Chronic Kidney Disease (CKD), also known as chronic renal failure (CRF), is defined by a gradual and irreversible decline in kidney function. The insidious nature of kidney disease stems from the remarkable adaptability of the kidneys; significant nephron loss can occur before the condition becomes clinically apparent. In the early stages of CKD, patients are frequently asymptomatic, and noticeable symptoms often don’t manifest until the disease has progressed considerably.
In managing patients with CKD, particularly those progressing towards kidney failure, nurses play a crucial role. Accurate nursing diagnoses are paramount to guide effective interventions and improve patient outcomes. This article provides a comprehensive guide to understanding kidney failure nursing diagnoses, focusing on assessment, interventions, and care planning to optimize patient care in chronic kidney disease.
Stages of Chronic Kidney Disease
The classification of CKD into stages is based on the Glomerular Filtration Rate (GFR), a key indicator of kidney function:
- Stage 1: GFR ≥ 90 mL/min/1.73m² (Normal or increased GFR)
- Stage 2: GFR 60-89 mL/min/1.73m² (Mildly decreased GFR)
- Stage 3a: GFR 45-59 mL/min/1.73m² (Moderately decreased GFR)
- Stage 3b: GFR 30-44 mL/min/1.73m² (Moderately decreased GFR)
- Stage 4: GFR 15-29 mL/min/1.73m² (Severely decreased GFR)
- Stage 5: GFR < 15 mL/min/1.73m² (Kidney Failure, End-Stage Renal Disease – ESRD, requiring dialysis or transplant)
As kidney function deteriorates, the kidneys’ ability to filter toxins diminishes, impacting other organ systems and potentially causing irreversible damage. Stage 5 CKD represents end-stage renal disease (ESRD), necessitating renal replacement therapy such as dialysis or kidney transplantation.
Nursing Process in Chronic Kidney Disease
The primary objectives in managing and treating CKD are to preserve remaining kidney function, mitigate cardiovascular disease risks, prevent complications, and enhance patient comfort. Nurses are instrumental in promoting health activities that can delay or prevent CKD onset and progression. Providing patients with accurate information about CKD and encouraging adherence to necessary lifestyle modifications are integral nursing responsibilities.
Nursing Assessment for Kidney Failure
The nursing assessment is the initial critical step in providing holistic care. It involves gathering comprehensive physical, psychosocial, emotional, and diagnostic data. For patients with or at risk of kidney failure, a thorough assessment is essential to formulate appropriate nursing diagnoses and care plans.
Review of Health History
1. General Symptom Inquiry: Elicit information about general symptoms. Clinical manifestations of CKD arise from the retention of substances normally cleared by the kidneys, such as creatinine, urea, phenols, electrolytes, and water. Symptom presentation varies with disease severity and may include:
- Fatigue
- Weakness
- Loss of appetite
- Edema (swelling)
- Shortness of breath
- Changes in urine output
2. Risk Factor Identification: Determine the presence of CKD risk factors. These factors increase susceptibility to CKD:
- Advanced age
- Certain ethnicities (African-American, Native American, Asian American)
- Family history of kidney disease
- Congenital kidney or urinary tract defects
3. Medical History Review: Identify pre-existing conditions that could contribute to CKD. Numerous diseases and conditions can compromise kidney function and lead to CKD:
- Hypertension (High Blood Pressure)
- Diabetes Mellitus
- Cardiovascular disease
- Existing kidney diseases (e.g., glomerulonephritis, polycystic kidney disease)
- Inherited kidney diseases
- Conditions causing prolonged urinary tract obstruction (e.g., kidney stones)
- Cancer
- Recurrent kidney infections (pyelonephritis)
- Recurrent urinary tract infections (UTIs)
- Vesicoureteral reflux (persistent urine backflow to the kidneys)
4. Lifestyle and Environmental Factors: Assess lifestyle and environmental factors that may exacerbate kidney damage:
- Exposure to nephrotoxic substances (e.g., mold, heavy metals like arsenic and lead, certain medications)
- Obesity
- Smoking
5. Medication Review: Scrutinize the patient’s medication list, as many drugs are metabolized and excreted by the kidneys. Certain over-the-counter (OTC) and prescription medications can be nephrotoxic:
- Statins
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
- Antibiotics
- Antiretrovirals
- Antidiabetic agents and insulin
- Antacids
Alt text: Nurse measuring patient’s blood pressure with cuff, crucial in kidney failure nursing assessment due to hypertension risk.
