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Clinical Judgment Map- ESRD

Assessments (Physiological Adaptation) 1. VS- check BP (hypertension is commen in ESRD) 2. Cardiac- check pulmonary edema, JVD, HTN 3. Respiratory- check for SOB, dehydration, crackles in the lungs Risk Factors (Health Promotion & Maintenance/Reduction of Risk Potential) 1. Diabetes 2. HTN 3. Family hx, smoking Clinical Judgment Map- ESRD Concept / Related Concept(s) Poor renal filtration Exemplar(s) Pain, elimination, family dynamics, stress and coping Brief Pathophysiology (Physiological Adaptation) When the kidneys do not filter correctly a build up of toxins occur, fluid and electrolyte imbalances occur and can contribute to organ damage. Psychosocial Concerns (Psychosocial Integrity) 1. Body image-changes in appearance, weight 2. Social isolation- may miss out on social events because dialysis 3.quality of life will decrease- fatigue, pain, diet changes— reduced enjoyment Labs & Diagnostics (Reduction of Risk Potential) 1.BUN, creatinine, GFR 2.serum electrolytes= K+, Na+, Ca+, Phosphorous 3. CBC- to check H&H for anemia/ ABGS Medical Diagnosis End Stage Renal Disease Nursing Interventions (Basic Care & Comfort/ Safety & Infection Contral) 1.Regular assessments(BP, HR, RR, Temp)/ monitor skin, daily weights, labs: BUN, CR, GFR 2. Fluid management- 1&Os, fluid restriction 3. Dialysis care/ emotional support Medications (Pharmacological & Parenteral Therapies) L.Ace inhibitors- to help BP 2.Heparin- to manage dialysis complications (during dialysis 3.Erythropoiesis stimulating agents- for anemia Patential & actual complications from treatments/ procedures (Physiological Adaptation/Reduction of Risk Potential) L.infection- surgery/dialysis can bring in foreign bodies 2.kidney transplant rejection 3.depression & suicidal ideation Patient Teaching (Health Promotion & Maintenance/Safety & Infection Control/ Management of Care) 1.Educate and inform pt on dialysis process 2.collaborate with a licensed dietician about new diet plans- Na+/K+ restriction, 3.Educate patient to only drink 1 L of water a day 4.Educate the patient of proper hand hygiene ta avoid infection 5.Educate and offer pt services to manage stress/anxiety/depression 6.Place proper safety precautions- fall risk