Nursing Diagnoses for End-Stage Renal Disease (ESRD): A Comprehensive Guide

End-Stage Renal Disease (ESRD), the irreversible culmination of chronic kidney disease, signifies a critical juncture where the kidneys can no longer sustain life independently. At this stage, individuals necessitate life-sustaining treatments such as dialysis or kidney transplantation to survive. For healthcare professionals, especially nurses, a profound understanding of ESRD and its multifaceted challenges is paramount to delivering optimal patient care. This comprehensive guide delves into the essential nursing diagnoses associated with ESRD, providing a framework for effective assessment, intervention, and improved patient outcomes.

Understanding End-Stage Renal Disease (ESRD)

Chronic Kidney Disease (CKD) is not a singular event but a progressive decline in kidney function over time, often spanning years. It is categorized into five distinct stages, primarily based on the estimated Glomerular Filtration Rate (eGFR), a key indicator of kidney function. Understanding these stages is crucial for recognizing the progression towards ESRD:

Stages of Chronic Kidney Disease Leading to ESRD

• 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: Indicates mild CKD with an eGFR between 60-89 ml/min. Similar to Stage 1, symptoms are usually absent, but indicators like protein in the urine may signal kidney damage.
• Stage 3a CKD: Represents mild to moderate kidney damage with an eGFR of 45-59 ml/min. Subtle symptoms may start to emerge.
• Stage 3b CKD: Signifies moderate to severe kidney damage, with an eGFR of 30-44 ml/min. Symptoms become more noticeable and can include fatigue, edema, muscle cramps, and alterations in urination patterns.
• Stage 4 CKD: Indicates severe kidney damage, functioning as the stage immediately preceding kidney failure, with an eGFR of 15-29 ml/min.
• Stage 5 CKD (ESRD): The final stage, defined by an eGFR of less than 15 ml/min. At this point, kidney function is severely compromised or absent, necessitating renal replacement therapy.

The Critical Role of Nursing Care in ESRD

ESRD is an irreversible condition, making nursing care pivotal in managing its complexities and improving patient well-being. Nursing priorities are multifaceted, encompassing:

• Proactive Management of Complications: ESRD precipitates a cascade of complications including fluid overload, electrolyte imbalances (hyperkalemia, hyperphosphatemia, hypocalcemia), anemia, renal bone disease, and metabolic disturbances. Vigilant monitoring and timely interventions are crucial to mitigate these risks.
• Facilitating Renal Replacement Therapies: Nurses play a central role in educating patients about and preparing them for dialysis (hemodialysis, peritoneal dialysis) and kidney transplantation. This includes vascular access management, pre- and post-procedure care, and ongoing support throughout the treatment journey.
• Empowering Patient Education and Self-Management: Effective self-management is essential for ESRD patients. Nurses provide comprehensive education on medication adherence, dietary and fluid restrictions, lifestyle modifications, and recognizing signs and symptoms requiring prompt medical attention.
• Promoting Physical and Psychosocial Well-being: ESRD significantly impacts both physical and mental health. Nursing care addresses physical symptoms like fatigue, pain, and pruritus while also supporting patients’ emotional and psychological needs, coping mechanisms, and mental health.
• Enhancing Quality of Life: The ultimate goal of nursing care in ESRD is to maximize patients’ quality of life. This involves holistic care that addresses physical, emotional, social, and spiritual needs, focusing on comfort, dignity, and independence to the greatest extent possible.
• Providing Patient and Family Support: ESRD affects not only the patient but also their families. Nurses offer emotional support, education, and resources to families, helping them understand the disease, treatment options, and how to provide effective support at home.
• Fostering Interdisciplinary Collaboration: Optimal ESRD care requires a collaborative approach. Nurses work closely with nephrologists, dietitians, social workers, pharmacists, and other healthcare professionals to ensure coordinated and comprehensive patient care.

Comprehensive Nursing Assessment for ESRD

A thorough nursing assessment is the cornerstone of effective care planning. It involves gathering both subjective and objective data across physical, psychosocial, emotional, and diagnostic domains.

Review of Health History: Gathering Subjective Data

• 1. Assess General Symptoms: As ESRD advances, patients may report a range of symptoms affecting various body systems. Detailed questioning is vital to understand the patient’s experience.

  • Central Nervous System (CNS): Explore the frequency, intensity, and triggers of headaches. Assess for altered mentation, ranging from mild confusion to lethargy, noting any recent changes. Inquire about sleep patterns, including insomnia or excessive daytime sleepiness.
  • Respiratory System: Investigate dyspnea, noting its onset (sudden or gradual), triggers (exertion, rest), and alleviating factors. Assess for chest pain, differentiating between cardiac (angina) and non-cardiac causes.
  • Gastrointestinal (GI) System: Evaluate the severity and frequency of nausea and vomiting. Assess appetite changes, including loss of appetite or early satiety. Inquire about a metallic taste in the mouth, a common symptom of uremia.
  • Musculoskeletal System: Quantify fatigue levels and their impact on daily activities. Assess for muscle weakness, noting location and severity. Investigate muscle twitches and cramps, including frequency, duration, and triggers (e.g., exercise, night-time).
  • Genitourinary System: Carefully document changes in urine amount (oliguria, anuria) and characteristics (color, odor, presence of foam or blood).
  • Integumentary System: Assess for edema, noting location (feet, ankles, generalized), severity (pitting vs. non-pitting), and associated symptoms. Evaluate persistent itching (pruritus), its intensity, and relieving measures.

• 2. Identify Risk Factors: Certain factors accelerate CKD progression to ESRD. Identifying these helps tailor preventive strategies.

