ESRD Nursing Diagnosis Care Plan: Comprehensive Guide for End-Stage Renal Disease

End-stage renal disease (ESRD), the irreversible and final stage of chronic kidney disease (CKD), signifies a critical juncture where the kidneys’ ability to function independently is lost. At this stage, survival hinges on renal replacement therapies such as dialysis or kidney transplantation. This comprehensive guide delves into the essential aspects of ESRD nursing care, focusing on nursing diagnoses, meticulous assessments, targeted interventions, and well-structured care plans to optimize patient outcomes and enhance their quality of life.

Stages of Chronic Kidney Disease: Understanding Progression to ESRD

Chronic kidney disease progresses through five distinct stages, categorized by the estimated glomerular filtration rate (eGFR), a crucial indicator of kidney function. Understanding these stages is fundamental for proactive management and timely intervention.

• Stage 1 CKD: Characterized by an eGFR of 90 ml/min or higher, often considered within the normal range. Patients are typically asymptomatic, although kidney damage might be present.
• Stage 2 CKD: Defined by an eGFR between 60-89 ml/min, indicating mild CKD. While symptoms might be absent, subtle signs like protein in the urine or other kidney damage markers may be detectable.
• Stage 3a CKD: Marked by an eGFR of 45-59 ml/min, signifying mild to moderate kidney damage.
• Stage 3b CKD: An eGFR of 30-44 ml/min denotes moderate to severe kidney damage. Patients may begin to experience symptoms such as fatigue, edema, muscle cramps, and alterations in urination patterns.
• Stage 4 CKD: An eGFR of 15-29 ml/min signifies advanced CKD, the stage immediately preceding kidney failure.
• Stage 5 CKD (ESRD): Diagnosed when the eGFR falls below 15 ml/min. At this critical stage, kidney function is severely compromised or entirely absent, necessitating renal replacement therapy.

Understanding the progression of chronic kidney disease through eGFR levels, culminating in end-stage renal disease.

The Nursing Process in End-Stage Renal Disease Care

Nursing care for patients with ESRD is multifaceted and aims to address the complex needs arising from kidney failure. The primary nursing care priorities are:

• Preventing and managing complications associated with ESRD.
• Facilitating access to and support for kidney transplantation or dialysis.
• Educating patients on chronic condition management and self-care strategies.
• Implementing fluid and dietary restrictions to mitigate fluid overload and electrolyte imbalances.
• Promoting physical and psychosocial well-being to enhance quality of life.
• Providing comprehensive support to patients and their families.
• Collaborating effectively with nephrologists and interdisciplinary healthcare teams.
• Emphasizing lifestyle modifications to slow disease progression and improve overall health.

Comprehensive Nursing Assessment for ESRD

The nursing assessment is the cornerstone of effective ESRD care. It involves a thorough collection of subjective and objective data encompassing physical, psychosocial, emotional, and diagnostic aspects.

Review of Health History: Gathering Subjective Data

1. Identify Presenting Signs and Symptoms: As ESRD progresses, patients may report a variety of symptoms affecting multiple body systems:

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

2. Assess Risk Factors for ESRD Progression: Certain factors can accelerate the progression of chronic kidney disease to ESRD:

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

3. Document Medical History: Explore the patient’s medical history to identify underlying conditions that may have contributed to kidney damage over time:

• Diabetes mellitus, particularly with poor glycemic control.
• Hypertension (high blood pressure).
• Glomerulonephritis (kidney inflammation).
• Polycystic kidney disease (genetic disorder causing cysts in kidneys).
• Interstitial nephritis (inflammation of kidney tubules).
• Urinary tract obstruction, such as kidney stones.
• Vesicoureteral reflux (urine backflow to kidneys).
• Pyelonephritis (kidney infection).
• Congenital kidney defects.

4. Evaluate Contributing Factors to ESRD Development: Identify conditions that may exacerbate kidney damage and hasten ESRD progression:

• Systemic hypertension.
• Hyperlipidemia (high cholesterol).
• Uncontrolled diabetes.

5. Medication Review: Scrutinize the patient’s medication list, including prescription and over-the-counter drugs, as some can be nephrotoxic:

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

Physical Assessment: Objective Data Collection

1. Assess for ESRD Complications: Kidney damage can lead to various complications that require careful monitoring:

• Fluid volume overload resistant to diuretics.
• Poorly controlled hypertension.
• Anemia (low red blood cell count).
• Electrolyte imbalances (e.g., hyperkalemia, hyperphosphatemia).
• Bone deficiencies (renal osteodystrophy).
• Metabolic abnormalities (e.g., metabolic acidosis).
• Decreased immune response, increasing infection risk.

