Chronic Renal Failure (CRF), also known as Chronic Kidney Disease (CKD), signifies a gradual and irreversible decline in kidney function. The kidneys, vital for filtering waste and regulating body fluids, possess remarkable adaptability. Consequently, significant nephron loss can occur before kidney disease becomes apparent. In the early stages, individuals with CKD often exhibit no symptoms, and recognition may be delayed until the condition progresses.
Understanding Chronic Kidney Disease Stages
Chronic Kidney Disease is classified into stages based on the Glomerular Filtration Rate (GFR), a key indicator of kidney function:
- Stage 1: GFR ≥ 90 mL/min/1.73 m² – Kidney damage with normal or increased GFR.
- Stage 2: GFR 60-89 mL/min/1.73 m² – Mild reduction in GFR.
- Stage 3a: GFR 45-59 mL/min/1.73 m² – Moderate reduction in GFR.
- Stage 3b: GFR 30-44 mL/min/1.73 m² – Moderate reduction in GFR.
- Stage 4: GFR 15-29 mL/min/1.73 m² – Severe reduction in GFR.
- Stage 5: GFR < 15 mL/min/1.73 m² – Kidney failure, requiring dialysis or transplant.
As kidney function deteriorates, their capacity to eliminate toxins diminishes, impacting other bodily systems and potentially causing irreversible damage. End-Stage Renal Disease (ESRD), the final stage, necessitates dialysis or kidney transplantation for survival.
The Nursing Process in Renal Failure Care
The cornerstone of CKD management is to preserve remaining kidney function, minimize cardiovascular risks, prevent complications, and enhance patient comfort. Nurses play a crucial role in promoting health and preventing CKD onset and progression. Providing patients with comprehensive disease information and supporting lifestyle modifications are integral nursing responsibilities.
Nursing Assessment for Renal Failure
The initial phase of nursing care involves a thorough assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. This section will explore subjective and objective data pertinent to chronic kidney disease.
Health History Review
1. Elicit General Symptoms: Accumulation of waste products like creatinine, urea, phenols, electrolytes, and water leads to diverse clinical manifestations in CKD, varying with severity. Common symptoms include:
- Fatigue and weakness
- Appetite loss
- Edema (swelling)
- Dyspnea (shortness of breath)
- Changes in urination patterns
2. Identify Risk Factors: Several factors elevate CKD risk:
- Advanced age
- Specific ethnicities (African-American, Native American, Asian American)
- Family history of kidney disease
- Congenital kidney defects
3. Document Medical History: CKD often arises from underlying conditions. Diseases that can lead to renal failure include:
- Hypertension (high blood pressure)
- Diabetes Mellitus
- Cardiovascular disease
- Pre-existing kidney diseases (glomerulonephritis, polycystic kidney disease)
- Inherited kidney disorders
- Urinary tract obstructions (kidney stones)
- Cancer
- Recurrent kidney or urinary tract infections
- Vesicoureteral reflux (urine backflow to kidneys)
4. Evaluate Lifestyle and Environmental Factors: Certain lifestyle and environmental exposures can exacerbate kidney damage:
- Exposure to nephrotoxic substances (mold, arsenic, lead, certain medications)
- Obesity
- Smoking
5. Medication Review: Kidneys metabolize and eliminate numerous drugs. Certain over-the-counter and prescription medications can be nephrotoxic:
- Statins
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
- Antibiotics
- Antiretrovirals
- Antidiabetic medications and insulin
- Antacids
Physical Examination
1. Asymptomatic Early Stages: Patients in CKD stages 1-3 are often asymptomatic. Clinical manifestations of endocrine or metabolic imbalances in fluid and electrolytes typically emerge in stages 4-5. Initial symptoms might include fatigue and edema in extremities.