  • Age (60 years or older): Older age is an independent risk factor due to age-related decline in kidney function.
  • Family History of Kidney Failure: Genetic predisposition increases the risk. Obtain a detailed family history of kidney disease.
  • Race/Ethnicity: Certain racial and ethnic groups (Asian, Pacific Islander, American Indian, Black, Hispanic) have a higher incidence of ESRD, potentially due to genetic and socioeconomic factors.
  • Obesity: Obesity contributes to hypertension and diabetes, major risk factors for CKD. Assess BMI and weight history.
  • Tobacco Use: Smoking damages blood vessels, exacerbating kidney damage. Document smoking history and current status.

• 3. Record Medical History: Underlying conditions are primary drivers of kidney damage. A comprehensive medical history is essential.

  • Diabetes with Poor Glucose Control: Diabetic nephropathy is a leading cause of ESRD. Assess diabetes duration, glycemic control (HbA1c levels), and diabetes management strategies.
  • Hypertension: Hypertensive nephrosclerosis is another major cause. Document hypertension history, blood pressure control, and antihypertensive medications.
  • Glomerulonephritis: Inflammation of the kidney’s filtering units. Inquire about history of glomerulonephritis and its specific type.
  • Polycystic Kidney Disease (PKD): A genetic disorder causing cyst formation in kidneys. Assess for family history of PKD and previous diagnoses.
  • Interstitial Nephritis: Inflammation of kidney tubules and surrounding tissue. Explore potential causes like medications or infections.
  • Urinary Tract Obstruction: Conditions like kidney stones can obstruct urine flow and damage kidneys. Assess for history of kidney stones, urinary strictures, or prostate issues.
  • Vesicoureteral Reflux: Urine backflow into kidneys, common in children but can persist into adulthood. Inquire about childhood history of UTIs or reflux.
  • Pyelonephritis: Kidney infection. Document history of pyelonephritis and recurrent UTIs.
  • Congenital Kidney Defects: Structural abnormalities present at birth. Assess for known congenital kidney conditions.

• 4. Assess Factors Influencing ESRD Development: Certain conditions accelerate kidney damage in those with existing CKD.

  • Systemic Hypertension: Uncontrolled hypertension further damages kidney blood vessels. Monitor BP trends and medication adherence.
  • Hyperlipidemia: Elevated lipids contribute to vascular disease, including renal artery stenosis. Assess lipid profiles and management strategies.
  • Uncontrolled Diabetes: Poor glycemic control worsens diabetic nephropathy. Monitor HbA1c and diabetes management.

• 5. Review Medication List: Kidneys process and filter medications; some can be nephrotoxic.

  • Cholesterol Medications: Statins, while generally kidney-protective long-term, can rarely cause rhabdomyolysis, potentially harmful to kidneys.
  • Pain Medications (NSAIDs): Chronic NSAID use is a significant nephrotoxic risk. Assess NSAID use (prescription and OTC), frequency, and duration.
  • Antibiotics: Aminoglycosides and other antibiotics can be nephrotoxic, especially with prolonged use or in individuals with pre-existing kidney disease.
  • Antiretrovirals: Certain antiretroviral medications used for HIV treatment can have nephrotoxic effects.
  • Antidiabetic Medications: Metformin should be used with caution in advanced CKD due to risk of lactic acidosis.

Physical Assessment: Identifying Objective Signs of ESRD

• 1. Assess for ESRD Complications: Objective findings can confirm complications and guide interventions.

  • Volume Overload Resistant to Diuretics: Assess for persistent edema, jugular venous distention (JVD), and pulmonary edema despite diuretic therapy.
  • Poorly Controlled Hypertension: Monitor blood pressure readings for persistent elevation despite antihypertensive medications.
  • Anemia: Observe for pallor, fatigue, and shortness of breath, indicative of anemia.
  • Electrolyte Abnormalities: Although not directly observable, be alert for signs of electrolyte imbalances (e.g., muscle weakness or cardiac arrhythmias in hyperkalemia).
  • Bone Deficiencies: While not immediately visible, consider risk factors for renal bone disease (osteodystrophy) like prolonged CKD and abnormal calcium/phosphate levels.
  • Metabolic Abnormalities: Assess for signs of metabolic acidosis (Kussmaul breathing) or uremia (altered mental status).
  • Decreased Immune Response: Monitor for signs of infection, as ESRD patients are immunocompromised.

• 2. Assess for Uremic Toxicity: Uremia, the buildup of waste products, has distinct clinical manifestations.

  • Observe for altered mental status, ranging from mild confusion to coma.
  • Assess for signs of metabolic acidosis (rapid, deep breathing – Kussmaul respirations).
  • While blood vessel calcification is not directly observable in physical assessment, consider it as a long-term consequence of uremia contributing to cardiovascular risk.

• 3. Perform Physical Assessment Systematically: ESRD affects multiple organ systems, requiring a comprehensive assessment.

  • General: Assess for malnutrition, noting weight loss, muscle wasting, and overall weakness.
  • CNS: Evaluate for encephalopathy, manifested as confusion, irritability, drowsiness, asterixis (flapping tremor of the hands).
  • Cardiovascular: Auscultate for pericarditis, indicated by a pericardial friction rub, and assess for signs of heart failure (edema, dyspnea, abnormal heart sounds).
  • Gastrointestinal: Assess for vomiting, diarrhea, and signs of GI bleeding (hematemesis, melena).
  • Genitourinary: Inquire about erectile dysfunction in men and amenorrhea or infertility in women. Monitor urine output for oliguria or anuria.
  • Musculoskeletal: Evaluate for peripheral neuropathy (numbness, tingling, pain, especially in feet and hands), muscle cramps, and muscle weakness.
  • Integumentary: Inspect skin for dryness, pruritus, ecchymosis (bruising), edema, and uremic frost (urea crystals on the skin, rare but significant).
  • Hematological: While platelet dysfunction and anemia are lab findings, observe for signs of bleeding (easy bruising, petechiae) and anemia (pallor, fatigue).

