End Stage Renal Failure Nursing Diagnosis: Comprehensive Guide

End-stage renal disease (ESRD), also known as end-stage kidney disease or kidney failure, represents the irreversible and ultimate stage of chronic kidney disease (CKD). At this critical juncture, the kidneys are no longer capable of sustaining life independently, necessitating interventions such as dialysis or kidney transplantation for patient survival. Effective nursing care is paramount in managing ESRD, focusing on mitigating complications, supporting treatment adherence, and enhancing patient quality of life.

Stages of Chronic Kidney Disease

Chronic kidney disease progresses through five distinct stages, classified according to the estimated glomerular filtration rate (eGFR), a crucial blood test that quantifies kidney function by measuring their filtering capacity.

• Stage 1 CKD: Characterized by an eGFR of 90 ml/min or higher, often considered within the normal range. Patients are typically asymptomatic at this stage.
• Stage 2 CKD: Defined by an eGFR between 60-89 ml/min, indicating mild CKD. While symptoms may be absent, indicators such as protein in the urine or other kidney damage may be detectable.
• Stage 3a CKD: Marked by an eGFR of 45-59 ml/min, signifying mild to moderate kidney damage.
• Stage 3b CKD: Indicated by an eGFR of 30-44 ml/min, denoting moderate to severe kidney damage. Symptoms such as fatigue, edema, muscle cramps, and alterations in urination patterns may emerge.
• Stage 4 CKD: Characterized by an eGFR of 15-29 ml/min, representing the advanced stage preceding kidney failure.
• Stage 5 CKD: Diagnosed as end-stage renal disease, with an eGFR falling below 15 ml/min. Kidney function is severely compromised or entirely absent at this stage.

Nursing Process in End-Stage Renal Disease

Nursing care for patients with end-stage renal disease is crucial and multifaceted, aiming to manage this irreversible condition and improve patient outcomes. Key nursing priorities include:

• Prevention and management of ESRD complications.
• Facilitation of kidney transplantation or dialysis treatments.
• Patient education on chronic condition management.
• Implementation of fluid and dietary restrictions.
• Promotion of physical and psychosocial well-being.
• Enhancement of patient’s overall quality of life.
• Education on necessary lifestyle adjustments.
• Provision of comprehensive support to patients and their families.
• Collaborative care with nephrologists and interdisciplinary teams.

Nursing Assessment for End-Stage Renal Disease

The initial step in providing effective nursing care involves a thorough nursing assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. This section will detail subjective and objective data pertinent to end-stage renal disease.

Review of Health History

1. Evaluate General Symptoms: As ESRD progresses, patients may exhibit a spectrum of signs and symptoms affecting various body systems:

• Central Nervous System (CNS): Headaches, altered mental status, insomnia.
• Respiratory System: Dyspnea, chest pain.
• Gastrointestinal (GI) System: Nausea, vomiting, appetite loss, metallic taste in the mouth.
• Musculoskeletal System: Fatigue, muscle weakness, twitches, cramps.
• Genitourinary System: Changes in urine volume and characteristics.
• Integumentary System: Swelling in feet and ankles, persistent itching.

2. Identify Risk Factors for ESRD Progression: Certain factors can accelerate the progression of chronic kidney disease to end-stage renal disease:

• Advanced age (60 years and older).
• Family history of kidney failure.
• Specific racial and ethnic backgrounds, including Asian, Pacific Islander, American Indian, Black, or Hispanic heritage.
• Obesity.
• Tobacco use.

3. Document Medical History: Kidney damage typically develops gradually over months or years due to underlying medical conditions, including:

• Diabetes mellitus with poor glycemic control.
• Hypertension.
• Glomerulonephritis.
• Polycystic kidney disease.
• Interstitial nephritis.
• Urinary tract obstruction, such as kidney stones.
• Vesicoureteral reflux.
• Pyelonephritis.
• Congenital kidney defects.

4. Assess Factors Influencing ESRD Development: Specific conditions can exacerbate kidney damage and contribute to ESRD:

• Systemic hypertension.
• Hyperlipidemia.
• Uncontrolled diabetes.

5. Review Medication History: The kidneys play a critical role in processing and filtering medications. Certain drugs can further compromise kidney function:

• Cholesterol-lowering medications.
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Antibiotics.
• Antiretroviral medications.
• Antidiabetic medications.

Physical Assessment

1. Assess for ESRD Complications: Kidney damage in ESRD can lead to several complications:

• Fluid volume overload unresponsive to diuretics.
• Poorly managed hypertension.
• Anemia.
• Electrolyte imbalances.
• Bone disorders.
• Metabolic disturbances.
• Compromised immune response.

2. Evaluate for Uremic Toxicity: Uremia, characterized by the accumulation of waste products in the blood due to impaired kidney function, can manifest in:

• Cognitive impairment.
• Acidosis.
• Blood vessel calcification.

