Chronic Kidney Disease (CKD), also known as chronic renal failure (CRF), signifies a gradual and irreversible decline in kidney function. The insidious nature of kidney disease stems from the kidneys’ remarkable adaptability, often masking significant nephron loss until considerable damage has occurred. Early stages of CKD frequently present asymptomatically, with noticeable symptoms typically emerging in later, more advanced stages.
In this article, we will delve into the essential aspects of nursing care for patients with kidney failure, focusing on nursing diagnoses, assessments, interventions, and care plans.
Understanding the Stages of Chronic Kidney Disease
The classification of CKD severity relies on the Glomerular Filtration Rate (GFR), a key indicator of kidney function:
- Stage 1: GFR within normal range or elevated (≥ 90 mL/min/1.73m²)
- Stage 2: Mild reduction in GFR (60-89 mL/min/1.73m²)
- Stage 3a: Moderate decrease in GFR (45-59 mL/min/1.73m²)
- Stage 3b: Moderate decrease in GFR (30-44 mL/min/1.73m²)
- Stage 4: Severe reduction in GFR (15-29 mL/min/1.73m²)
- Stage 5: Kidney Failure (GFR < 15 mL/min/1.73m²) requiring dialysis
As kidney function deteriorates, the kidneys’ ability to effectively filter toxins diminishes, impacting various organ systems and potentially causing irreversible damage. The culmination of CKD is End-Stage Renal Disease (ESRD), necessitating dialysis or kidney transplantation for survival.
The Nursing Process in Chronic Kidney Disease Management
The cornerstone of CKD management and treatment lies in preserving remaining kidney function, mitigating cardiovascular disease risks, preventing complications, and enhancing patient comfort. Nurses play a pivotal role in promoting health-enhancing behaviors to slow down or prevent CKD onset. Providing patients with accurate disease information and empowering them to adhere to necessary lifestyle adjustments are crucial nursing responsibilities.
Comprehensive Nursing Assessment for Kidney Failure
The initial phase of nursing care involves a thorough nursing assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. This section will outline both subjective and objective data pertinent to chronic kidney disease.
Health History Review
1. Inquiry into General Symptoms: Clinical manifestations in CKD arise from the retention of metabolic byproducts such as creatinine, urea, phenols, electrolytes, and water. Symptom presentation varies depending on disease severity and may include:
- Fatigue and generalized weakness
- Appetite loss
- Edema (swelling)
- Dyspnea (shortness of breath)
- Alterations in urinary patterns
2. Identification of Risk Factors: Certain factors elevate the likelihood of developing CKD:
- Advanced age
- Specific ethnicities (African-American, Native American, Asian American)
- Family history of kidney disorders
- Congenital kidney structural abnormalities
3. Medical History Documentation: CKD often arises as a consequence of underlying diseases or conditions that compromise kidney function. Conditions predisposing to CKD include:
- Hypertension (high blood pressure)
- Diabetes Mellitus
- Cardiovascular disease
- Pre-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 kidneys)
4. Lifestyle and Environmental Assessment: Certain lifestyle and environmental exposures can exacerbate kidney damage:
- Exposure to nephrotoxic agents (e.g., mold, certain medications, arsenic, lead)
- Obesity
- Smoking
5. Medication Review: Many medications undergo metabolism and excretion via the kidneys. Certain over-the-counter and prescription drugs can potentially harm the kidneys:
- Statins
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and opioids (pain relievers)
- Antibiotics
- Antiretroviral medications
- Antidiabetic agents and insulin
- Antacids
Physical Examination
1. Asymptomatic Presentation in Early Stages: Patients in CKD stages 1-3 frequently exhibit no overt symptoms. Clinical manifestations related to endocrine or metabolic disturbances in fluid and electrolyte balance typically become apparent in stages 4-5. Early signs may include fatigue and peripheral edema in hands and feet.