• 4. Strictly Monitor Fluid Intake and Output: Fluid balance is critical in ESRD.

  • Accurately measure and record all fluid intake (oral, IV, enteral).
  • Precisely measure and record urine output, noting volume, color, and any abnormalities.
  • Be vigilant for discrepancies between intake and output, indicating fluid retention.

Diagnostic Procedures for ESRD

• 1. Determine eGFR: The eGFR is the definitive diagnostic test for ESRD.

  • Review recent eGFR results, confirming a value below 15 ml/min to diagnose ESRD (Stage 5 CKD).

• 2. Send Samples for Blood Testing: Blood tests provide crucial information about ESRD complications.

  • Complete Blood Count (CBC): Evaluate for anemia (low hemoglobin, hematocrit, red blood cell count), common in ESRD due to reduced erythropoietin production.
  • Basic Metabolic Panel (BMP):
    • Serum Creatinine and Blood Urea Nitrogen (BUN): Elevated levels indicate impaired kidney filtration.
    • Potassium Levels (Hyperkalemia): Assess for elevated potassium, a life-threatening electrolyte imbalance in ESRD.
    • Bicarbonate Levels: Monitor for low bicarbonate levels, indicating metabolic acidosis.
    • Serum Albumin Levels: Evaluate for low albumin, reflecting malnutrition and protein loss.
    • Serum Phosphate: Assess for elevated phosphate (hyperphosphatemia), contributing to renal bone disease.
    • Vitamin D: Check vitamin D levels, often deficient in ESRD, impacting bone health.
    • Lipid Profile: Assess cholesterol and triglycerides, as dyslipidemia is common in ESRD and increases cardiovascular risk.

• 3. Examine Urine Samples: Urinalysis provides insights into kidney function and damage.

  • Urine Protein/Creatinine Ratio: Measure albumin in urine (albuminuria), indicating kidney damage. Severe renal impairment is indicated by a ratio greater than 300 mg/g.
  • 24-Hour Urine Protein: Quantify total protein excretion over 24 hours. Proteinuria greater than 3.5 g is considered nephrotic range, indicating significant glomerular damage.

• 4. Prepare for Imaging Scans: Imaging visualizes kidney structure and identifies potential causes or complications.

  • Kidney Ultrasound: Detect hydronephrosis (kidney swelling due to urine backup) and structural abnormalities like cysts or tumors.
  • Retrograde Pyelogram: Diagnose urinary tract obstruction or kidney stones, using contrast dye injected into the ureters.
  • Computed Tomography (CT) Scan: Visualize kidney masses, cysts, stones, and assess kidney size and structure in detail.
  • Magnetic Resonance Angiography (MRA): Diagnose renal artery stenosis (narrowing), a cause of secondary hypertension and kidney damage.

• 5. Consider Kidney Biopsy: Biopsy provides a tissue sample for microscopic examination when diagnosis remains unclear.

  • Consider kidney biopsy when renal impairment and/or nephrotic-range proteinuria are present, but the underlying cause is not identified after standard workup.

Essential Nursing Interventions for ESRD Management

Nursing interventions are crucial for managing ESRD, slowing disease progression, and improving patient outcomes.

Strategies to Delay Progression of Kidney Disease

• 1. Manage Blood Pressure: Aggressive blood pressure control is paramount.

  • Aim for a blood pressure target of 130/80 mmHg or less.
  • For non-dialysis patients, a stricter target of less than 120 mmHg systolic may be advised.
  • Administer antihypertensive medications as prescribed (ACE inhibitors, ARBs, beta-blockers, calcium channel blockers, diuretics).
  • Educate patients on lifestyle modifications to lower blood pressure (low-sodium diet, weight management, exercise).

• 2. Control Blood Glucose Level: Strict glycemic control is vital for patients with diabetes.

  • Advise patients to maintain a hemoglobin A1c (HbA1c) level under 7% to prevent or delay diabetic nephropathy progression.
  • For type 2 diabetes, discuss the potential benefits of Sodium-Glucose Transporter 2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, empagliflozin), which have shown to slow eGFR decline.
  • Educate on diabetes management, including diet, exercise, medication adherence, and blood glucose monitoring.

• 3. Correct Metabolic Acidosis: Metabolic acidosis exacerbates ESRD progression.

  • Administer bicarbonate supplementation (sodium bicarbonate tablets) as prescribed to treat chronic metabolic acidosis.
  • Monitor serum bicarbonate levels and adjust dosage accordingly.

• 4. Manage Dyslipidemia: Dyslipidemia contributes to cardiovascular disease in ESRD.

  • Monitor lipid panels (total cholesterol, LDL, HDL, triglycerides) early in CKD.
  • Initiate cholesterol-lowering medications, such as HMG-CoA reductase inhibitors (statins), for adults over 50 with an eGFR less than 60 mL/min/1.73 m2.
  • For patients on dialysis, statin therapy may be discontinued as benefits are less clear in this population.

• 5. Control Fluid Volume: Fluid overload is a common and serious complication.

  • Use loop diuretics (furosemide, bumetanide) or ultrafiltration (dialysis) to treat volume overload or pulmonary edema.
  • Monitor fluid balance closely (intake and output, daily weights).
  • Educate patients on fluid restriction and strategies to manage thirst.

• 6. Manage Complications of ESRD: Proactively address ESRD-related complications.

