Chronic Kidney Disease (CKD), also known as chronic renal failure (CRF), is a condition marked by the gradual and irreversible decline of kidney function over time. The insidious nature of CKD often means it progresses significantly before detection, as the kidneys possess remarkable adaptability, compensating for nephron loss. Early stages of CKD are frequently asymptomatic, with noticeable symptoms typically emerging in the more advanced phases.
This article delves into the essential aspects of nursing care for patients with chronic kidney disease, focusing on nursing diagnoses, assessments, interventions, and care plans to optimize patient outcomes and quality of life.
Stages of Chronic Kidney Disease
The staging of CKD is crucial for guiding treatment and is based on the Glomerular Filtration Rate (GFR), a key indicator of kidney function:
- Stage 1: Kidney damage with normal or increased GFR (≥ 90 mL/min/1.73 m²)
- Stage 2: Mild CKD with mildly decreased GFR (60-89 mL/min/1.73 m²)
- Stage 3a: Moderate CKD with moderately decreased GFR (45-59 mL/min/1.73 m²)
- Stage 3b: Moderate CKD with moderately decreased GFR (30-44 mL/min/1.73 m²)
- Stage 4: Severe CKD with severely decreased GFR (15-29 mL/min/1.73 m²)
- Stage 5: End-Stage Renal Disease (ESRD) with kidney failure (GFR < 15 mL/min/1.73 m²) requiring dialysis or transplant
As CKD progresses, the kidneys’ ability to filter waste diminishes, impacting other organ systems and potentially causing irreversible damage. Stage 5 CKD culminates in End-Stage Renal Disease (ESRD), necessitating renal replacement therapy such as dialysis or kidney transplantation.
The Nursing Process in Chronic Kidney Disease
The cornerstone of CKD management in nursing is a holistic approach aimed at preserving remaining kidney function, mitigating cardiovascular risks, preventing complications, and enhancing patient comfort. Nurses play a vital role in promoting health and preventing CKD onset and progression. This includes providing comprehensive education about the disease and empowering patients to adhere to necessary lifestyle modifications and treatment plans.
Comprehensive Nursing Assessment for CKD
The nursing assessment is the initial and crucial step in providing patient-centered care. It involves gathering subjective and objective data encompassing physical, psychosocial, emotional, and diagnostic aspects.
Health History Review
1. General Symptom Inquiry: Elicit information regarding general symptoms. The accumulation of toxins such as creatinine, urea, phenols, electrolytes, and excess water leads to the varied clinical manifestations of CKD. Common symptoms include:
- Fatigue and weakness
- Loss of appetite
- Edema (swelling)
- Dyspnea (shortness of breath)
- Changes in urinary patterns
2. Risk Factor Identification: Determine the presence of CKD risk factors. Predisposing factors include:
- Advanced age
- Specific ethnicities (African-American, Native American, Asian American)
- Family history of kidney disease
- Congenital kidney or urinary tract defects
3. Medical History Documentation: Document pre-existing conditions that may contribute to CKD. Common causes include:
- Hypertension (high blood pressure)
- Diabetes mellitus
- Cardiovascular disease
- Glomerulonephritis and polycystic kidney disease
- Hereditary kidney diseases
- Urinary tract obstructions (e.g., kidney stones)
- Cancer
- Recurrent kidney infections or urinary tract infections
- Vesicoureteral reflux
4. Lifestyle and Environmental Factors: Assess lifestyle and environmental elements that can exacerbate kidney damage:
- Exposure to nephrotoxic substances (e.g., mold, certain medications, heavy metals)
- Obesity
- Smoking
5. Medication Review: Thoroughly review the patient’s medication list, including over-the-counter and prescription drugs, as many are processed by the kidneys. Nephrotoxic medications include:
- Statins
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
- Antibiotics
- Antiretrovirals
- Antidiabetic medications and insulin
- Antacids
Physical Examination
1. Asymptomatic Early Stages: Recognize that early CKD (stages 1-3) is often asymptomatic. Clinical manifestations of endocrine and 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 and 5, indicating severe kidney damage. Symptoms include:
- Oliguria or anuria (reduced or absent urine production)
- Edema
- Muscle cramps
- Nausea and vomiting
- Anorexia (loss of appetite)
- Shortness of breath
3. Fluid and Electrolyte Imbalance Evaluation: Monitor for complications arising from impaired electrolyte and fluid regulation:
- Hypertension
- Peripheral edema
- Pulmonary edema
- Hyperkalemia (high potassium)
- Hyperphosphatemia (high phosphate)
4. Anemia Monitoring: Assess for signs of anemia, a common CKD complication:
- Fatigue
- Activity intolerance
- Cold intolerance
- Pallor (pale skin)
- Difficulty concentrating
- Dizziness or lightheadedness
- Heart palpitations
Diagnostic Procedures
1. CKD Screening Tests: Implement CKD screening, including:
- Urinalysis
- Urine albumin-to-creatinine ratio (ACR)
- Serum creatinine measurement
- GFR estimation using the CKD-EPI equation
2. Blood Tests: Conduct additional blood tests to evaluate for underlying conditions and complications:
- Complete blood count (CBC)
- Basic metabolic panel
- Serum albumin levels
- Lipid profile
3. Bone Status Assessment: Evaluate bone health through:
- Serum calcium and phosphate levels
- 25-hydroxyvitamin D levels
- Alkaline phosphatase levels
- Intact parathyroid hormone (PTH) levels
4. Imaging Studies: Prepare patients for imaging as ordered to visualize kidneys and surrounding structures:
- Renal ultrasonography
- Retrograde pyelography
- Computed tomography (CT) scan
- Magnetic resonance imaging (MRI)
- Renal radionuclide scanning
5. Kidney Biopsy Preparation: Prepare patients for kidney biopsy if indicated, typically when diagnosis remains uncertain or to guide treatment in diagnosed conditions.