Physical Assessment
1. Asymptomatic Early Stages: Be aware that patients in early CKD stages (1-3) are often asymptomatic. Clinical manifestations of endocrine or metabolic imbalances typically become evident in later stages (4-5). Early symptoms may be subtle, such as fatigue and peripheral edema.
2. Metabolic Acidosis Assessment: Assess for signs of metabolic acidosis, a serious complication in stages 4-5 CKD, resulting from the kidneys’ inability to eliminate waste and toxins. Symptoms of later-stage CKD include:
- Oliguria or anuria (decreased or absent urine output)
- Edema
- Muscle cramps
- Nausea
- Loss of appetite
- Shortness of breath
3. Fluid and Electrolyte Balance Evaluation: Determine any imbalances in fluid and electrolytes resulting from impaired kidney filtration:
- Hypertension
- Peripheral edema
- Pulmonary edema
- Hyperkalemia (elevated potassium)
- Hyperphosphatemia (elevated phosphate)
4. Anemia Monitoring: Monitor for signs of anemia, a common CKD complication due to reduced erythropoietin production:
- Fatigue
- Activity intolerance
- Feeling cold
- Pale skin
- Difficulty concentrating
- Lightheadedness or dizziness
- Heart palpitations
Alt text: Nurse assessing patient’s leg for edema, a key indicator in kidney failure nursing diagnosis related to fluid overload.
Diagnostic Procedures
1. CKD Screening: Conduct or review CKD screening tests to evaluate kidney function:
- Urinalysis (to detect protein, blood, and other abnormalities)
- Urine albumin-creatinine ratio (ACR) (to quantify proteinuria)
- Serum creatinine (to estimate kidney function)
- Estimated GFR (eGFR) using the CKD-EPI equation
2. Blood Tests: Review or order additional serum tests to assess for underlying conditions and complications:
- Complete blood count (CBC) (to evaluate for anemia and infection)
- Basic metabolic panel (BMP) (to assess electrolytes, BUN, creatinine, glucose)
- Serum albumin levels (to evaluate nutritional status and protein loss)
- Lipid profile (to assess cardiovascular risk)
3. Bone Status Assessment: Determine bone health through relevant tests for renal bone disease:
- Serum calcium and phosphate
- 25-hydroxyvitamin D
- Alkaline phosphatase
- Intact parathyroid hormone (PTH) levels
4. Imaging Scans: Prepare patients for or review results of imaging studies to visualize kidneys and surrounding structures:
- Renal ultrasonography (to assess kidney size, structure, and obstruction)
- Retrograde pyelography
- Computed tomography (CT) scan
- Magnetic resonance imaging (MRI)
- Renal radionuclide scanning
5. Kidney Biopsy: Prepare the patient for a percutaneous kidney biopsy if clinically indicated. Biopsy is considered when the diagnosis remains uncertain after initial workup or to guide management based on the severity of renal involvement in diagnosed conditions.
Nursing Interventions for Kidney Failure
Nursing interventions are critical in managing CKD and slowing the progression towards kidney failure.
Delaying Kidney Disease Progression
1. Treat Underlying Conditions: While existing kidney damage is irreversible, managing the underlying causes is paramount to slowing disease progression and reducing complications. This includes:
- Managing hypertension: Maintain blood pressure below 130/80 mmHg.
- Controlling diabetes: Optimize glycemic control (HbA1c targets).
- Weight management: Encourage weight loss in overweight or obese patients.
- Avoiding nephrotoxic substances: Minimize exposure to medications and environmental toxins harmful to kidneys.
- Managing hyperlipidemia: Control high cholesterol levels.
2. Blood Pressure Management: For hypertensive CKD patients, maintain blood pressure below 130/80 mmHg. Administer antihypertensive medications, such as ACE inhibitors or angiotensin II receptor blockers, to lower blood pressure and provide renal protection.
3. Protein Restriction: Dietary protein restriction has been shown to slow the progression of proteinuria. The type and quantity of protein intake should be individualized. Collaborate with a nephrologist and dietitian to determine appropriate protein intake.
4. NSAID Avoidance: Educate patients with CKD about the nephrotoxic nature of NSAIDs and advise them to avoid these medications.
5. Smoking Cessation: Counsel smokers on the importance of smoking cessation, as smoking accelerates CKD progression to ESRD.
6. Fluid Retention Management: Address fluid retention, a common issue in CKD, which can lead to hypertension and edema. Loop diuretics can be used to promote diuresis.
7. Erythropoiesis Promotion: Administer erythropoietin-stimulating agents (ESAs) to promote red blood cell production and alleviate anemia-related symptoms.
8. Cholesterol Management: Encourage the use of statin medications to lower cholesterol levels and reduce the risk of cardiovascular disease in CKD patients.