2. Assessment for Metabolic Acidosis: Advanced CKD (stages 4 and 5) indicates severe kidney damage, impairing toxin and waste product filtration, potentially leading to metabolic acidosis. Late-stage CKD symptoms can include:
- Oliguria or anuria (reduced or absent urine output)
- Generalized edema
- Muscle cramps
- Nausea and vomiting
- Anorexia (loss of appetite)
- Shortness of breath
3. Evaluation of Fluid and Electrolyte Imbalances: Kidney dysfunction disrupts electrolyte and fluid balance, leading to complications such as:
- Hypertension
- Peripheral edema
- Pulmonary edema
- Hyperkalemia (elevated potassium)
- Hyperphosphatemia (elevated phosphate)
4. Monitoring for Anemia Signs: Anemia, characterized by low red blood cell count, is a common CKD complication. Anemia manifestations include:
- Fatigue
- Activity intolerance
- Cold intolerance
- Pallor (pale skin)
- Cognitive difficulties (impaired concentration)
- Lightheadedness or dizziness
- Palpitations
Diagnostic Procedures
1. CKD Screening: Screening procedures to evaluate kidney function include:
- Urinalysis
- Urine Albumin-to-Creatinine Ratio (ACR)
- Serum creatinine measurement
- Estimation of GFR using the CKD-EPI equation
2. Blood Tests: Additional serum tests to assess for underlying conditions or complications:
- Complete Blood Count (CBC)
- Basic Metabolic Panel (BMP)
- Serum albumin levels
- Lipid profile
3. Bone Status Assessment: Tests to diagnose renal bone disease:
- Serum calcium and phosphate levels
- 25-hydroxyvitamin D level
- Alkaline phosphatase level
- Intact Parathyroid Hormone (PTH) levels
4. Imaging Studies: Imaging techniques to 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 may be indicated when the diagnosis remains uncertain after initial workup or to guide management based on the severity of renal involvement in diagnosed conditions.
Image alt text: Anatomical illustration of the renal system, highlighting kidneys, ureters, bladder, and urethra, essential organs for filtering waste and maintaining fluid balance in the body.
Nursing Interventions for Chronic Kidney Disease
Nursing interventions are crucial in managing CKD and improving patient outcomes. The following section outlines key nursing interventions for patients with chronic kidney disease.
Slowing Kidney Disease Progression
1. Management of Underlying Conditions: While existing kidney damage is irreversible, managing the underlying causes is crucial for slowing disease progression and preventing complications. This includes:
- Blood pressure control
- Diabetes management (HbA1c monitoring and control)
- Weight management
- Avoidance of nephrotoxic substances
- Management of hyperlipidemia
2. Blood Pressure Goals: CKD patients with hypertension should aim to maintain blood pressure below 130/80 mmHg. Medications such as ACE inhibitors or angiotensin II receptor blockers may be prescribed to lower blood pressure and protect kidney function.
3. Protein Restriction: Dietary protein restriction can help slow the progression of proteinuria (protein in urine). The type and quantity of protein intake need individual determination, often in consultation with a nephrologist and dietitian.
4. NSAID Avoidance: NSAIDs are nephrotoxic and should be avoided in CKD patients. Patient education on alternative pain management strategies is essential.
5. Smoking Cessation: Smoking accelerates CKD progression to ESRD. Smoking cessation significantly reduces the risk of kidney failure.
6. Fluid Retention Management: Fluid retention is a common CKD complication, contributing to hypertension and edema. Loop diuretics can be used to promote diuresis and manage fluid overload.
7. Erythropoiesis Stimulation: Erythropoietin-stimulating agents (ESAs) can promote red blood cell production, mitigating anemia-related symptoms.
8. Cholesterol Management: Maintaining healthy cholesterol levels is crucial. Statins may be prescribed to lower cholesterol and reduce cardiovascular risk in CKD patients.
9. Bone Health Maintenance: Vitamin D and calcium supplementation can reduce fracture risk and prevent bone weakening. Phosphate binders may be administered to lower blood phosphate levels and protect blood vessels from calcification.
10. Electrolyte Imbalance Correction: CKD patients are prone to electrolyte imbalances (hyperphosphatemia, hypocalcemia, hyperkalemia, hyponatremia). Management may involve medications, supplements, and dietary adjustments.
Renal Replacement Therapy Initiation
1. Dialysis and Transplantation Discussion: Renal replacement therapy becomes necessary for CKD patients experiencing severe complications like metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable fluid overload, and malnutrition.
2. Options Counseling: Patients who decline renal replacement therapy should receive information about palliative and conservative care options focused on symptom management, comfort, and quality of life.