Nursing Interventions for Chronic Kidney Disease
Nursing interventions are crucial for managing CKD progression and improving patient outcomes.
Slowing CKD Progression
1. Address Underlying Conditions: Managing the root causes of CKD is paramount to slowing its progression. This includes:
- Blood pressure management
- Diabetes control (HbA1c monitoring and management)
- Weight management
- Avoiding nephrotoxic agents
- Cholesterol management
2. Blood Pressure Goals: Maintain blood pressure below 130/80 mmHg for CKD patients with hypertension. Administer ACE inhibitors or angiotensin II receptor blockers as prescribed to lower blood pressure and protect kidney function.
3. Protein Restriction: Implement dietary protein restriction as advised by a nephrologist and dietitian. This can slow proteinuria progression. Protein intake should be individualized based on CKD stage and dialysis status.
4. NSAID Avoidance Education: Educate patients about the nephrotoxic effects of NSAIDs and advise against their use.
5. Smoking Cessation Promotion: Counsel smokers on the accelerated progression of CKD to ESRD in smokers and the benefits of quitting.
6. Fluid Retention Management: Manage fluid overload with loop diuretics as prescribed to alleviate edema and hypertension.
7. Erythropoiesis Promotion: Administer erythropoietin-stimulating agents (ESAs) as prescribed to stimulate red blood cell production and manage anemia.
8. Cholesterol Management: Encourage statin use to manage hyperlipidemia and reduce cardiovascular risk in CKD patients.
9. Bone Health Improvement: Administer vitamin D and calcium supplements and phosphate binders as prescribed to prevent renal bone disease and manage electrolyte imbalances.
10. Electrolyte Balance Management: Address electrolyte imbalances (hyperphosphatemia, hypocalcemia, hyperkalemia, hyponatremia) through medications, supplements, and dietary modifications as prescribed.
Renal Replacement Therapy Initiation
1. Dialysis and Transplant Discussion: Discuss renal replacement therapy options (dialysis and transplantation) with patients progressing to ESRD or experiencing severe complications (metabolic acidosis, hyperkalemia, fluid overload, etc.).
2. Palliative and Conservative Care: For patients not pursuing renal replacement, provide information and support for palliative and conservative care focused on symptom management and quality of life.
3. Vascular Access Preparation: Prepare patients for vascular access creation (AV fistula or AV graft) if hemodialysis is planned. Provide pre- and post-operative care and education.
4. Peritoneal Dialysis Education: Educate suitable patients about peritoneal dialysis (PD) as a home-based dialysis option, including catheter care and procedure.
5. Kidney Transplant Information: Provide information about kidney transplantation, including donor options, eligibility criteria, and lifelong immunosuppression requirements.
6. Psychosocial Support: Offer emotional support and counseling to patients and families coping with a chronic illness diagnosis. Address misconceptions and provide accurate information.
7. Interdisciplinary Collaboration: Collaborate with nephrologists, dietitians, cardiologists, endocrinologists, social workers, and transplant teams to provide comprehensive care.
Nursing Care Plans and Diagnoses for Chronic Kidney Disease
Nursing care plans are essential for organizing and prioritizing nursing care based on identified nursing diagnoses. Here are examples of common nursing diagnoses and associated care plan components for CKD:
Excess Fluid Volume
Nursing Diagnosis: Excess Fluid Volume
Related Factors: Kidney dysfunction, decreased urine output, sodium retention, excessive fluid intake, compromised regulatory mechanisms.
Evidenced By: Altered mental status, adventitious breath sounds, pulmonary congestion, edema, imbalanced intake and output, jugular vein distension, oliguria.