9. Bone Health Maintenance: Prescribe vitamin D and calcium supplements to reduce fracture risk and prevent renal bone disease. Administer phosphate binders to control hyperphosphatemia and prevent vascular calcification.
10. Electrolyte Imbalance Correction: Manage electrolyte imbalances common in CKD, such as hyperphosphatemia, hypocalcemia, hyperkalemia, and hyponatremia, through medications, supplements, and dietary modifications.
Initiating Renal Replacement Therapy
1. Dialysis and Transplantation Discussion: For patients with advanced CKD experiencing severe complications (e.g., metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable fluid overload, malnutrition), renal replacement therapy becomes necessary.
2. Palliative and Conservative Care: For patients who decline renal replacement therapy, provide information about palliative and conservative care options focused on symptom management, comfort, and quality of life.
3. Vascular Access Preparation: For patients choosing hemodialysis, surgical creation of vascular access is required.
- Arteriovenous (AV) Graft: Surgically implanted tube connecting artery and vein, usable within days to weeks.
- AV Fistula: Recommended access, surgically created connection of artery and vein, lower infection risk and better patency, but requires months to mature before use.
4. Peritoneal Dialysis Education: Educate suitable patients about peritoneal dialysis (PD), a home-based dialysis option where a catheter is placed in the abdomen, and dialysate is infused into the peritoneal cavity to filter waste products.
5. Kidney Transplant Information: Discuss kidney transplantation as an option, including living and deceased donor transplantation. Emphasize the need for lifelong immunosuppression post-transplant. Explain recipient eligibility criteria (e.g., general health, substance abstinence).
6. Psychosocial Support: Provide emotional support to help patients cope with the CKD diagnosis. Allow time for adjustment and acceptance. Address patient inquiries and clarify misconceptions.
7. Interdisciplinary Collaboration: Collaborate with the nephrologist, dietitian, and other healthcare professionals (cardiologist, endocrinologist, social worker, transplant team) to provide comprehensive, patient-centered care.
Alt text: Doctor explaining blood test results to patient, a routine part of managing kidney failure and related nursing care.
Nursing Care Plans for Kidney Failure
Once nursing diagnoses are identified, nursing care plans guide the prioritization of assessments and interventions to achieve short- and long-term patient care goals. Common nursing diagnoses related to kidney failure include:
Excess Fluid Volume
Excess fluid volume is a common complication of kidney failure as impaired renal function leads to fluid and waste product accumulation.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Kidney dysfunction
- Decreased urine output
- Sodium retention
- Excessive fluid intake
- Compromised regulatory mechanisms
As evidenced by:
- Altered mental status
- Adventitious breath sounds (rales/crackles)
- Pulmonary congestion
- Altered pulmonary artery pressure
- Altered urine specific gravity
- Edema
- Imbalanced intake and output
- Jugular vein distension
- Oliguria
Expected Outcomes:
- Patient will maintain clear lung sounds and be free from edema and dyspnea.
- Patient will maintain balanced fluid intake and output.
Assessments:
- Auscultate lung sounds: Adventitious sounds (rales/crackles) and dyspnea indicate fluid retention complications.
- Monitor intake and output: Accurate documentation is crucial for detecting fluid imbalances and overload. Impaired kidneys produce less urine.
- Review laboratory values: BUN, creatinine, GFR, and electrolytes are monitored to assess renal function and fluid balance.
Interventions:
- Daily weight monitoring: 1 kg (2.2 lbs) weight gain approximates 1 liter of fluid retention. Use the same scale, time, and clothing for accuracy.
- Fluid restriction: Restrict oral, IV, and enteral fluid intake to prevent fluid overload.
- Administer diuretics: Diuretics increase urinary fluid elimination and reduce retention.
- Edema care: Reposition patient every 2 hours to prevent pressure ulcers, elevate edematous extremities to improve venous return and reduce swelling.
- Dialysis preparation: Prepare patients with Stage 5 renal failure for dialysis.
Imbalanced Nutrition: Less Than Body Requirements
Malnutrition is prevalent in CKD due to disease processes and dialysis.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process (uremia)
- Malabsorption
- Metabolic acidosis
- Chronic inflammation
- Food aversions
- Dialysis
As evidenced by:
- Constipation
- Diarrhea
- Weight loss
- Nausea
- Vomiting
- Altered nutritional markers (e.g., low albumin)
- Poor appetite
- Low energy levels
- Muscle wasting
Expected Outcomes:
- Patient will report adequate appetite.
- Patient will maintain electrolytes and protein levels within acceptable ranges.
