Antonia Herrerapicazo Benítez*; Moses Navarro Bermúdez*,**
** Degree in social and cultural anthropology
Jerez Hospital.
Establishment plan
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82 years old, diagnosed with chronic renal failure (CRF) of unknown etiology, widow, with five daughters, although woman only had one of them, this being her primary caregiver.
The rest actively participate in self-care and patient needs.
His primary caregiver is 54 years old, single and does not work, lives with the punishment of his mother, although they have requested the authenticity law and are pending resolution.
She is a collaborator and is very motivated and involved in the care of her mother.
It has no limitation or incapacity that prevents him from attending his mother, nor overload of the role of caregiver.
The patient can read and write, but currently has learning difficulties due to cognitive impairment.
He performs leisure activities (with physical and psychological limitations) such as watching television, being with his family, walking away, etc. He is Catholic, non-practitioner.
She is obese due to her sedentarism due to her motor deficit.
She reported no toxic habits or past alcohol consumption.
Currently, it has important physical limitations (lifestyle in wheels) and presents: speech difficulty, loss of strength in the right limbs (hemiparesis dcha.).
Left limbs also present decreased sensitivity, strength and mobility.
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Clinical history
• ESRD in conservative treatment since December 2000 on dialysis therapy.
• During the years 2000/2003, the patient had a right-sided humeral-ceffistula and a left-sided honeycombing prosthesis.
Both thrombi.
Currently, Hickman-type permanent catheter in the left subclavian artery, with normal functioning.
• Diabetes Mellitus type II insulin dependent.
Chronic auricular fibrillation, currently controlled.
• Hypothyroidism under treatment.
• Left condyle fracture in sept.-01.
• Frac seals in February-03.
• Ischemic ACVA in April-08 with right hemiplegia.
• Left frontal ischaemia.
• Left neck fracture.
• She is currently admitted for a pertrochanteric fracture of the right hip.
Dialysis scheme
Treatment schedule:
• Turn: M-J-S (from 13 to 17 hours).
Time: 4
• Vascular access: Hickman catheter in subclavian izq. with blood flows of 350 mI/mm
• Dializer: FLx 1-8
• Bathing: Bicarbonate (Bicart)
• Concentrate: Diasol 306-A
• Heparin alone
• Dry weight: 60.5 kg
• Interdialysis funding: ranges from 1.5 - 2 kg
• TA pre HD: 100/70.
TA post HD: 100/50 mm Hg.
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Nursing assessment
The 14 basic needs were assessed in the data collection, following Virginia Henderson's model.
Data were obtained from medical records of the patient (observation, consolidation, auscultation) and his primary caregiver.
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Normal breathing.
2.
Cholestasis, hyposodic diet, low potassium, one piece of fruit a day
You are obese.
Acknowledgement of total compliance.
The level of knowledge of food prohibited/allowed by the caregiver/s in relation to the patient is acceptable.
It has fluid restrictions and should not ingest more than 1.5 l of liquid between hemodialysis session and session.
3.
Elimination: anuria.
Irregularities, sometimes, in defecation, due to fluid restrictions, low dietary fiber intake and medication.
Caregivers have skills, knowledge and attitudes to successfully address and resolve these irregularities.
4.
Movement: mobility limited to the use of wheels and bed due to deterioration physical-cognitive status.
The level of dependence for daily activities is complete.
For this, we performed the "Barthel Index" obtaining a result of 15 points, indicating total dependence.
5.
Sleep and rest: restorative sleep, eight hours night, sometimes napping periods.
It does not need to use somnifera.
6.
Hygiene and integrity of the skin and mucous membranes: due to their physical and mental limitations, they need self-care for bathing/hygiene, self-care food, self-care dressed/healing and self-care satisfied with the use of the WCPSURPLENCIA, in their main way home care.
However, this supplementation is of vital importance during admission to the hospital to which special interest will be given.
To rule out a possible risk of pressure ulcers, the following questionnaire was applied: "ESCALA DE BRADEN" obtaining a score of 17, indicating a moderate risk.
However, despite the patient's age and functional status, the patient's skin condition is perfectly hydrated and no pressure lesions are observed.
7.
Selection of adequate clothing: requires total help in dressing as well as hygiene, satisfactorily provided by the caregiver at home.
8.
Body T maintenance: africa.
9.
Establishment of environmental hazards Normal state of consciousness, although with memory impairment.
Right hemiparesis as a consequence of the ACVA suffered and significant motor deficit.
There are constant manipulations (passing from one bed to another, weighing it in hemodialysis sessions, performing daily hygiene, etc.).
10.
Communication with others: to express needs, fears and opinions despite their physical and psychic limitations is perfectly integrated with their family into a social life.
Families and the environment.
He performs leisure activities such as watching television, walking around, he has his grandchildren, etc.
11.
Living according to Catholic beliefs: non-practitioner.
12.
Working adequately provides a sense of satisfaction: despite their dependence situation, they feel dear and respected by their relatives.
13.
Playing or participating in several kinds of authentic activities Performs ludic and leisure activities
Integrated into a social life.
14.
Learning, discovering or satisfying the curiosity to allow normal development and health. Due to the patient's state of completeness this need will be considered from the point of view of their primary caregiver and other caregivers.
Thus, they show great interest in following their conservative therapy, regularly attending their hemodialysis sessions at the scheduled times, accepting any unforeseen situation, administration of post-HD medication, performing post-HD Rx, etc.