3. Vascular Access Preparation (Hemodialysis): For patients opting for hemodialysis, surgical creation of vascular access is required.
- Arteriovenous (AV) Graft: Surgically implanted tube connecting artery and vein in the arm. Can be used within days to weeks.
- AV Fistula: Preferred access type with good patency and low infection rates. Requires months to mature before use.
4. Peritoneal Dialysis Education: Peritoneal dialysis (PD) may be suitable for some patients, depending on kidney function, overall health, and ability to perform home dialysis. PD involves catheter insertion into the abdomen, using the peritoneum as a natural filter.
5. Kidney Transplant Considerations: Kidney transplantation from living or deceased donors is an option. Lifelong immunosuppression is necessary to prevent organ rejection. Eligibility requires meeting specific criteria, including overall good health and abstinence from substance use.
6. Psychosocial Support: Receiving a CKD diagnosis can be emotionally challenging. Nurses should provide time for adjustment and acceptance, address patient inquiries, and clarify misconceptions.
7. Interdisciplinary Collaboration: Nephrologists lead CKD management. Nurses collaborate with dietitians for renal diet planning, and other specialists like cardiologists, endocrinologists, social workers, and transplant teams as needed.
Nursing Care Plans for Kidney Failure
Once nursing diagnoses are identified for chronic kidney disease, nursing care plans guide the prioritization of assessments and interventions for both short-term and long-term care goals. The following are examples of nursing care plans for common nursing diagnoses in chronic kidney disease.
Excess Fluid Volume Nursing Care Plan
Excess fluid volume is a frequent issue in CRF due to impaired kidney function in removing excess fluids and waste. Fluid overload can lead to complications like edema, hypertension, and cardiac strain.
Nursing Diagnosis: Excess Fluid Volume
Related Factors:
- Kidney dysfunction
- Decreased urine production (oliguria)
- Sodium and water retention
- Excessive fluid intake
- Compromised regulatory mechanisms
Evidenced by:
- Altered mental status
- Adventitious breath sounds (rales/crackles)
- Pulmonary congestion
- Altered pulmonary artery pressure
- Altered urine specific gravity
- Edema (peripheral, pulmonary)
- Imbalanced fluid intake and output
- Jugular vein distension (JVD)
- Oliguria
Expected Outcomes:
- Patient will maintain fluid balance, evidenced by absence of edema and clear breath sounds without dyspnea.
- Patient will demonstrate balanced fluid intake and output.
Nursing Assessments:
- Auscultate lung sounds: Adventitious sounds (rales, crackles) and dyspnea indicate fluid overload and pulmonary congestion.
- Monitor intake and output (I&O): Accurate I&O monitoring is crucial for detecting fluid imbalances. Impaired kidneys produce less urine.
- Review laboratory values: BUN, creatinine, GFR, and electrolytes provide insights into renal function and fluid balance.
Nursing Interventions:
- Daily weight monitoring: Weight gain (1 kg ≈ 1 liter fluid) indicates fluid retention. Consistent weighing protocols are essential.
- Fluid restriction: Limit fluid intake (oral, IV, enteral) as prescribed to prevent and manage fluid overload.
- Medication administration: Administer diuretics as ordered to promote fluid excretion and reduce fluid retention.
- Edema care: Reposition patient regularly, elevate edematous extremities to promote venous return and reduce swelling, and prevent pressure ulcers.
- Dialysis preparation: Prepare patient for dialysis as indicated, especially in stage 5 renal failure, to remove excess fluid and waste products.
Image alt text: Nurse assessing a patient’s lower leg for edema by pressing gently on the skin above the ankle, a common sign of fluid retention in patients with kidney failure.
Imbalanced Nutrition: Less Than Body Requirements Nursing Care Plan
Malnutrition is common in CKD due to disease processes and dialysis-related factors.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related Factors:
- Disease process (uremia)
- Malabsorption
- Metabolic acidosis
- Chronic inflammation
- Food aversions
- Dialysis-related nutrient loss
Evidenced by:
- Constipation or Diarrhea
- Weight loss
- Nausea and vomiting
- Altered nutritional markers (e.g., low albumin)
- Poor appetite
- Low energy levels
- Muscle wasting
Expected Outcomes:
- Patient will report improved appetite.
- Patient will maintain electrolytes and protein levels within acceptable ranges.