Assessments:
- Eating patterns and contributing factors: Assess dietary habits, appetite, and factors contributing to malnutrition (uremic effects, metabolic acidosis, malabsorption, dialysis-related protein loss, inflammation).
- Review laboratory results: Monitor serum albumin, vitamin D, calcium, and electrolytes.
- Hydration status and daily weight: Monitor for fluid overload, which can mask or contribute to nutritional imbalances.
Interventions:
- Dietary restrictions: Advise patient to avoid foods high in potassium, sodium, and phosphorus to manage hypertension, protect the heart, and prevent bone disease.
- Protein management: Recommend appropriate protein intake (lower for non-dialysis, higher for dialysis patients).
- Limit alcohol intake: Alcohol places additional strain on kidney function.
- Limit saturated and trans fats: Reduce intake of unhealthy fats to minimize cardiovascular risk. Encourage healthier fat sources.
- Increase fiber intake: Recommend 20-38g of fiber daily to prevent constipation.
- Renal dietitian referral: Consult a renal dietitian for personalized dietary recommendations.
Impaired Urinary Elimination
Impaired urinary elimination is a hallmark of kidney failure as kidneys lose their urine-producing capacity.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Chronic kidney disease
As evidenced by:
- Oliguria
- Dysuria
- Urinary retention
- Urinary incontinence
Expected Outcomes:
- Patient will produce at least 400 mL urine per 24 hours (minimum for waste removal).
- Patient will not experience complications from oliguria.
Assessments:
- Urinary elimination patterns: Assess normal patterns to identify deviations and guide interventions.
- Urine characteristics: Evaluate amount, color, clarity, and odor for signs of infection or other issues.
Interventions:
- Administer diuretics: Use cautiously to promote urinary elimination while monitoring fluid and electrolyte balance.
- Fluid administration with caution: Fluid therapy can support elimination but can worsen fluid overload. Closely monitor.
- Patient education: Educate about expected changes in urine production as CKD progresses.
- Infection prevention: Monitor for infection in dialysis patients (catheter/fistula sites).
Risk for Decreased Cardiac Output
Fluid overload, electrolyte imbalances, and uremic toxins in kidney failure increase the risk of decreased cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Altered contractility, afterload, heart rate, preload, rhythm, stroke volume
- Fluid imbalance affecting circulating volume and myocardial workload
- Accumulation of toxins and soft-tissue calcification
As evidenced by:
(Risk diagnosis – no defining signs/symptoms yet)
Expected Outcomes:
- Patient will maintain vital signs within normal limits.
- Patient will remain free from symptoms of decreased cardiac output (dyspnea, dysrhythmias, activity intolerance).
Assessments:
- Blood pressure monitoring: Assess for hypertension and orthostatic hypotension.
- Chest pain assessment: Evaluate for chest pain related to cardiovascular complications.
- Review laboratory studies: Monitor electrolytes, especially potassium, which can impact cardiac rhythm.
- Signs and symptoms of decreased cardiac output: Assess for fatigue, dyspnea, edema, and decreased peripheral pulses.
Interventions:
- Administer medications: Antihypertensives (ACE inhibitors, ARBs) are used to manage blood pressure and protect cardiac function.
- Fluid status monitoring and restriction: Strict fluid management and diuretics as needed.
- Ejection fraction monitoring: Monitor ejection fraction as an indicator of cardiac function.
- Dialysis preparation: Dialysis helps manage fluid overload, electrolyte imbalances, and uremic toxins, supporting cardiac function.
Risk for Electrolyte Imbalance
Impaired kidney function predisposes patients to electrolyte imbalances.
Nursing Diagnosis: Risk for Electrolyte Imbalance
Related to:
- Renal failure
- Kidney dysfunction
As evidenced by:
(Risk diagnosis – no defining signs/symptoms yet)
Expected Outcomes:
- Patient will maintain normal serum potassium, sodium, calcium, magnesium, and phosphorus levels.
Assessments:
- Laboratory data review: Monitor electrolyte panels regularly.
- Vital signs monitoring: Assess for vital sign changes and ECG abnormalities indicative of electrolyte imbalances.
Interventions:
- Administer lactulose: For hyperkalemia, lactulose promotes fecal potassium excretion.
- Administer loop diuretics: Potassium-wasting diuretics can help manage hyperkalemia (use cautiously, may worsen other imbalances).
- Dietary management: Adjust diet based on electrolyte levels (restrict or supplement).
- Patient education: Educate patients on signs and symptoms of hyperkalemia and hyponatremia and when to seek medical attention.
References
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