  • Anemia: Administer erythropoiesis-stimulating agents (ESAs) (epoetin alfa, darbepoetin alfa) when hemoglobin levels drop below 10 g/dL. Monitor hemoglobin levels and iron status.
  • Hyperphosphatemia: Give phosphate binders (calcium acetate, sevelamer carbonate, lanthanum carbonate) with meals to reduce phosphate absorption. Restrict dietary phosphate intake (dairy products, processed foods, organ meats).
  • Hypocalcemia: Administer calcium supplements and calcitriol (active vitamin D) to improve calcium absorption and address hypocalcemia.
  • Hyperparathyroidism: Manage secondary hyperparathyroidism with calcitriol, vitamin D analogs (paricalcitol, doxercalciferol), or calcimimetics (cinacalcet) to regulate parathyroid hormone levels.

• 7. Assist with Meal Planning: Renal diet adherence is crucial for managing ESRD.

  • Promote adherence to a renal diet, emphasizing avoidance of foods high in phosphorus and potassium.
  • Recommend a low salt intake (less than 2 g/day).
  • Advise on a daily protein limit, typically around 0.8 g per kg body weight (may be adjusted based on dialysis status).
  • Refer patients to a registered dietitian for individualized meal planning and nutritional counseling.

• 8. Encourage Lifestyle Modifications: Healthy lifestyle choices improve overall health and may slow ESRD progression.

  • Promote regular physical activity, tailored to patient’s functional capacity. Aerobic exercise is particularly beneficial for dialysis patients.
  • Strongly encourage smoking cessation and provide resources for quitting.
  • Advise patients to maintain an ideal body weight through diet and exercise.

• 9. Restrict Fluids: Fluid restriction is necessary due to impaired kidney function.

  • Individualize fluid restrictions based on urine output, dialysis status, and fluid balance.
  • Patients on dialysis are often restricted to approximately 32 ounces (about 1 liter) of fluid per day.
  • Educate patients on strategies to manage thirst (sugar-free candies, ice chips, frequent small sips).

Planning for Long-Term Renal Replacement Therapy

• 1. Encourage Treatment Adherence: Renal replacement therapy is life-sustaining; adherence is critical.

  • Emphasize the importance of dialysis treatments (hemodialysis or peritoneal dialysis) when kidneys can no longer function adequately.
  • Explain the commitment required for dialysis, including treatment frequency, duration, and potential lifestyle adjustments.
  • Discuss renal replacement therapy options early in ESRD management.

• 2. Educate about Prognosis and Treatment Options: Informed patients are better equipped to make decisions and cope with ESRD.

  • Initiate early patient education about kidney transplantation, various dialysis modalities (hemodialysis, peritoneal dialysis), and the natural progression of ESRD.
  • Facilitate open discussions about prognosis, treatment benefits and risks, and patient preferences.

• 3. Discuss Vascular Access Options: Vascular access is essential for hemodialysis.

  • Explain arteriovenous (AV) fistula as the preferred long-term vascular access option due to lower risk of clotting and infection. However, emphasize that fistula maturation takes months.
  • Discuss AV grafts as an alternative option, using a synthetic catheter to connect an artery to a vein, which can be used sooner (days to weeks) than a fistula.
  • Educate patients on vascular access care and potential complications (infection, bleeding, thrombosis).

• 4. Instruct on Peritoneal Dialysis: For suitable patients, peritoneal dialysis offers home-based therapy.

  • If peritoneal dialysis is chosen, provide comprehensive instruction on performing dialysis at home, including catheter care, exchange procedures, and infection prevention.
  • Educate patients to monitor for complications like peritonitis (abdominal pain, cloudy dialysate).

• 5. Prepare for Kidney Transplant: Kidney transplantation is the optimal treatment for ESRD, offering improved quality of life and survival.

  • Discuss kidney transplantation as the only treatment that replaces the function of the diseased organ.
  • Explain eligibility criteria for kidney transplantation, which may exclude patients with:
    • Older age (relative contraindication)
    • Severe heart disease
    • Active or recent cancer
    • Dementia
    • Severe obesity (BMI > 40)
    • Poor medication adherence history
    • Current drug or alcohol abuse
    • Limited or no health insurance (may affect access to transplant in some systems).
  • Initiate referral to a transplant center for evaluation if the patient is a potential candidate.

• 6. Discuss Palliative and End-of-Life Care: For patients not eligible for transplant or when dialysis becomes ineffective, palliative and hospice care are essential.

  • Introduce palliative care services for pain and symptom management in ESRD, regardless of dialysis status or transplant eligibility.
  • If transplantation is not an option and dialysis is no longer effective or desired, discuss hospice and end-of-life care options, focusing on comfort and dignity.

Common Nursing Diagnoses and Care Plans for ESRD

Nursing diagnoses provide a standardized framework for identifying patient problems and guiding care. Here are key nursing diagnoses relevant to ESRD:

1. Deficient Knowledge related to End-Stage Renal Disease

• Related to:

  • Misinformation about ESRD and its management, including inaccurate online resources or myths.
  • Inadequate access to reliable resources, such as written materials, support groups, or online education programs.
  • Inadequate commitment to learning, potentially due to fatigue, depression, or overwhelming nature of the diagnosis.
  • Inadequate information provided by healthcare providers, possibly due to time constraints or communication barriers.
  • Inadequate interest in learning, which may stem from denial, fear, or lack of perceived control.
  • Inadequate participation in care planning, leading to a passive role in managing their health.
  • Misconceptions about ESRD treatment, including dialysis and transplantation, causing anxiety or resistance.