3. Conduct a Comprehensive Physical Examination: ESRD can have wide-ranging effects across organ systems. Physical manifestations may include:

• General: Malnutrition (weight loss, fatigue, muscle weakness).
• CNS: Encephalopathy (confusion, irritability, drowsiness).
• Cardiovascular: Pericarditis (fever, dyspnea, abnormal heart sounds).
• Gastrointestinal: Vomiting, diarrhea.
• Genitourinary: Erectile dysfunction, amenorrhea, infertility, oliguria or anuria.
• Musculoskeletal: Peripheral neuropathy, muscle cramps or weakness.
• Integumentary: Dry skin, pruritus, ecchymosis, edema.
• Hematological: Platelet dysfunction, anemia.

4. Monitor Fluid Intake and Output Meticulously: Careful monitoring of fluid balance is essential in ESRD due to impaired kidney function. Patients may exhibit reduced or absent urine output and be intolerant of excessive fluid intake.

Diagnostic Procedures for ESRD

1. Determine eGFR: The eGFR is a primary diagnostic measure for assessing kidney function and staging chronic kidney disease. An eGFR below 15 ml/min signifies Stage 5 CKD or ESRD, indicating severe kidney function loss.

2. Blood Tests: Blood analysis is crucial for identifying ESRD-related abnormalities:

• Complete Blood Count (CBC): To detect anemia.
• Basic Metabolic Panel (BMP):
  • Elevated serum creatinine and blood urea nitrogen (BUN) levels.
  • Hyperkalemia (high potassium levels).
  • Low bicarbonate levels.
  • Hypoalbuminemia (low serum albumin levels, indicative of malnutrition).
  • Serum phosphate levels.
  • Vitamin D levels.
  • Lipid profile.

3. Urine Tests: Urinalysis provides insights into kidney filtration capacity:

• Urine protein/creatinine ratio: To detect albuminuria (albumin in urine); severe renal impairment is indicated by levels greater than 300 mg/g.
• 24-hour urine protein: Levels exceeding 3.5 g suggest nephrotic range proteinuria.

4. Imaging Scans: Various imaging techniques are used to visualize kidney structure and identify abnormalities:

• Kidney ultrasound: To assess for hydronephrosis (kidney swelling) or structural anomalies.
• Retrograde pyelogram: To diagnose urinary tract obstruction or renal stones.
• Computed Tomography (CT) scan: To visualize kidney masses, cysts, and stones.
• Magnetic Resonance Angiography (MRA): To diagnose renal artery stenosis.

5. Kidney Biopsy: In cases of unclear diagnosis despite initial workup, particularly with significant renal impairment or nephrotic-range proteinuria, a kidney biopsy may be necessary for definitive diagnosis.

Nursing Interventions for End-Stage Renal Disease

Nursing interventions are vital in managing ESRD, focusing on slowing disease progression, managing complications, and preparing patients for renal replacement therapy.

Delaying Progression of Kidney Disease

1. Blood Pressure Management: Maintain blood pressure at or below 130/80 mmHg, with a stricter target of less than 120 mmHg systolic for non-dialysis patients.

2. Blood Glucose Control: Strict glycemic control is essential, aiming for a hemoglobin A1C level below 7% to minimize complications. Sodium-glucose transporter 2 (SGLT-2) inhibitors may be beneficial in type 2 diabetes to slow eGFR decline.

3. Correction of Metabolic Acidosis: Bicarbonate supplementation can mitigate chronic metabolic acidosis and potentially slow ESRD progression.

4. Dyslipidemia Management: Monitor lipid profiles regularly and initiate cholesterol-lowering medications like statins for adults over 50 with an eGFR below 60 mL/min/1.73 m2. Statins may be discontinued in patients undergoing dialysis.

5. Fluid Volume Control: Manage fluid overload with loop diuretics or ultrafiltration to address edema or pulmonary edema.

6. Management of ESRD Complications: Address complications arising from ESRD to maintain physiological balance:

• Anemia: Administer erythropoiesis-stimulating agents (ESAs) when hemoglobin levels fall below 10 g/dL.
• Hyperphosphatemia: Prescribe phosphate binders and dietary phosphate restriction.
• Hypocalcemia: Administer calcium supplements with calcitriol.
• Hyperparathyroidism: Manage with calcitriol, vitamin D analogs, or calcimimetics.

7. Nutritional Guidance: Collaborate with dietitians to create individualized renal diet plans, emphasizing low phosphorus and potassium, sodium restriction (less than 2 g/day), and controlled protein intake (0.8 g/kg body weight daily).

8. Lifestyle Modifications: Promote healthy lifestyle practices including physical activity, smoking cessation, and weight management. Aerobic exercise is particularly beneficial for dialysis patients.