To contrast this information we have passed a questionnaire to their primary caregiver "Pfeifer test" Spanish version, obtaining a total score = 1, which implies that there is no suspicion of cognitive impairment of the primary caregiver.
During her stay in the Nephrology/HD service, motivated by hip fracture, the patient has remained stable and has evolved satisfactorily (inside her previous physical-cognitive limitations) with no motor impairment in our unit.
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Care plan
During her stay in our unit, the patient presented the following nursing diagnoses:
NANDA 0045.
RISK OF CADAS R/C use of wheels, decreased strength of the lower limbs, and impaired physical mobility.
• NOC 1909.
SECURITY CONDUCT: PREVENTION OF MEASURES
o Outcome indicator: 190901 Correct use of assistive devices (initial Likert 25/3/2009 de 3 and Likert evaluated 13/04/2009 de 4).
o Outcome indicator: 190919 Use of secure means of transportation (initial Likert type 2 and Likert type 4 assessed).
o Indicator of results: 190920 Component of physical limitations (initial Likert of 3 and Likert assessed of 4).
• NOC 1902 RISK CONTROL
o Indicator of results: 1902,000
or Outcome Indicator: 1902004 Effective risk control strategies (family) (initial Likert 3 and Likert 4 assessed).
o Indicator of results: 190210 identified in the systematic identification of risks (the family) (initial Likert 3 and Likert 4 assessed).
• CIN 6490 PREVENTION OF MEASURES
Establishment plan
o Identify the patient's cognitive or physical deficits that may increase the possibility of falls in a given environment.
Keep the aid devices in good use.
Block the wheels of the bed, or other devices for patient transfer
o Use the appropriate technique for placing and lifting the patient with wheelchair, bed, etc.
o Having adequate height, with support and support for a simpler transfer
or educate family members about the risk factors that contribute to falls and how to reduce these risks.
NANDA 00046 RISK FOR CUTAN INTEGRITY DETERIORO, moisture R/C, medications, nutritional status alteration, immunological deficit and alteration of the circulation and M/P alteration of the skin surface.
- NOC 1105 INTEGRIDAD TISULAR
o Indicator of results: 110101 Tissue Temperature ERE (initial Likert 3 and evaluated Likert 3).
o Indicator of results: 110104 H engagement ERE (initial Likert 4 and Likert 4 assessed).
o Indicator of results: 110110 Absence of tissue injury (initial Likert type 2 and evaluated Likert type 3).
o Outcome indicator: 110113 Unchanged Skin (initial Likert 2 and Likert 3).
• CIN 3590 LIKE SURVEILLANCE.
Establishment plan
Inserting the state of the venous catheter insertion site is considered convenient.
or Look for signs of inflammation around the catheter.
Observe if there are infections.
Or to the caregiver about signs and symptoms of loss of skin integrity.
• IAS 3540 PREVENTION FOR UNBLISTERED LEVELS.
Establishment plan
or Use an established risk assessment tool (self-report scale)
Skin condition
or Monitor closely any red area.
Apply protective barriers (to remove excess moisture, if applicable).
or Monitor the source of pressure and friction.
Ensure adequate nutrition.
or Teaching the family/caregiver to monitor for signs of skin breakdown.
Collaboration problem: Risk for infection, being a patient with central venous catheter.
• NOC 1105 INTEGRITY OF THE DIALYSIS ACCESS
o Indicator of results: 110502 Local skin color (initial Likert 2 and Likert 3).
o Indicator of results: 10503 Absence of local suppuration (initial Likert 3 and Likert type 4 evaluated).
o Outcome indicator: 110504 Body temperature (initial Likert type 3 and evaluated Likert type 4).
• NIC 3440 EP INCISSION TABLE.
Establishment plan
Call your family about how to care for the catheter insertion site in case of bathing or showering, and ensure that the dressings are always dry.
The attachment to the family about the signs and symptoms of infection and isolation should inform the professionals.
or Observe signs and symptoms of localized systemic infection.
• CIN 6540 INFECTION CONTROL.
Establishment plan
or Ensure adequate wound care technique.
Focus on adequate nutritional intake.
Administer antibiotic therapy, if applicable.
Call the family about signs and symptoms of infection and when the professional should be informed.
or Teaching the family to avoid infections (patient-related).
• CIN 2380 MAINTAIN OF THE MEASURE.
Establishment plan
o Determine the necessary drugs and administer according to the medical prescription and/or protocol.
o To prove the family's ability to self-medicate the patient, if applicable.
Observe the therapeutic effects of the medication.
or Regularly review with the family the types and doses of medicines taken.
Establishment of strategies with the caregiver/caregiver to enhance e! compliance with the prescribed medication regimen.
In view of this clinical case, we can observe that although the patient has been fully evaluated, this type of patients present associated pathologies, which causes many variations in the health-disease process, making us continuously alert for new care plans.
Another aspect of vital importance is the need to promote inter-level communication, as this patient only comes to our unit three days a week, and the development of the care plan can be carried out with the community nurse in a joint way.
Another aspect to be highlighted and of vital importance is the development and implementation of fall and risk protocols PPT, in order to prevent or prevent undesirable effects in these patients with special frailty and provide these patients with a safe environment.
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Correspondence address: Moisés Navarro Bermúdez c/ Rodrigo de Bastidas 12, 2o A 11500 Pto Sta Maria (C.com) Email: monavber@