• As evidenced by:

  • Frequent inquiries about ESRD, its progression, and treatment options, indicating information gaps.
  • Inaccurate follow-through of instructions regarding diet, medications, or fluid restrictions, suggesting misunderstanding.
  • Expressed myths or misconceptions about ESRD, dialysis, or transplantation, revealing knowledge deficits.
  • Nonparticipation in care activities, such as self-monitoring of blood pressure or weight, reflecting a lack of understanding of their importance.
  • Nonadherence to treatment regimen, including missed dialysis appointments or medication noncompliance, potentially due to knowledge deficits.
  • Development of preventable complications, such as hyperkalemia or fluid overload, indicating inadequate self-management knowledge.

• Expected Outcomes:

  • Patient will verbalize accurate understanding of ESRD, its pathophysiology, symptoms, and long-term management strategies within 1-2 teaching sessions.
  • Patient will adhere to the prescribed treatment plan, including dietary modifications, medication regimen, and dialysis schedule, as evidenced by stable lab values (potassium, phosphate, BUN, creatinine) within expected ranges at follow-up appointments.
  • Patient will not develop preventable complications related to ESRD, such as hypervolemia or electrolyte imbalances, throughout the course of their treatment.

• Assessment:

  • 1. Assess the patient’s current knowledge about ESRD: Use open-ended questions like, “Tell me what you understand about your kidney condition.” or “What has your doctor told you about end-stage renal disease?”. This helps identify knowledge gaps and tailor teaching.
  • 2. Determine the patient’s willingness and motivation to learn: Assess patient’s readiness to learn and identify any barriers, such as emotional distress, denial, or lack of perceived benefit. Use motivational interviewing techniques to enhance engagement.
  • 3. Check the patient’s health literacy: Evaluate the patient’s ability to understand health information. Use validated health literacy assessment tools or observe patient’s ability to understand medication labels, appointment instructions, and dietary guidelines. Identify preferred learning styles (visual, auditory, kinesthetic).

• Interventions:

  • 1. Instruct the patient on lifestyle modifications: Provide clear, concise, and culturally sensitive education on the importance of exercise, smoking cessation, medication adherence, and stress management in preserving kidney function and overall health. Use written materials, videos, and demonstrations to reinforce teaching.
  • 2. Allow inquiries about dialysis and kidney transplant: Create a safe and supportive environment for patients to ask questions about dialysis modalities (hemodialysis, peritoneal dialysis), transplantation process, and alternative treatment options. Provide access to reliable resources, such as patient advocacy groups and online information portals.
  • 3. Instruct on appropriate diets: Provide detailed, easy-to-understand written instructions and visual aids on kidney-friendly diets, including specific foods to limit (potassium, phosphorus, sodium, protein) and portion control guidelines. Offer sample meal plans and recipes. Refer to a registered dietitian for personalized dietary counseling.
  • 4. Have the patient verbalize symptoms of concern: Teach patients to recognize and verbalize signs and symptoms that require immediate medical attention, such as dyspnea, chest pain, confusion, significant changes in urination, unexplained weight gain, edema, and muscle cramps. Provide clear instructions on when and how to contact their healthcare provider or seek emergency care. Use teach-back method to confirm understanding.
  • 5. Educate on fistula care: For patients with AV fistulas or grafts, provide thorough education on proper vascular access care, including daily hygiene, monitoring for signs of infection (redness, warmth, pain, drainage), avoiding constriction of the access arm, and reporting any concerns promptly. Demonstrate proper technique and have patient demonstrate return. Provide written instructions and contact information for questions.

2. Excess Fluid Volume related to End-Stage Renal Disease

• Related to:

  • Sodium retention due to impaired kidney function, leading to fluid retention.
  • Imbalanced electrolytes, particularly hyponatremia, which can contribute to fluid shifts.
  • Uncontrolled hypertension, increasing hydrostatic pressure and promoting fluid extravasation.
  • Loss of kidney function, reducing the kidneys’ ability to excrete excess fluid and sodium.
  • Decreasing filtering capability of the kidney (glomerular infiltration rate), leading to reduced fluid removal.
  • Inappropriate diet, including high sodium intake, exacerbating fluid retention.
  • Nonadherence to fluid restriction, contributing to fluid overload.
  • Comorbidities like heart failure, further compromising fluid balance and increasing susceptibility to fluid overload.

• As evidenced by:

  • Peripheral edema, noting location (ankles, legs, sacrum), severity (pitting scale), and extent.
  • Pulmonary congestion, auscultated as crackles or rhonchi, indicating fluid accumulation in the lungs.
  • Altered blood pressure, including hypertension (elevated systolic and diastolic readings) or changes from baseline.
  • Altered urine specific gravity, potentially decreased due to impaired concentrating ability or increased if fluid intake is severely restricted.
  • Intake exceeds output, documented through accurate fluid balance monitoring over 24 hours.
  • Oliguria (decreased urine output), defined as less than 400 mL in 24 hours, reflecting impaired renal excretion.
  • Altered mental status, including confusion, restlessness, or lethargy, potentially due to fluid shifts and electrolyte imbalances affecting brain function.
  • Hypoalbuminemia (low serum albumin levels), reducing oncotic pressure and contributing to fluid shifts into interstitial spaces.
  • Electrolyte imbalances, particularly hyponatremia, hyperkalemia, and hyperphosphatemia, often associated with fluid volume overload.

• Expected Outcomes:

  • Patient will achieve an acceptable fluid balance, as evidenced by balanced intake and output within 24-48 hours and stable weight within 1-2 days.
  • Patient will remain free from symptoms of excess fluid volume, such as peripheral edema, pulmonary congestion (absence of crackles, normal respiratory rate and effort), and dyspnea, throughout hospitalization and ongoing care.
  • Patient will display electrolytes within an acceptable range (sodium 135-145 mEq/L, potassium 3.5-5.0 mEq/L, phosphate 2.5-4.5 mg/dL) as evidenced by lab reports within 2-3 days of intervention.

