.

d. Give stool softener if the client gets an aluminum antacid.

e. Giving vitamin and mineral supplements according to the ordered.

f. Protecting patients from infection

g. Assess client's environment and protect from injury in a manner that closely.

h. Prevent gastrointestinal bleeding is more severe by using a toothbrush fluffy and antacid administration.

2. Pursuing Leisure

a. Seek to reduce itching, pruritis by giving anti-drug needs.

b. Pursuing a warm and muscle spasms message from the hands and lower legs.

c. Matol water to prepare artificial ocular irritation.

d. Pursuing a rest when tired

e. Ensuring that clients can sleep through wise

f. Pursuing several times daily oral hygiene, especially before eating.

3. Consultation and Guidance

a. Setting up the person who can provide an opportunity to discuss a variety of feelings about the chronicity of the disease.

b. Seek consultation if there is a disturbing rejection therapy

c. Encouraging people to give help on how I manage the new way of life.

d. Providing information about the nature of CRF, rational therapy, medication rules and the need to continue treatment. (Medical Surgical Nursing, Barbara C. Long)

E. Evaluation

Common questions to be asked on the evaluation of people with chronic renal failure consists of the following.

1. Are there symptoms of increased fluid retention?

2. Do people pursue the necessary fluid dietvdan message?

3. Are there symptoms are too tired?

4. Are people excessive scratching?

5. Do people sleep soundly at night?

6. Were prevention of infection, additional gastrointestinal bleeding?

7. Whether one can decipher the nature of CRF, rational and therapy, drug regulation and symptom-gejalayang should be reported?


(Medical Surgical Nursing, Barbara C. Long)

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