Expected Outcomes: Patient will maintain fluid balance, evidenced by absence of edema, clear lung sounds, stable weight, and balanced intake and output.
Nursing Interventions:
- Lung Auscultation: Assess lung sounds for adventitious sounds indicating fluid overload.
- Fluid Balance Monitoring: Strictly monitor and document intake and output.
- Laboratory Value Monitoring: Monitor BUN, creatinine, GFR, and electrolytes.
- Daily Weight Monitoring: Monitor daily weight using the same scale and conditions.
- Fluid Restriction: Implement fluid restriction as prescribed.
- Diuretic Administration: Administer diuretics as prescribed.
- Edema Management: Provide care for edematous extremities, including repositioning and elevation.
- Dialysis Preparation: Prepare patient for dialysis as indicated.
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related Factors: Disease process, malabsorption, metabolic acidosis, chronic inflammation, anorexia, dialysis.
Evidenced By: Weight loss, nausea, vomiting, poor appetite, muscle wasting, altered nutritional markers.
Expected Outcomes: Patient will achieve and maintain adequate nutritional intake, evidenced by stable weight, improved appetite, and laboratory values within acceptable limits.
Nursing Interventions:
- Nutritional Assessment: Assess eating patterns, appetite, and contributing factors to malnutrition.
- Laboratory Value Review: Monitor serum albumin, vitamin D, calcium, and electrolytes.
- Hydration and Weight Monitoring: Monitor hydration status and daily weight.
- Dietary Modifications (Potassium, Sodium, Phosphorus Restriction): Educate on and encourage dietary restrictions as prescribed.
- Protein Management: Educate on appropriate protein intake based on CKD stage and dialysis status.
- Alcohol Limitation: Advise on limiting alcohol intake.
- Fat Restriction: Educate on limiting saturated and trans fats.
- Fiber Increase: Encourage increased fiber intake.
- Renal Dietitian Referral: Refer to a renal dietitian for specialized dietary counseling.
Impaired Urinary Elimination
Nursing Diagnosis: Impaired Urinary Elimination
Related Factors: Chronic kidney disease.
Evidenced By: Oliguria, dysuria, urinary retention, urinary incontinence.
Expected Outcomes: Patient will maintain optimal urinary elimination patterns, evidenced by urine output within acceptable parameters and absence of complications.
Nursing Interventions:
- Urinary Pattern Assessment: Assess and document urinary elimination patterns.
- Urine Characteristic Assessment: Assess urine characteristics (amount, color, clarity, odor).
- Diuretic Administration: Administer diuretics as prescribed.
- Cautious Fluid Administration: Administer fluids cautiously, monitoring for fluid overload.
- Patient Education: Educate patient on expected changes in urine output with CKD progression.
- Infection Prevention: Implement infection prevention measures, especially for dialysis patients.
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related Factors: Fluid imbalance, electrolyte imbalances, altered contractility, afterload, preload, and heart rate, accumulation of toxins.
Evidenced By: (Risk diagnosis – no evidence by symptoms, interventions are preventative)
Expected Outcomes: Patient will maintain adequate cardiac output, evidenced by stable vital signs, absence of dyspnea, dysrhythmias, and activity intolerance.
Nursing Interventions:
- Blood Pressure Monitoring: Regularly monitor blood pressure, including orthostatic measurements.
- Chest Pain Assessment: Assess for chest pain and associated characteristics.
- Laboratory Monitoring (Electrolytes): Monitor electrolytes, especially potassium.
- Cardiac Output Symptom Monitoring: Monitor for signs and symptoms of decreased cardiac output.
- Antihypertensive Medication Administration: Administer antihypertensive medications as prescribed.
- Fluid Status Management: Closely monitor and manage fluid status, including fluid restriction.
- Ejection Fraction Monitoring: Monitor ejection fraction as indicated.
- Dialysis Preparation: Prepare patient for dialysis if indicated.
Risk for Electrolyte Imbalance
Nursing Diagnosis: Risk for Electrolyte Imbalance
Related Factors: Renal failure, kidney dysfunction.
Evidenced By: (Risk diagnosis – no evidence by symptoms, interventions are preventative)
Expected Outcomes: Patient will maintain serum electrolyte levels within normal limits.
Nursing Interventions:
- Laboratory Data Monitoring (Electrolytes): Regularly monitor electrolyte levels.
- Vital Sign Monitoring: Monitor vital signs for indicators of electrolyte imbalance.
- Lactulose Administration: Administer lactulose as prescribed for hyperkalemia.
- Loop Diuretic Administration: Administer loop diuretics as prescribed for hyperkalemia.
- Dietary Management: Provide or restrict dietary electrolytes based on lab values.
- Patient Education (Electrolyte Imbalance Signs): Educate patient on signs and symptoms of electrolyte imbalances.
References
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