• Assessment:

  • 1. Weigh the patient daily: Use the same scale, at the same time each day (preferably in the morning after voiding), and with similar clothing. Sudden weight gain (more than 2 pounds in 24 hours or 5 pounds in a week) can indicate fluid retention.
  • 2. Monitor the patient’s intake and output: Accurately measure and document all oral, intravenous, enteral, and other fluid intake. Precisely measure and document all urine output, and any other fluid losses (e.g., emesis, diarrhea, drainage). Calculate 24-hour fluid balance.
  • 3. Check the electrolytes: Review daily electrolyte lab results, paying close attention to sodium, potassium, phosphate, calcium, and magnesium levels. Note trends and report significant abnormalities to the healthcare provider.
  • 4. Obtain urine samples for testing: Collect urine samples as ordered for urinalysis and urine protein/creatinine ratio to assess kidney function and protein loss (albuminuria), which can contribute to fluid shifts.
  • 5. Monitor for respiratory distress and changes in mentation: Assess respiratory rate, effort, and oxygen saturation. Auscultate lung sounds for crackles or wheezes. Monitor for signs of pulmonary edema (cough, dyspnea, orthopnea, frothy sputum). Evaluate mental status for confusion, restlessness, lethargy, or changes in orientation.

• Interventions:

  • 1. Administer albumin as indicated: If hypoalbuminemia is present and prescribed, administer intravenous albumin infusions as ordered to increase oncotic pressure and shift fluid back into the intravascular space. Monitor for signs of fluid overload during and after albumin administration.
  • 2. Promote diuresis: Administer loop diuretics (furosemide, bumetanide, torsemide) as prescribed to enhance fluid excretion by the kidneys. Monitor urine output, electrolytes (especially potassium), and blood pressure. Consider combination diuretic therapy (loop and thiazide) if needed for refractory fluid overload.
  • 3. Limit sodium intake: Educate patients and families about sodium restriction (typically 2 grams per day or less). Provide dietary counseling on low-sodium food choices, reading food labels, and avoiding processed foods, canned goods, and restaurant meals high in sodium.
  • 4. Elevate edematous extremities: Elevate edematous legs and feet above heart level when possible to promote venous return and reduce edema. Use pillows to support elevated extremities. Encourage range-of-motion exercises to improve circulation.
  • 5. Restrict fluids as ordered: Implement prescribed fluid restrictions diligently. Provide patient education on fluid restriction rationale, strategies for managing thirst (ice chips, sugar-free candies, frequent small sips, oral hygiene), and measuring fluid intake. Collaborate with dietitian for meal planning within fluid limits.
  • 6. Regulate the blood pressure: Administer antihypertensive medications as prescribed to control hypertension. Monitor blood pressure regularly and titrate medications as needed. Educate patients on the importance of blood pressure control in managing fluid balance and preventing further kidney damage.

3. Imbalanced Nutrition: Less Than Body Requirements related to End-Stage Renal Disease

• Related to:

  • Disease process of ESRD, leading to metabolic disturbances, uremia, and anorexia.
  • Chronic inflammation associated with ESRD, contributing to catabolism and reduced appetite.
  • Uremic toxins accumulating in the blood, causing nausea, vomiting, taste changes, and decreased appetite.
  • Metabolic acidosis, affecting nutrient utilization and contributing to muscle wasting.
  • Food aversion due to taste changes, nausea, or psychological factors related to chronic illness and dietary restrictions.

• As evidenced by:

  • Fluid and electrolyte imbalances, such as hyperkalemia, hyperphosphatemia, hypocalcemia, and hyponatremia, reflecting nutritional deficits and metabolic disturbances.
  • Constipation or diarrhea, often related to dietary changes, fluid restrictions, medication side effects, and uremia.
  • Nausea and vomiting, common symptoms of uremia, reducing oral intake and nutrient absorption.
  • Weight loss, unintentional and progressive, indicating inadequate calorie and protein intake.
  • Anorexia (loss of appetite), a frequent symptom in ESRD, reducing food consumption.
  • Lethargy and fatigue, reflecting energy deficit and malnutrition.

• Expected Outcomes:

  • Patient will report consuming the recommended daily intake of protein (0.8-1.2 g/kg body weight, adjusted for dialysis), potassium (2-3 g), sodium (2 g), and phosphorus (0.8-1 g) within 1 week, verbalizing understanding of dietary guidelines.
  • Patient will remain free from fluid and electrolyte imbalances (potassium, phosphate, sodium, calcium within normal limits) as evidenced by stable lab values at weekly monitoring and absence of related symptoms (muscle weakness, arrhythmias, edema).

• Assessment:

  • 1. Assess the patient’s nutritional status and nutrient deficits: Conduct a comprehensive nutritional assessment, including dietary history (24-hour recall, food frequency questionnaire), food preferences, cultural and religious dietary practices, socioeconomic factors affecting food access, and presence of symptoms affecting intake (nausea, taste changes). Identify specific nutrient deficits based on dietary history and lab values.
  • 2. Assess weight loss associated with end-stage renal disease: Monitor weight trends, calculating percentage of weight loss over time. Assess BMI, mid-arm circumference, and triceps skinfold thickness to evaluate body composition and muscle mass. Document any signs of muscle wasting or cachexia.
  • 3. Assess the patient’s serum albumin, red blood cell count, and electrolyte levels: Review lab results for serum albumin (indicator of protein status), red blood cell count (anemia), and electrolyte levels (potassium, phosphate, sodium, calcium). Monitor trends and report abnormalities to the healthcare provider.