Nursing Assessments:
- Nutritional assessment: Assess eating patterns, appetite, and contributing factors to malnutrition. Uremia, metabolic acidosis, malabsorption, dialysis losses, inflammation, and oxidative stress contribute to poor appetite and malnutrition.
- Review laboratory results: Serum albumin, vitamin D, calcium, and electrolytes provide insights into nutritional status and potential deficiencies.
- Hydration and weight status: Assess for fluid overload, which can mask or exacerbate nutritional deficits. Daily weight monitoring is essential.
Nursing Interventions:
- Dietary modifications: Educate patient to limit foods high in potassium, sodium, and phosphorus to manage hypertension, protect the heart, and prevent bone disease.
- Protein intake management: Provide guidance on appropriate protein intake. Low-protein diets are often indicated pre-dialysis (0.6-0.8g/kg/day), while dialysis patients require higher intake (1-1.2g/kg/day).
- Alcohol limitation: Educate on limiting alcohol intake, as it further stresses kidney function.
- Fat intake modification: Advise limiting saturated and trans fats to reduce cardiovascular risk. Encourage healthier unsaturated fats.
- Fiber increase: Promote adequate fiber intake (20-38g/day) to prevent constipation, a common CKD complaint, and support gut health.
- Renal dietitian referral: Refer patient to a renal dietitian for individualized dietary planning tailored to CKD stage, nutritional status, and treatment modalities.
Impaired Urinary Elimination Nursing Care Plan
Impaired urinary elimination is common in CRF as kidneys lose their ability to filter waste and produce urine effectively. Oliguria (urine output <400ml/day or <20ml/hr) is an early sign of impaired renal function.
Nursing Diagnosis: Impaired Urinary Elimination
Related Factors:
- Chronic kidney disease
Evidenced by:
- Oliguria
- Dysuria (painful urination)
- Urinary retention
- Urinary incontinence
Expected Outcomes:
- Patient will maintain urine output of at least 400 mL per 24 hours, if applicable to their stage of CKD.
- Patient will not experience complications of oliguria.
Nursing Assessments:
- Urinary pattern assessment: Assess normal urinary habits to identify deviations and guide interventions.
- Urine characteristics: Assess urine amount, color, clarity, and odor to detect potential complications like infection.
Nursing Interventions:
- Diuretic administration: Administer diuretics as prescribed to promote urinary elimination and manage fluid overload.
- Cautious fluid administration: Administer fluids judiciously, monitoring for fluid retention and electrolyte imbalances.
- Patient education: Educate patient that urine production may fluctuate in CKD and will likely decrease as disease progresses.
- Infection prevention: For dialysis patients, monitor for infection risks associated with catheters and fistulas. Assess for fever and abdominal pain.
Risk for Decreased Cardiac Output Nursing Care Plan
Declining kidney function leads to sodium and fluid retention, increasing extracellular volume, causing edema and hypertension. Compensatory mechanisms can then lead to decreased cardiac output to maintain kidney perfusion.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related Factors:
- Altered myocardial contractility
- Altered afterload and preload
- Altered heart rate and rhythm
- Fluid imbalance affecting circulating volume and myocardial workload
- Accumulation of uremic toxins and soft-tissue calcification
Evidenced by:
Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- Patient will maintain vital signs within acceptable limits.
- Patient will remain free from symptoms of decreased cardiac output (dyspnea, dysrhythmias, activity intolerance).
Nursing Assessments:
- Blood pressure monitoring: Assess for hypertension (common in CKD due to RAAS alterations) and orthostatic hypotension (due to intravascular deficits).
- Chest pain assessment: Assess for chest pain characteristics (location, severity, intensity) as cardiovascular complications are common (vasospasm, pulmonary edema, pericarditis).
- Laboratory studies review: Monitor electrolytes, especially potassium, as hyperkalemia can cause dysrhythmias and compromise cardiac output.
- Signs and symptoms of decreased cardiac output: Assess for fatigue, dyspnea, orthopnea, edema, and diminished peripheral pulses, enabling early intervention.
Nursing Interventions:
- Medication administration: Administer antihypertensives (ACE inhibitors, ARBs) to manage blood pressure, protect kidneys, and prevent cardiac complications.