2. Assess for Metabolic Acidosis: Stages 4 and 5 CKD indicate severe kidney damage, impairing toxin and waste filtration, potentially leading to metabolic acidosis. Later-stage symptoms include:
- Oliguria or anuria (reduced or absent urine output)
- Edema
- Muscle cramps
- Nausea
- Anorexia (loss of appetite)
- Shortness of breath
3. Fluid and Electrolyte Imbalance Assessment: Impaired kidney function disrupts electrolyte and fluid balance, causing:
- Hypertension
- Peripheral edema
- Pulmonary edema
- Hyperkalemia (elevated potassium)
- Hyperphosphatemia (elevated phosphate)
4. Monitor for Anemia: Anemia, a common CKD complication, is characterized by low red blood cell count. Signs of anemia include:
- Fatigue
- Activity intolerance
- Cold intolerance
- Pallor (pale skin)
- Difficulty concentrating
- Lightheadedness or dizziness
- Palpitations
Diagnostic Tests
1. CKD Screening Tests: These tests evaluate kidney function:
- Urinalysis
- Urine Albumin-to-Creatinine Ratio (ACR)
- Serum Creatinine
- Estimated GFR (eGFR) using CKD-EPI equation
2. Blood Tests: Additional serum tests assess underlying conditions and complications:
- Complete Blood Count (CBC)
- Basic Metabolic Panel (BMP)
- Serum Albumin
- Lipid Profile
3. Bone Status Assessment: Tests for renal bone disease diagnosis:
- Serum Calcium and Phosphate
- 25-hydroxyvitamin D
- Alkaline Phosphatase
- Intact Parathyroid Hormone (PTH) levels
4. Imaging Studies: Imaging techniques visualize kidneys and surrounding structures:
- Renal Ultrasonography
- Retrograde Pyelography
- Computed Tomography (CT) Scan
- Magnetic Resonance Imaging (MRI)
- Renal Radionuclide Scanning
5. Kidney Biopsy: Percutaneous kidney biopsy is indicated when diagnosis remains unclear after initial workup or to guide management based on renal involvement severity.
Nursing Interventions for Renal Failure
Nursing interventions and comprehensive care are critical for patient management and well-being in chronic renal failure.
Slowing CKD Progression
1. Treat Underlying Conditions: While existing kidney damage is irreversible, managing underlying causes is crucial to slow progression and minimize complications:
- Blood pressure control
- Diabetes management (HbA1c targets)
- Weight reduction
- Avoidance of nephrotoxic substances
- Management of hyperlipidemia
2. Blood Pressure Goals: CKD patients with hypertension should maintain blood pressure below 130/80 mmHg. Medications like ACE inhibitors or angiotensin II receptor blockers are used to lower blood pressure and protect kidney function.
3. Protein Restriction: Limiting protein intake can slow proteinuria progression. Protein type and quantity should be individualized, guided by a nephrologist and dietitian.
4. NSAID Avoidance: NSAIDs are nephrotoxic and should be avoided by CKD patients. Patient education is essential.
5. Smoking Cessation: Smoking accelerates ESRD progression. Quitting smoking reduces kidney failure risk.
6. Fluid Retention Management: Fluid retention is common in CKD, leading to hypertension and edema. Loop diuretics can induce diuresis.
7. Erythropoiesis Promotion: Erythropoietin supplements stimulate red blood cell production, alleviating anemia symptoms.
8. Cholesterol Management: Statins are used to maintain acceptable cholesterol levels, protecting against cardiovascular disease in CKD patients.
9. Bone Health: Vitamin D and calcium supplements reduce fracture risk and prevent bone weakening. Phosphate binders lower blood phosphate levels and protect blood vessels from calcification.
10. Electrolyte Balance: CKD patients are susceptible to electrolyte imbalances (hyperphosphatemia, hypocalcemia, hyperkalemia, hyponatremia), requiring medications, supplements, and dietary modifications.
Renal Replacement Therapy Initiation
1. Dialysis and Transplantation Discussion: Renal replacement therapy is necessary for CKD patients with severe complications like metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable fluid retention, and malnutrition.
2. Patient Options Information: Patients declining renal replacement should receive palliative and conservative care information, focusing on symptom management, comfort, and quality of life.
3. Vascular Access Preparation for Hemodialysis: Surgical creation of vascular access is needed for hemodialysis.
- AV Graft: Surgically implanted tube connecting artery and vein, usable within days/weeks.
- AV Fistula: Recommended access, lower infection risk, but requires months to mature.
4. Peritoneal Dialysis Education: Peritoneal dialysis (PD) may be suitable for some patients, depending on kidney function, health, and home dialysis capability. A catheter is inserted into the abdomen, and dialysate uses the peritoneum as a natural filter.
5. Kidney Transplant Consideration: Kidney transplants can be from living or deceased donors. Lifelong immunosuppression is required post-transplant. Patient eligibility requires good general health and abstinence from drugs and smoking.
6. Psychosocial Support: A CKD diagnosis can be emotionally challenging. Nurses should allow patients time to adjust, address questions, and dispel misconceptions.