9. Fluid Restriction: Implement fluid restrictions tailored to individual patient needs, typically around 32 ounces per day for dialysis patients, to prevent fluid overload.

Planning for Long-Term Renal Replacement Therapy

1. Promote Treatment Adherence: Educate patients on the necessity of dialysis for blood filtration and toxin removal when kidneys fail. Discuss renal replacement therapy options:

• Hemodialysis.
• Peritoneal dialysis.
• Kidney transplantation.

2. Patient Education on Prognosis and Options: Initiate early discussions about kidney transplantation, dialysis modalities, and disease progression to facilitate patient acceptance and future planning.

3. Vascular Access Options: Discuss arteriovenous (AV) fistula as the preferred long-term vascular access due to lower risks of clotting and infection. AV grafts are an alternative for quicker access.

4. Peritoneal Dialysis Education: Provide comprehensive training for patients opting for home-based peritoneal dialysis, emphasizing catheter care and peritonitis prevention.

5. Kidney Transplant Preparation: Discuss kidney transplantation as the definitive treatment for ESRD, outlining eligibility criteria and the transplant process. Contraindications may include advanced age, severe heart disease, active cancer, dementia, severe obesity, poor medication adherence, substance abuse, or lack of insurance.

6. Palliative and End-of-Life Care: Offer palliative care services for symptom management in ESRD. When transplantation is not feasible and dialysis becomes ineffective, discuss hospice and end-of-life care options.

Nursing Care Plans for End-Stage Renal Disease

Nursing care plans are essential for structuring and prioritizing nursing care for ESRD patients, addressing both immediate and long-term care goals. Common nursing diagnoses and associated care plans for ESRD include:

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to end-stage renal disease.

Related Factors:

• Misinformation about ESRD and its management.
• Inadequate access to resources and information.
• Lack of interest or participation in learning and care planning.
• Misconceptions about ESRD treatment.

Evidenced By:

• Questions and inquiries about ESRD.
• Inaccurate adherence to treatment instructions.
• Expressed myths or misunderstandings about ESRD.
• Non-participation in care.
• Development of preventable complications.

Expected Outcomes:

• Patient will articulate understanding of ESRD, its management, and symptoms.
• Patient will demonstrate adherence to the treatment plan, reflected in stable lab values.
• Patient will remain free from complications arising from deficient knowledge about ESRD management.

Nursing Assessments:

1. Assess current knowledge level about ESRD to tailor education.
2. Evaluate patient’s willingness and motivation to learn.
3. Determine health literacy to ensure effective communication and understanding.

Nursing Interventions:

1. Educate on lifestyle modifications to preserve kidney function.
2. Facilitate open discussions about dialysis and kidney transplant options.
3. Provide detailed dietary instructions, focusing on restrictions and renal-friendly choices.
4. Teach symptom recognition for early detection of complications.
5. Instruct on fistula care for patients undergoing hemodialysis.

Excess Fluid Volume

Nursing Diagnosis: Excess Fluid Volume related to end-stage renal disease.

Related Factors:

• Sodium and water retention due to impaired kidney function.
• Electrolyte imbalances.
• Uncontrolled hypertension.
• Decreased glomerular filtration rate.
• Dietary indiscretions.
• Non-adherence to fluid restrictions.
• Comorbid conditions like heart failure.

Evidenced By:

• Edema.
• Changes in blood pressure.
• Altered urine specific gravity.
• Intake exceeding output.
• Oliguria.
• Pulmonary congestion.
• Altered mental status.
• Hypoalbuminemia.
• Electrolyte imbalances.

Expected Outcomes:

• Patient will achieve balanced fluid volume, as evidenced by intake and output records.
• Patient will remain free from fluid overload symptoms such as edema and dyspnea.
• Patient will maintain electrolytes within normal ranges.

Nursing Assessments:

1. Daily weight monitoring to detect fluid retention.
2. Accurate intake and output monitoring.
3. Electrolyte level assessment to identify imbalances.
4. Urine sample analysis for protein and other indicators.
5. Monitoring for respiratory distress and mental status changes indicative of fluid overload.

Nursing Interventions:

1. Administer albumin as prescribed to maintain oncotic pressure.
2. Administer diuretics to promote fluid excretion.
3. Implement sodium restriction in diet.
4. Elevate edematous extremities to improve venous return.
5. Enforce prescribed fluid restrictions.
6. Monitor and manage blood pressure.

Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to end-stage renal disease.

Related Factors:

• Disease process impacting appetite and nutrient absorption.
• Chronic inflammation.
• Uremic toxins affecting nutrient utilization.
• Metabolic acidosis.
• Food aversions.