• Interventions:

  • 1. Encourage strict fluid management: Reinforce the importance of fluid restriction and provide strategies to manage thirst. Educate patients about fluid sources in diet (soups, fruits, vegetables). Collaborate with dietitian to incorporate fluid restrictions into meal plans.
  • 2. Encourage adequate protein intake: Emphasize the need for adequate protein intake, especially for dialysis patients (1.2 g/kg body weight or higher). Recommend high-quality protein sources (lean meats, poultry, fish, eggs, soy products). Consider protein supplements if dietary intake is insufficient, under dietitian guidance.
  • 3. Instruct the patient to limit foods high in potassium, sodium, and phosphorus: Provide detailed lists of foods high in potassium, sodium, and phosphorus to avoid or limit. Offer alternatives and low-potassium, low-sodium, low-phosphorus recipes and meal ideas. Educate on reading food labels for sodium and phosphorus content. Refer to dietitian for personalized dietary guidance.
  • 4. Instruct on supplements as prescribed: Administer prescribed vitamin and mineral supplements (vitamin D, C, E, B complex, L-carnitine, iron, calcium) as ordered. Educate patients on the purpose and importance of each supplement and potential side effects.
  • 5. Provide nutritional counseling: Refer patients to a registered dietitian specializing in renal nutrition for individualized nutritional assessment, counseling, and meal planning. Ensure counseling addresses cultural preferences, socioeconomic factors, and patient’s specific needs and challenges.
  • 6. Encourage exercise as tolerated: Encourage regular, moderate-intensity exercise (aerobic and resistance training, as tolerated) to improve appetite, muscle strength, and overall well-being. Consult with physical therapist or healthcare provider to develop an appropriate exercise plan based on patient’s functional status and comorbidities.

4. Impaired Urinary Elimination related to End-Stage Renal Disease

• Related to:

  • Disease process of ESRD, causing progressive nephron damage and loss of kidney function.
  • Loss of nephrons, reducing the functional units responsible for urine production.
  • Decreasing filtering capability of the kidney (glomerular infiltration rate), leading to reduced urine formation.
  • Urinary tract obstruction, although less common in ESRD itself, pre-existing obstruction can contribute to kidney damage.
  • Inflamed urinary tract, such as chronic interstitial nephritis or glomerulonephritis, impairing kidney function.
  • Kidney infection (pyelonephritis), causing acute or chronic kidney damage and impaired urine production.

• As evidenced by:

  • Decreased urine output (oliguria), defined as less than 400 mL of urine output in 24 hours.
  • Painful urination (dysuria), although less common in ESRD itself, may occur with underlying UTI or related conditions.
  • Absence of urine output (anuria), indicating complete kidney failure and cessation of urine production.
  • Urinary retention, although less typical in ESRD, may occur in certain situations or with co-existing conditions.
  • Difficulty in starting urination (urinary hesitancy), may be present due to reduced bladder sensation or other factors.
  • Increased urge to urinate (urinary urgency), paradoxically, can occur despite reduced urine volume due to bladder irritation or altered bladder function.
  • Increased urination at night (nocturia), although less pronounced in late-stage ESRD, may persist from earlier stages of CKD.
  • Urinary incontinence, may develop due to bladder dysfunction or overflow incontinence related to urinary retention (less common in ESRD directly).

• Expected Outcomes:

  • Patient will manifest improved urine output within the target limit set by the healthcare provider, considering the stage of ESRD and renal function (e.g., maintaining residual urine output if present or accepting anuria with dialysis).
  • Patient will participate in dialysis treatments as prescribed (hemodialysis or peritoneal dialysis) to manage fluid and waste removal in the absence of adequate urinary elimination.

• Assessment:

  • 1. Assess the patient’s urinary elimination status: Inquire about current urine output patterns, including frequency, amount, color, odor, and presence of any unusual characteristics (e.g., foam, blood). Document any changes from baseline urinary habits.
  • 2. Observe the patient’s urine characteristics: Examine urine for color (pale yellow, amber, cloudy, bloody), odor (ammonia-like, foul), and clarity (clear, cloudy, sediment). Note any unusual findings.
  • 3. Know the patient’s eGFR: Review recent eGFR values to understand the degree of kidney function impairment. Correlate eGFR with current urinary output and symptoms.
  • 4. Obtain blood samples for creatinine and BUN: Monitor serum creatinine and BUN levels regularly as indicators of kidney function and waste product accumulation. Note trends and report significant elevations to the healthcare provider.
  • 5. Palpate the bladder: Palpate the suprapubic area to assess for bladder distention, which may indicate urinary retention, although less common in ESRD.
  • 6. Check for costovertebral angle tenderness: Assess for CVA tenderness by gently percussing the costovertebral angle (angle formed by the rib cage and vertebral column). CVA tenderness may suggest kidney infection or inflammation, although less specific to ESRD itself.

• Interventions:

  • 1. Closely monitor the patient’s intake and output: Maintain accurate and frequent monitoring of fluid intake and urine output. Document all oral, intravenous, and enteral intake. Measure and record urine output every shift or more frequently as needed. Calculate 24-hour fluid balance.
  • 2. Explain the importance of dialysis: Provide clear and concise education about the purpose and necessity of dialysis (hemodialysis or peritoneal dialysis) in ESRD to replace kidney function in removing waste products and excess fluid. Explain the dialysis procedure, schedule, and potential benefits and risks.
  • 3. Anticipate a possible kidney transplant: If the patient is a transplant candidate, provide information about kidney transplantation as the optimal treatment option for ESRD. Discuss the transplant evaluation process, waiting list, surgery, and post-transplant care. Offer hope and support while being realistic about the process.
  • 4. Refer to a dietitian: Ensure referral to a registered dietitian specializing in renal nutrition. The dietitian will provide individualized dietary counseling on fluid restriction, sodium, potassium, phosphorus, and protein management to support overall health and minimize complications related to impaired urinary elimination.

