4.1 Nursing Assessment, Planning and Evaluation

Assessment as Clinical Reasoning

The nursing process consists of assessment, diagnosis or problem identification, planning, implementation and evaluation. It is continuous during dialysis. A predialysis review does not end when the patient is connected, and the post-treatment assessment is not merely a discharge checklist. New symptoms can change the priority at any stage. A nurse combines subjective information, observed findings, current orders and prior trends while respecting the scope of the nurse's license.

Begin with the patient's own report: breathing, pain, dizziness, appetite, sleep, recent bleeding, fever, medication changes and difficulties since the previous session. Compare with the record and ask about emergency visits or hospital discharge. Confirm identity and the current prescription. A familiar patient can still have a new potassium order, changed anticoagulant or recently revised target weight. Familiarity must not replace verification.

Focused Physical Examination

Assess general appearance, consciousness, respiratory effort, pulse, blood pressure, temperature when indicated, weight and vascular access. Inspect dependent edema and signs of dehydration, but interpret them together. A patient can have edema and low effective circulating volume. Auscultate lungs and assess oxygenation if symptoms or policy warrant. Chest pain, new focal weakness, severe breathlessness or reduced consciousness requires immediate evaluation rather than finishing routine setup first.

Access examination includes the skin, thrill or bruit, distal circulation and recent cannulation history. Inspect catheter dressing integrity and look for drainage, tenderness or tunnel symptoms. A clean dressing does not exclude bloodstream infection. Review the patient's mobility and fall risk, particularly after an unstable treatment. Functional information such as difficulty transferring to the chair affects safe staffing and the care plan.

Separate the Finding From the Conclusion

Clinical problem identification connects evidence to the patient's response. For example, activity intolerance may reflect anemia, congestion, deconditioning or another illness. The nurse should not assert a medical cause without sufficient evidence. Use actual findings and seek the appropriate interdisciplinary evaluation.

Planning and Intervention

Set a goal that can be assessed: the patient will complete the ordered session without recurrent symptomatic hypotension; will demonstrate safe catheter dressing protection; or will identify whom to call after access bleeding. 'Improve compliance' is vague and risks blaming the patient. Specify the barrier, intervention, responsible person and review interval. Transportation failure needs a different response from nausea caused by an iron infusion.

Prioritize threats to airway, breathing, circulation and neurologic function. Then address the urgent treatment problem, comfort and education. When an event occurs, implement the authorized emergency protocol and notify the appropriate clinician. An unsafe fluid-removal prescription requires clarification; symptomatic instability requires immediate protective action. Do not delay an emergency UF pause solely to obtain approval for a routine permanent prescription change.

Teaching, counseling and referral are interventions. Teaching explains the task; counseling explores concerns and choices; referral connects the patient with expertise or services. A nurse can teach the effect of dietary sodium, explore why affordable food choices are difficult, and refer to the dietitian and social worker. These approaches complement each other. Giving a printed restriction sheet does not prove the patient can use it.

Evaluation During and After Care

Reassess at a time appropriate to the intervention. After a saline bolus, evaluate symptoms, BP, respiratory findings and the remaining fluid goal. After an access intervention, verify flow, skin and distal circulation. After education, ask for explanation or demonstration. Document whether the goal was achieved, partly achieved or unmet and why. An unmet goal directs revision, not an automatic label of nonadherence.

Consider a patient with recurrent cramps near the end of treatment. The nurse reviews symptom timing, UFR, target weight, BP, sodium intake and medication timing. The plan may include prescriber review of duration or weight and practical dietitian support. Evaluation asks whether symptoms improved while congestion and adequacy remained acceptable. Eliminating cramps by shortening every session without reassessing clearance can create another problem.

Team Communication and Continuity

Use a concise structured report containing the clinical change, relevant background, assessment and requested action. State 'BP fell from 142/80 to 88/52 with nausea after 2.4 L UF; UF is paused and the standing protocol is in progress' rather than 'patient feels bad.' Include what has already been done and the response. At handoff, identify unresolved risks, pending laboratory results, the access plan and the patient's preferences. Patient participation and accurate reassessment make the care plan a living clinical tool rather than an admission form.

Source: CMS Part 494 patient assessment and plan requirements.