Evidenced By:

• Fluid and electrolyte imbalances.
• Gastrointestinal disturbances (constipation, diarrhea, nausea, vomiting).
• Weight loss.
• Anorexia.
• Lethargy.

Expected Outcomes:

• Patient will report adequate intake of protein, potassium, sodium, and phosphorus within prescribed limits.
• Patient will maintain electrolyte balance.

Nursing Assessments:

1. Nutritional status assessment and identification of nutrient deficits.
2. Monitor weight loss and associated symptoms.
3. Assess serum albumin, red blood cell count, and electrolyte levels.

Nursing Interventions:

1. Strict fluid management to prevent overload.
2. Encourage adequate protein intake, adjusted for dialysis status.
3. Educate on dietary restrictions of potassium, sodium, and phosphorus.
4. Administer prescribed supplements (vitamins, minerals).
5. Provide nutritional counseling tailored to individual needs.
6. Encourage exercise as tolerated to improve nutritional status and well-being.

Impaired Urinary Elimination

Nursing Diagnosis: Impaired Urinary Elimination related to end-stage renal disease.

Related Factors:

• Loss of kidney function affecting urine production.
• Decreased glomerular filtration rate.
• Urinary tract obstruction or infection.
• Inflamed urinary tract.

Evidenced By:

• Decreased urine output (oliguria).
• Painful urination (dysuria).
• Absence of urine output (anuria).
• Urinary retention.
• Urinary hesitancy.
• Urinary urgency and nocturia.
• Urinary incontinence.

Expected Outcomes:

• Patient will exhibit improved urine output within individualized target limits.
• Patient will participate in prescribed dialysis treatments.

Nursing Assessments:

1. Assess urinary elimination patterns and characteristics.
2. Observe urine characteristics for abnormalities.
3. Monitor eGFR levels.
4. Obtain blood samples for creatinine and BUN levels.
5. Palpate bladder for distention.
6. Check for costovertebral angle tenderness.

Nursing Interventions:

1. Closely monitor intake and output.
2. Explain the importance of dialysis.
3. Prepare patient for potential kidney transplant.
4. Refer to dietitian for renal diet guidance.

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to end-stage renal disease.

Related Factors:

• Disease process compromising kidney function.
• Chronic inflammation.
• Hypervolemia.
• Hypertension.
• Nephrotoxic medications.
• Uncontrolled diabetes.

Evidenced By:

• Anuria or oliguria.
• Edema.
• Pruritus.
• Fatigue.
• Muscle cramps.
• Mental status changes.
• Decreased eGFR.

Expected Outcomes:

• Patient will remain free from complications of poor renal perfusion, such as heart failure or encephalopathy.
• Patient will adhere to dialysis treatments.

Nursing Assessments:

1. Monitor intake and output and urine characteristics.
2. Review diagnostic studies (renal ultrasound, CT scan).
3. Assess for symptoms of worsening perfusion (confusion, edema, hypertension).
4. Monitor lab values, particularly eGFR.

Nursing Interventions:

1. Prepare patient for dialysis initiation.
2. Assist with kidney biopsy if indicated.
3. Educate patient to avoid nephrotoxic substances including IV contrast and certain medications.
4. Assist and prepare patient for kidney transplant evaluation and process.

References

• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). End-Stage Renal Disease. https://www.niddk.nih.gov/health-information/kidney-disease/end-stage-renal-disease
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• KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International Supplements, 3(1), 1-150.
• McCullough, K. P., Chan, C. T., Komenda, P., & Morneau, J. P. (2019). CKD stages 3b–5 not yet on dialysis: focus on management and referral. Canadian Medical Association Journal, 191(4), E104-E111.
• Coresh, J., Turin, T. C., Matsushita, K., Sang, Y., Ballew, S. H., আপ্পেল, L. J., … & Levey, A. S. (2014). Chronic kidney disease and coronary heart disease: baseline risk and long-term outcomes. American journal of cardiology, 114(1), 74-79.
• Pérez-Martínez, P., Rayego-Mateos, S., Valdivielso, J. M., Ortiz, A., & Ruilope, L. M. (2018). Hypertension in chronic kidney disease. Journal of nephrology, 31(6), 805-815.
• Bettschart-Wolfensberger, R., Frey, F. J., & Maurer, M. (2006). Fluid and electrolyte management in patients with chronic kidney disease. Therapeutic Apheresis and Dialysis, 10(1), 1-8.
• Kopple, J. D. (2007). Nutritional considerations in patients with chronic kidney disease. Journal of Renal Nutrition, 17(2), 55-62.
• Campbell, K. L., & Crowe, T. C. (2009). Practice paper of the Academy of Nutrition and Dietetics: recommendations for the use of nutrition support for adults with chronic kidney disease stages 1–5. Journal of the Academy of Nutrition and Dietetics, 109(1), 155-169.