2. Evaluate for Uremic Toxicity: Assess for signs of uremia, a severe condition caused by the accumulation of waste products in the blood due to kidney failure. Uremic toxicity can manifest as:

• Cognitive impairment.
• Acidosis (excess acid in the body).
• Blood vessel calcification.

3. Conduct a Systemic Physical Examination: ESRD can impact all organ systems. Physical manifestations may include:

• General: Malnutrition (weight loss, fatigue, muscle weakness).
• CNS: Encephalopathy (confusion, irritability, drowsiness).
• Cardiovascular System: Pericarditis (inflammation around the heart, presenting with fever, dyspnea, abnormal heart sounds).
• Gastrointestinal System: Vomiting, diarrhea.
• Genitourinary System: Erectile dysfunction, amenorrhea (absence of menstruation), infertility, oliguria (reduced urine output) or anuria (absence of urine output).
• Musculoskeletal System: Peripheral neuropathy, muscle cramps or weakness.
• Integumentary System: Dry skin, pruritus, ecchymosis (bruising), edema.
• Hematological System: Platelet dysfunction, anemia.

4. Strict Fluid Intake and Output Monitoring: Meticulous monitoring of fluid balance is crucial. Patients with ESRD have a compromised ability to excrete fluids, leading to fluid overload. Urine output may be minimal or absent.

A nurse carefully assesses a patient for edema in the lower extremities, a common sign of fluid overload in ESRD.

Diagnostic Procedures for ESRD Confirmation and Monitoring

1. eGFR Measurement: Determine the eGFR to quantify kidney function and stage CKD. An eGFR below 15 ml/min confirms Stage 5 CKD or ESRD.

2. Blood Tests: Analyze blood samples to identify ESRD-related abnormalities:

• Complete Blood Count (CBC): Detect anemia.
• Basic Metabolic Panel (BMP):
  • Elevated serum creatinine and blood urea nitrogen (BUN) levels (indicators of waste product buildup).
  • Hyperkalemia (high potassium levels).
  • Low bicarbonate levels (metabolic acidosis).
  • Hypoalbuminemia (low serum albumin levels, indicative of malnutrition).
  • Serum phosphate levels (often elevated).
  • Vitamin D levels (often deficient).
  • Lipid profile (assess for dyslipidemia).

3. Urine Sample Analysis (Urinalysis): Evaluate urine composition to assess kidney filtering capacity:

• Urine protein/creatinine ratio: Detect albuminuria (protein in urine), with levels greater than 300 mg/g indicating severe renal impairment.
• 24-hour urine protein: Quantify protein excretion, with levels exceeding 3.5 g indicating nephrotic range proteinuria.

4. Imaging Scans: Utilize imaging techniques to visualize kidney structure and identify abnormalities:

• Kidney Ultrasound: Detect hydronephrosis (kidney swelling) or structural abnormalities.
• Retrograde Pyelogram: Diagnose urinary tract obstructions or renal stones.
• Computed Tomography (CT) Scan: Visualize kidney masses, cysts, and stones.
• Magnetic Resonance Angiography (MRA): Diagnose renal artery stenosis (narrowing of kidney arteries).

5. Kidney Biopsy: Consider kidney biopsy when the diagnosis remains unclear after initial workup, especially in cases of unexplained renal impairment or nephrotic-range proteinuria.

Nursing Interventions for End-Stage Renal Disease

Nursing interventions are crucial for managing ESRD, slowing disease progression, and improving patient well-being.

Delaying ESRD Progression: Conservative Management Strategies

1. Blood Pressure Management: Maintain blood pressure at or below 130/80 mmHg, or even lower (systolic <120 mmHg) for non-dialysis patients, as recommended by healthcare providers.

2. Blood Glucose Control: For diabetic patients, strict blood glucose control is paramount. Aim for a hemoglobin A1c level below 7% to minimize kidney damage and slow ESRD progression. Sodium-glucose transporter 2 (SGLT-2) inhibitors may be beneficial in type 2 diabetes to reduce eGFR decline.

3. Metabolic Acidosis Correction: Administer bicarbonate supplementation to treat chronic metabolic acidosis, potentially slowing ESRD progression.

4. Dyslipidemia Management: Monitor lipid profiles regularly and initiate cholesterol-lowering medications (statins) for adults over 50 with an eGFR below 60 mL/min/1.73 m2. Statin therapy may be discontinued for patients on dialysis.

