Question

Mr. James Bean, a patient 67 years of age, is 3 days postoperative after a coronary artery bypass graft operation. The patient has a history of hypertension, type 1 diabetes, coronary artery disease, and end-stage renal disease, which is treated with hemodialysis three times per week. The patient has a left atriovenous (AV) shunt. You have been handed this patient this morning and have to provide care for the next 12 hours. What is the priority nursing diagnosis and non-pharmacological interventions that will improve his state.

Medical Diagnosis: Renal failure

1) What is the priority nursing diagnosis in NANDA format. EX: Excess fluid volume related to...as evidenced by....

2) What is the RISK diagnosis? EX: Patient is at risk for.....related to.

List 3 non-pharmacological nursing interventions related to priority nursing diagnosis that will improve the state that he is in.

Answer 1

Answer 1 . Decreased cardiac output related to increased afterload associated with fluid overload as evidence by decreased urine output, increased Central venous pressure, decreased arterial oxygen saturation.

Answer 2. Risk for infection related to invasive surgery.

Non-pharmacological nursing interventions

• Assist patient in assuming a fowlers position, elevate legs and encourage active and passive exercises
• change the position of the client every 2 hourly
• Maintain strict aseptic technique while providing wound care, changing the dressing,peripheral IV and centralvenous management or any procedures.