The nurse would identify which nursing diagnosis for the patient experiencing dialysis disequilibrium syndrome?

Question

1. Infection
2. Altered thought processes
3. Fluid volume deficit
4. Anxiety

Answer 1

2
Rationale 1: Disequilibrium syndrome affects the brain and is not related to exposure to pathogens.
Rationale 2: Dialysis disequilibrium syndrome is especially common in patients undergoing their first or second dialysis treatment who experience sudden, large decreases in their BUN. The most likely explanation for this syndrome is that the levels of urea do not drop as rapidly in the brain as the plasma because of the blood-brain barrier. The higher levels of urea in the brain result in an osmotic concentration gradient between the brain cells and the plasma. Fluid enters the brain cells by osmosis until the concentration levels equal that of the extracellular fluid, resulting in cerebral edema and the dialysis disequilibrium syndrome. Manifestations of the syndrome include headache and mental impairment that may progress to confusion, agitation, seizures, and nausea and vomiting.
Rationale 3: Fluid volume deficit would be manifested by physiologic signs such as hypotension and tachycardia.
Rationale 4: Anxiety is a manifestation of hypoxia and fluid volume overload.