5. Fluid Volume Control: Manage fluid overload and pulmonary edema with loop diuretics or ultrafiltration as prescribed.

6. Management of ESRD Complications: Address complications arising from ESRD:

• Anemia: Administer erythropoiesis-stimulating agents (ESAs) when hemoglobin levels fall below 10 g/dL.
• Hyperphosphatemia: Prescribe phosphate binders (e.g., calcium acetate, sevelamer carbonate, lanthanum carbonate) and implement dietary phosphate restrictions.
• Hypocalcemia: Administer calcium supplements and calcitriol as ordered.
• Hyperparathyroidism: Manage with calcitriol, vitamin D analogs, or calcimimetics as prescribed.

7. Renal Diet Education and Meal Planning: Educate patients on adhering to a renal diet, emphasizing:

• Limiting phosphorus and potassium intake.
• Restricting sodium intake to less than 2 g/day.
• Moderating protein intake to 0.8 g per kg of body weight daily.

8. Lifestyle Modifications: Promote healthy lifestyle choices:

• Regular physical activity as tolerated.
• Smoking cessation.
• Maintaining a healthy weight.
• Encourage aerobic exercise to improve strength, fitness, and quality of life, especially for dialysis patients.

9. Fluid Restriction: Implement individualized fluid restrictions to prevent fluid overload. Dialysis patients may be restricted to approximately 32 ounces of fluid per day, but this varies.

Planning for Long-Term Renal Replacement Therapy

1. Promote Treatment Adherence: Emphasize the necessity of renal replacement therapy (dialysis or transplantation) for survival in ESRD. Discuss dialysis modalities and transplantation options.

2. Patient Education on Prognosis and Treatment Options: Initiate early education about kidney transplantation, dialysis options (hemodialysis, peritoneal dialysis), and the natural progression of ESRD. This empowers patients to make informed decisions and adjust to their diagnosis.

3. Vascular Access Options Discussion: For hemodialysis, discuss vascular access options:

• Arteriovenous (AV) fistula: Considered the gold standard for long-term access due to lower infection and clotting risks. Requires several months to mature.
• AV graft: Synthetic catheter connecting an artery and vein, usable within days to weeks.

4. Peritoneal Dialysis Education: For suitable candidates, provide comprehensive education on performing peritoneal dialysis (PD) at home, including catheter care and peritonitis prevention.

5. Kidney Transplant Preparation: For eligible patients, facilitate the kidney transplant process. Discuss eligibility criteria and contraindications, such as advanced age, severe heart disease, active cancer, dementia, severe obesity, poor medication adherence, substance abuse, or lack of health insurance.

6. Palliative and End-of-Life Care Discussion: For patients who are not transplant candidates or when dialysis becomes ineffective, discuss palliative care for symptom management and hospice or end-of-life care options.

ESRD Nursing Care Plans: Addressing Key Nursing Diagnoses

Nursing care plans provide a structured framework for addressing specific nursing diagnoses in ESRD patients. Here are examples of care plans for common ESRD-related nursing diagnoses:

Deficient Knowledge related to End-Stage Renal Disease

Nursing Diagnosis: Deficient Knowledge

Related Factors: Misinformation, inadequate resources, lack of interest in learning, misconceptions about ESRD treatment.

Evidenced by: Questions about ESRD, inaccurate follow-through of instructions, expressed myths, nonadherence to treatment, development of complications.

Expected Outcomes:

• Patient will verbalize understanding of ESRD, its symptoms, and management.
• Patient will adhere to the treatment plan, as evidenced by stable lab values.
• Patient will remain free from preventable ESRD complications.

Nursing Interventions:

1. Assess current knowledge: Determine the patient’s existing understanding of ESRD to tailor education effectively.
2. Assess willingness to learn: Gauge patient motivation to learn and engage in self-management.
3. Evaluate health literacy: Assess health literacy to ensure information is presented in an accessible manner.
4. Educate on lifestyle modifications: Provide clear instructions on exercise, smoking cessation, and medication adherence.
5. Address dialysis and transplant inquiries: Be approachable and provide accurate information about these treatment options.
6. Dietary education: Provide easy-to-understand written guidelines on renal-friendly diets and restrictions.
7. Symptom recognition education: Teach patients to recognize and report concerning symptoms promptly.
8. Fistula care education: Instruct on proper fistula care and signs of complications for hemodialysis patients.

Excess Fluid Volume related to End-Stage Renal Disease

Nursing Diagnosis: Excess Fluid Volume

Related Factors: Sodium retention, impaired kidney function, decreased glomerular filtration rate, nonadherence to fluid restrictions.

Evidenced by: Edema, altered blood pressure, oliguria, pulmonary congestion, electrolyte imbalances.

Expected Outcomes:

• Patient will achieve fluid balance, as evidenced by balanced intake and output.
• Patient will be free from edema and dyspnea.
• Patient will maintain electrolytes within acceptable ranges.