- Fluid management: Closely monitor fluid status and restrict fluids as indicated. Diuretics may be needed to manage fluid overload.
- Ejection fraction monitoring: Monitor ejection fraction as an indicator of cardiac function, as CKD increases heart failure risk.
- Dialysis preparation: Prepare for dialysis in ESRD to remove uremic toxins, correct imbalances, manage fluid status, and prevent cardiac complications.
Risk for Electrolyte Imbalance Nursing Care Plan
CRF patients are at high risk for electrolyte imbalances due to impaired kidney function, commonly including decreased sodium and calcium, and increased potassium, magnesium, and phosphate.
Nursing Diagnosis: Risk for Electrolyte Imbalance
Related Factors:
- Renal failure
- Kidney dysfunction
Evidenced by:
Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- Patient will maintain serum potassium, sodium, calcium, magnesium, and phosphorus levels within normal ranges.
Nursing Assessments:
- Laboratory data review: Regularly monitor electrolyte panels to detect and manage imbalances indicative of CRF progression.
- Vital signs monitoring: Electrolyte imbalances can lead to complications like respiratory failure and dysrhythmias, detectable through vital signs and ECG monitoring.
Nursing Interventions:
- Lactulose administration: Administer lactulose to promote fecal excretion of potassium, ammonia, urea, and creatinine, particularly in hyperkalemia.
- Loop diuretic administration: Administer loop diuretics (potassium-wasting) to reduce potassium levels, often in combination with thiazide diuretics.
- Dietary management: Adjust nutrition based on lab results. Restrict intake of foods high in specific electrolytes when levels are elevated or supplement if deficient.
- Patient education: Educate patient on signs and symptoms of hyperkalemia (muscle weakness, cramping, slow heart rate) and hyponatremia (muscle cramps, nausea, disorientation).
References
End-Stage Renal Disease Nursing Diagnosis & Care Plan
Subjective vs. Objective Data Nursing: Key Differences
Fatigue Nursing Diagnosis & Care Plan
Edema Nursing Diagnosis & Care Plan
Shortness of Breath (Dyspnea) Nursing Diagnosis & Care Plan
Hypertension Nursing Diagnosis & Care Plan
Diabetes Nursing Diagnosis & Care Plan Guide
Kidney Stones Nursing Diagnosis & Care Plan
Cancer Nursing Diagnosis & Care Plan
Urinary Tract Infection (UTI) Nursing Diagnosis & Care Plan
Obesity Nursing Diagnosis & Care Plan
Smoking: Nicotine Dependence Nursing Diagnosis & Care Plan
Pulmonary Edema Nursing Diagnosis & Care Plan
Hypokalemia & Hyperkalemia Nursing Diagnosis & Care Plan
Nausea Nursing Diagnosis & Care Plan
Activity Intolerance Nursing Diagnosis & Care Plan
Vertigo (Dizziness) Nursing Diagnosis & Care Plan
Nursing Interventions: Comprehensive Guide
Hypocalcemia & Hypercalcemia Nursing Diagnosis Guide
Hyponatremia & Hypernatremia Nursing Diagnosis & Care Plan
Nursing Diagnosis Guide: Complete List for Nurses
Nursing Care Plans (NCP): Ultimate Guide and Database
Excess Fluid Volume Nursing Diagnosis & Care Plan
Altered Mental Status Nursing Diagnosis & Care Plan
Pressure Ulcer Nursing Diagnosis & Care Plan
Imbalanced Nutrition: More or Less Than Body Requirements
Malnutrition Nursing Diagnosis & Care Plan Guide
Metabolic Acidosis Nursing Diagnosis & Care Plan
Constipation Nursing Diagnosis & Care Plan
Diarrhea Nursing Diagnosis & Care Plan
Impaired Urinary Elimination Nursing Diagnosis & Care Plan
Urinary Retention Nursing Diagnosis & Care Plan
Risk for Infection Nursing Diagnosis & Care Plan Guide
Abdominal Pain Nursing Diagnosis & Care Plan
Decreased Cardiac Output Nursing Diagnosis & Care Plan
Hypotension Nursing Diagnosis & Care Plan
Risk for Electrolyte Imbalance Nursing Diagnosis & Care Plan
Acute Respiratory Failure Nursing Diagnosis & Care Plan