7. Interdisciplinary Collaboration: Nephrologists lead CKD management. Nurses collaborate with dietitians for renal diet plans, cardiologists, endocrinologists, social workers, and transplant teams.
Nursing Care Plans for Renal Failure
Nursing care plans prioritize assessments and interventions for both short-term and long-term care goals based on identified nursing diagnoses. Examples for chronic kidney disease include:
Excess Fluid Volume Care Plan
Excess fluid volume is common in CRF due to impaired kidney function in fluid and waste removal, potentially leading to complications like edema, hypertension, and heart failure.
Nursing Diagnosis: Excess Fluid Volume
Related Factors:
- Kidney dysfunction
- Decreased urine output
- Sodium retention
- Excessive fluid intake
- Impaired regulatory mechanisms
Evidenced by:
- Altered mental status
- Adventitious breath sounds
- 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 without dyspnea and be free from edema.
- Patient will maintain balanced fluid intake and output.
Nursing Assessments:
1. Auscultate Lung Sounds: Adventitious sounds (rales/crackles) and dyspnea indicate fluid retention complications.
2. Monitor Intake and Output: Accurate documentation helps detect imbalances and fluid overload. Damaged kidneys produce less urine.
3. Review Laboratory Values: BUN, creatinine, GFR, and electrolytes assess renal function and fluid balance.
Nursing Interventions:
1. Daily Weight Monitoring: 1 kg weight gain ≈ 1 liter fluid retention. Consistent daily weight monitoring is crucial.
2. Fluid Restriction: Limit all fluid intake types (oral, IV, enteral) to prevent and reduce fluid overload.
3. Administer Diuretics: Prescribed diuretics increase urinary fluid elimination and reduce retention.
4. Edema Care: Reposition edematous extremities every 2 hours to prevent pressure ulcers and elevate extremities to improve circulation and reduce swelling.
5. Dialysis Preparation: Stage 5 renal failure often necessitates dialysis. Dialysis nurses provide hemodialysis or peritoneal dialysis.
Imbalanced Nutrition: Less Than Body Requirements Care Plan
Malnutrition is prevalent in CKD due to disease processes and dialysis.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related Factors:
- Disease process
- Malabsorption
- Metabolic acidosis
- Chronic inflammation
- Food aversion
- Dialysis
Evidenced by:
- Constipation
- Diarrhea
- Weight loss
- Nausea
- Vomiting
- Altered nutritional markers
- Poor appetite
- Low energy levels
- Muscle wasting
Expected Outcomes:
- Patient will report adequate appetite.
- Patient will maintain electrolytes and protein levels within acceptable ranges.
Nursing Assessments:
1. Eating Patterns and Contributing Factors: Assess eating habits, appetite, and factors causing imbalance to guide interventions. Uremic effects, acidosis, malabsorption, protein loss during dialysis, inflammation, and oxidative stress contribute to malnutrition.
2. Review Laboratory Results: Decreased serum albumin indicates protein loss, reduced synthesis, and fluid shifts. Low vitamin D and calcium increase fracture risk. Electrolyte imbalances are common.
3. Hydration Status and Daily Weight: CKD patients are fluid-sensitive. Sudden weight gain indicates fluid retention.
Nursing Interventions:
1. Limit Potassium, Sodium, and Phosphorus: As CKD progresses, dietary restrictions are needed to manage hypertension, protect the heart, and prevent bone weakening.
2. Protein Management: Low-protein diets are often indicated. Protein intake should be adjusted based on dialysis status (0.6-0.8g/kg/day non-dialysis, 1-1.2g/kg/day dialysis).
3. Limit Alcohol: Alcohol further strains kidney function and accelerates CKD progression.
4. Limit Saturated and Trans Fats: Reduce buildup in blood vessels, heart, and kidneys. Encourage healthier monounsaturated and polyunsaturated fats.
5. Increase Fiber: Fiber (20-38g/day) helps prevent constipation, common in CKD, and promotes gut health.
6. Renal Dietitian Referral: A renal dietitian can create individualized dietary plans considering nutritional status, fluid needs, and kidney health.
Impaired Urinary Elimination Care Plan
Impaired urinary elimination is common in CRF due to reduced kidney filtration and urine production. Oliguria (urine output <400mL/day or <20mL/hour) is an early sign of impaired renal function.
Nursing Diagnosis: Impaired Urinary Elimination
Related Factors:
- Chronic kidney disease
Evidenced by:
- Oliguria
- Dysuria
- Urinary retention
- Urinary incontinence
Expected Outcomes:
- Patient will produce at least 400 mL urine per 24 hours.