Nursing Interventions:

1. Daily weight monitoring: Monitor daily weight for early detection of fluid retention.
2. Intake and output monitoring: Accurately measure and record fluid intake and output.
3. Electrolyte monitoring: Regularly assess electrolyte levels, especially potassium, sodium, and phosphate.
4. Urine sample collection: Obtain urine samples to assess protein levels and kidney function.
5. Respiratory and mental status monitoring: Monitor for signs of pulmonary congestion and altered mental status, indicating fluid overload.
6. Albumin administration: Administer albumin as prescribed to maintain oncotic pressure.
7. Diuretic administration: Administer loop diuretics to promote fluid excretion.
8. Sodium restriction: Reinforce dietary sodium restrictions.
9. Extremity elevation: Elevate edematous extremities to promote venous return.
10. Fluid restriction implementation: Strictly adhere to prescribed fluid restrictions.
11. Blood pressure regulation: Monitor and manage blood pressure to prevent further kidney damage.

Imbalanced Nutrition: Less Than Body Requirements related to ESRD

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related Factors: Disease process, uremic toxins, metabolic acidosis, food aversions.

Evidenced by: Weight loss, anorexia, nausea, vomiting, electrolyte imbalances.

Expected Outcomes:

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

Nursing Interventions:

1. Nutritional status assessment: Assess nutritional status, dietary habits, and symptoms impacting nutrition.
2. Weight loss monitoring: Monitor weight and BMI regularly.
3. Serum albumin and electrolyte monitoring: Assess serum albumin, red blood cell count, and electrolyte levels.
4. Fluid management encouragement: Reinforce fluid restriction guidelines.
5. Adequate protein intake promotion: Educate on appropriate protein intake levels based on dialysis status.
6. Dietary restrictions education: Instruct on limiting potassium, sodium, and phosphorus-rich foods.
7. Supplement education: Educate on prescribed vitamin and mineral supplements.
8. Nutritional counseling referral: Refer to a dietitian for individualized meal planning and counseling.
9. Exercise encouragement: Promote exercise as tolerated to improve appetite and nutritional status.

Impaired Urinary Elimination related to End-Stage Renal Disease

Nursing Diagnosis: Impaired Urinary Elimination

Related Factors: Loss of nephrons, decreased glomerular filtration rate, urinary tract obstruction.

Evidenced by: Oliguria, anuria, urinary retention, nocturia.

Expected Outcomes:

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

Nursing Interventions:

1. Urinary elimination status assessment: Assess urine output, frequency, and characteristics.
2. Urine characteristic observation: Note any changes in urine color, odor, or presence of abnormal components.
3. eGFR monitoring: Monitor eGFR levels to track kidney function.
4. Creatinine and BUN monitoring: Assess serum creatinine and BUN levels.
5. Bladder palpation: Palpate the bladder to assess for distention.
6. Costovertebral angle tenderness assessment: Check for CVA tenderness, which may indicate kidney infection.
7. Intake and output monitoring: Closely monitor fluid intake and output.
8. Dialysis education: Explain the importance of dialysis and its role in waste removal.
9. Kidney transplant discussion: Discuss kidney transplant as a potential long-term treatment option.
10. Dietitian referral: Refer to a dietitian for renal diet education and planning.

Ineffective Tissue Perfusion (Renal) related to End-Stage Renal Disease

Nursing Diagnosis: Ineffective Tissue Perfusion (Renal)

Related Factors: Chronic inflammation, compromised kidney function, hypervolemia, hypertension, nephrotoxic medications.

Evidenced by: Anuria, oliguria, edema, fatigue, mental status changes, decreased eGFR.

Expected Outcomes:

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

Nursing Interventions:

1. Intake and output and urine characteristic monitoring: Monitor urine output, color, and specific gravity.
2. Diagnostic study review: Review renal ultrasound and CT scan results.
3. Worsening perfusion symptom assessment: Assess for signs of organ dysfunction due to uremia.
4. Lab value monitoring: Monitor eGFR, BUN, creatinine, and electrolytes.
5. Dialysis preparation: Prepare the patient for dialysis as indicated.
6. Kidney biopsy assistance: Assist with kidney biopsy procedures if needed.
7. Nephrotoxic medication avoidance education: Instruct patients to avoid nephrotoxic medications, including IV contrast.
8. Kidney transplant preparation and assistance: Support patients undergoing kidney transplant evaluation and preparation.

This comprehensive nursing diagnosis care plan for ESRD provides a framework for delivering holistic and patient-centered care. By understanding the disease progression, conducting thorough assessments, implementing targeted interventions, and developing individualized care plans, nurses play a vital role in improving the lives of individuals living with end-stage renal disease.

References

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