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

• Related to:

  • Disease process of ESRD, causing progressive kidney damage and reduced renal blood flow.
  • Chronic inflammation in the kidneys, impairing microcirculation and tissue oxygenation.
  • Compromised kidney function, reducing the kidneys’ ability to regulate blood pressure and fluid volume, impacting systemic perfusion.
  • Hypervolemia (fluid overload), increasing vascular pressure and potentially compromising tissue perfusion.
  • Hypertension, damaging blood vessels and impairing blood flow to organs, including kidneys.
  • Nephrotoxic medications, further damaging kidney tissue and reducing renal perfusion.
  • Uncontrolled diabetes, causing microvascular and macrovascular damage, including renal arteries and arterioles, impairing renal blood flow.

• As evidenced by:

  • Anuria (absence of urine output) or oliguria (decreased urine output), indicating severely reduced renal function and perfusion.
  • Peripheral edema, reflecting fluid overload and compromised microcirculation.
  • Itchy skin (pruritus), due to accumulation of uremic toxins and poor skin perfusion.
  • Fatigue and weakness, resulting from anemia, uremia, and reduced oxygen delivery to tissues.
  • Muscle cramps, potentially due to electrolyte imbalances and poor tissue perfusion.
  • Mental status changes, such as confusion, lethargy, or irritability, indicating uremic encephalopathy due to toxin buildup and impaired brain perfusion.
  • Decreased eGFR (estimated glomerular filtration rate) below 15 mL/min/1.73 m2, confirming severely impaired renal function and perfusion.

• Expected Outcomes:

  • Patient will be free from complications of poor renal perfusion causing other organ dysfunction, such as congestive heart failure, pulmonary edema, or encephalopathy, as evidenced by stable vital signs, absence of respiratory distress, and intact neurological function throughout care.
  • Patient will adhere to dialysis treatments (hemodialysis or peritoneal dialysis) as prescribed to support tissue perfusion by removing waste products and excess fluid, demonstrated by consistent attendance at dialysis sessions and active participation in care.

• Assessment:

  • 1. Note intake and output and urine characteristics: Monitor urine output closely, noting volume, color, and any abnormalities. Anuria or severe oliguria indicate critical impairment of renal perfusion. Compare intake and output to assess fluid balance and perfusion status.
  • 2. Assess the patient’s diagnostic studies: Review results of renal ultrasound, CT scan, or other imaging studies to evaluate kidney size, structure, and presence of any obstructions or abnormalities affecting renal perfusion.
  • 3. Assess for symptoms of worsening perfusion: Regularly assess for signs and symptoms of inadequate tissue perfusion, including:
    • Neurological: Assess mental status, level of consciousness, orientation, presence of confusion, lethargy, irritability, seizures.
    • Cardiovascular: Monitor blood pressure (hypertension or hypotension), heart rate, presence of edema, jugular venous distention, heart sounds (S3, S4), peripheral pulses, capillary refill.
    • Respiratory: Assess respiratory rate, depth, and effort, oxygen saturation, auscultate lung sounds for crackles or wheezes, signs of dyspnea or orthopnea.
    • Integumentary: Evaluate skin color, temperature, moisture, presence of pallor, cyanosis, delayed capillary refill, skin breakdown.
  • 4. Monitor lab values: Review relevant lab values that reflect renal perfusion and function, including:
    • eGFR (estimated glomerular filtration rate): Values below 15 mL/min/1.73 m2 indicate severe impairment.
    • Serum creatinine and BUN: Elevated levels reflect waste product accumulation due to poor renal perfusion.
    • Electrolytes (potassium, sodium, phosphate, calcium): Imbalances can result from impaired renal regulation and affect tissue perfusion.
    • Hemoglobin and hematocrit: Assess for anemia, which can contribute to reduced oxygen-carrying capacity and tissue hypoxia.

• Interventions:

  • 1. Prepare the patient for dialysis: For patients with ESRD and ineffective renal perfusion, prepare for initiation or continuation of dialysis (hemodialysis or peritoneal dialysis) as the primary intervention to remove waste products, excess fluid, and restore some degree of fluid and electrolyte balance, thereby improving tissue perfusion. Ensure timely vascular access placement and patient education about dialysis.
  • 2. Assist in conducting a kidney biopsy: If indicated to determine the cause of renal disease or assess the extent of kidney damage and perfusion compromise, assist with kidney biopsy procedure. Provide pre-procedure preparation, intra-procedure support, and post-procedure monitoring for bleeding or complications.
  • 3. Instruct the patient to avoid IV contrast and other nephrotoxic medications: Educate patients about the risks of nephrotoxic medications, including IV contrast dyes, NSAIDs, certain antibiotics, and other drugs that can further impair renal perfusion and function. Emphasize the importance of informing healthcare providers about their kidney disease before receiving any new medications or procedures involving contrast dye.
  • 4. Assist and prepare the patient for a kidney transplant: For eligible patients, assist in the evaluation and preparation process for kidney transplantation, the only curative treatment for ESRD that can restore renal perfusion and function. Provide education, emotional support, and coordinate referrals to transplant centers. Emphasize medication adherence and lifestyle modifications to optimize health prior to and after transplantation.

References

(Include references here if needed, mirroring the original article’s intent to cite sources, although the original article itself did not explicitly list references beyond linked articles within the text.)