- Patient will not experience oliguria-related complications.
Nursing Assessments:
1. Urinary Elimination Patterns: Assess normal patterns to guide interventions for healthy elimination.
2. Urine Characteristics: Evaluate amount, color, clarity, and odor to detect complications like infection.
Nursing Interventions:
1. Administer Diuretics: Diuretics promote urinary elimination and prevent fluid overload.
2. Cautious Fluid Administration: Fluid therapy can aid elimination but worsen fluid retention and electrolyte imbalances. Close monitoring is crucial.
3. Educate on Expectations: Urine production may fluctuate in CRF. Explain that it will progressively decrease and may cease entirely as the disease advances.
4. Infection Prevention: Dialysis patients are at risk for infections from catheters and fistulas. Monitor for fever and abdominal pain.
Risk for Decreased Cardiac Output Care Plan
Declining kidney function leads to sodium retention and fluid volume expansion, causing edema, pulmonary edema, and hypertension, potentially decreasing cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related Factors:
- Altered contractility, afterload, heart rate, preload, rhythm, stroke volume
- Fluid imbalance affecting circulating volume and myocardial workload
- Toxin accumulation and soft-tissue calcification
Evidenced by: (Risk diagnosis – no signs/symptoms present yet)
Expected Outcomes:
- Patient will maintain vital signs within normal limits.
- Patient will be free from decreased cardiac output symptoms (dyspnea, dysrhythmias, activity intolerance).
Nursing Assessments:
1. Blood Pressure Monitoring: Hypertension and orthostatic hypotension are common in CKD.
2. Chest Pain Assessment: Assess location, severity, and intensity. Cardiovascular complications are frequent in CKD.
3. Laboratory Studies Review: Electrolyte imbalances, especially hyperkalemia, increase dysrhythmia risk and compromise perfusion.
4. Decreased Cardiac Output Signs/Symptoms: Monitor for fatigue, dyspnea, orthopnea, edema, and decreased peripheral pulses for early intervention.
Nursing Interventions:
1. Administer Medications: Antihypertensives (ACE inhibitors, ARBs) reduce blood pressure, preserve kidney function, and prevent decreased cardiac output complications.
2. Fluid Status Monitoring and Restriction: Strict fluid management is essential. Diuretics may be necessary.
3. Ejection Fraction Monitoring: CKD is a heart failure risk factor. Ejection fraction is an indicator of cardiac function.
4. Dialysis Preparation: Dialysis helps remove uremic toxins, correct imbalances, manage fluid, and prevent complications like decreased cardiac output, hypertension, and pericardial effusion in ESRD.
Risk for Electrolyte Imbalance Care Plan
CRF patients are at high risk for electrolyte imbalances (decreased sodium and calcium, increased potassium, magnesium, and phosphate) due to impaired kidney function.
Nursing Diagnosis: Risk for Electrolyte Imbalance
Related Factors:
- Renal failure
- Kidney dysfunction
Evidenced by: (Risk diagnosis – no signs/symptoms present yet)
Expected Outcomes:
- Patient will maintain normal serum potassium, sodium, calcium, magnesium, and phosphorus levels.
Nursing Assessments:
1. Laboratory Data Review: Abnormal electrolyte panels indicate CRF progression.
2. Vital Signs Monitoring: Electrolyte imbalances can cause respiratory failure and dysrhythmias, reflected in vital signs and EKGs.
Nursing Interventions:
1. Administer Lactulose: Lactulose promotes fecal excretion of potassium, ammonia, urea, and creatinine, helpful for hyperkalemia.
2. Administer Loop Diuretics: Potassium-wasting loop diuretics help eliminate excess potassium.
3. Nutritional Management: Adjust diet based on lab results – restrict intake for high levels, supplement for deficiencies.
4. Patient Education: Educate on hyperkalemia (muscle weakness, restlessness, cramping, slow heart rate) and hyponatremia (muscle cramps, nausea, disorientation, altered mental status) signs.
References
- Национальный институт диабета и болезней органов пищеварения и почек (NIDDK). (n.d.). Хроническая болезнь почек (ХБП).
- Levey, A. S., & James, M. T. (2017). Chronic Kidney Disease. Annals of Internal Medicine, 167(9), ITC65-ITC80.
- KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International Supplements, 3(1), 1-150.
