End-stage renal disease (ESRD), the irreversible final stage of chronic kidney disease, necessitates life-sustaining treatments like dialysis or kidney transplantation. When kidney function ceases, dialysis becomes crucial for filtering waste and excess fluids from the blood, mimicking the kidney’s vital role. For nurses, understanding the specific needs of patients undergoing dialysis is paramount. This article delves into essential nursing diagnoses relevant to dialysis patients, providing a comprehensive guide for effective care and improved patient outcomes.
Understanding Chronic Kidney Disease and Dialysis
Chronic kidney disease (CKD) progresses through five stages, categorized by the estimated glomerular filtration rate (eGFR), which measures kidney function.
- Stage 1 CKD: eGFR ≥ 90 ml/min (Normal kidney function)
- Stage 2 CKD: eGFR 60-89 ml/min (Mild CKD)
- Stage 3a CKD: eGFR 45-59 ml/min (Mild to moderate CKD)
- Stage 3b CKD: eGFR 30-44 ml/min (Moderate to severe CKD)
- Stage 4 CKD: eGFR 15-29 ml/min (Severe CKD, pre-end-stage)
- Stage 5 CKD (ESRD): eGFR < 15 ml/min (Kidney failure)
Stage 5 CKD, or ESRD, signifies that the kidneys have lost almost all function. At this point, dialysis or kidney transplantation is essential for survival. Dialysis works by filtering waste products and excess fluid from the blood when the kidneys can no longer perform this function adequately. There are two main types of dialysis: hemodialysis and peritoneal dialysis, each with its own set of nursing considerations and potential complications.
Common Nursing Diagnoses for Patients on Dialysis
Nurses caring for patients on dialysis must be adept at identifying and managing a range of potential health issues. Several nursing diagnoses are particularly relevant in this population, reflecting the physiological and psychological challenges of ESRD and dialysis treatment.
1. Excess Fluid Volume
Nursing Diagnosis: Excess Fluid Volume related to decreased kidney function and dialysis regimen.
Related Factors:
- Decreased glomerular filtration rate
- Sodium and water retention
- Dialysis schedule and effectiveness
- Dietary indiscretions (sodium and fluid intake)
- Heart failure or other comorbidities
As Evidenced By:
- Edema (peripheral, pulmonary)
- Weight gain
- Elevated blood pressure
- Shortness of breath, orthopnea
- Jugular vein distention
- Decreased urine output (oliguria, anuria)
- Abnormal electrolyte levels (dilutional hyponatremia)
- Pulmonary congestion (rales, crackles on auscultation)
Expected Outcomes:
- Patient will maintain stable fluid balance as evidenced by absence of edema, stable weight, and blood pressure within acceptable limits.
- Patient will adhere to fluid restrictions and dialysis schedule.
- Patient will demonstrate understanding of fluid management.
Nursing Interventions:
- Daily Weight Monitoring: Accurate daily weights are crucial to detect fluid retention. Use the same scale at the same time each day.
- Intake and Output Monitoring: Strict monitoring of fluid intake and output provides valuable data on fluid balance.
- Fluid Restriction: Implement and reinforce prescribed fluid restrictions. Educate the patient and family on strategies to manage thirst and adhere to restrictions.
- Sodium Restriction: Teach the patient about sodium-restricted diets and the importance of avoiding high-sodium foods.
- Diuretics: Administer diuretics as prescribed to promote fluid excretion, especially between dialysis sessions.
- Dialysis Management: Collaborate with the dialysis team to ensure dialysis treatments are effective in removing excess fluid. Monitor post-dialysis weight and blood pressure.
- Monitor for Signs of Fluid Overload: Assess regularly for edema, respiratory distress, and changes in cardiovascular status.
2. Electrolyte Imbalance
Nursing Diagnosis: Risk for Electrolyte Imbalance related to impaired kidney function and dialysis treatment.
Related Factors:
- Decreased kidney function and inability to regulate electrolytes
- Dietary intake (potassium, phosphorus, sodium)
- Dialysis schedule and effectiveness
- Medications (e.g., phosphate binders, potassium-lowering agents)
As Evidenced By (Risk Diagnosis – Evidenced by risk factors):
- ESRD diagnosis
- Abnormal laboratory values (potassium, sodium, calcium, phosphorus)
- Dialysis treatment regimen
- Dietary non-adherence
- Medication non-adherence
Expected Outcomes:
- Patient will maintain electrolyte levels within acceptable limits.
- Patient will adhere to dietary recommendations and medication regimen to manage electrolyte balance.
- Patient will understand the importance of electrolyte management.
Nursing Interventions:
- Electrolyte Monitoring: Regularly monitor serum electrolyte levels (potassium, sodium, calcium, phosphorus, magnesium) and report abnormal values promptly.
- Dietary Management: Educate the patient on dietary restrictions of potassium and phosphorus. Provide resources and meal planning guidance.
- Medication Administration: Administer electrolyte-regulating medications as prescribed, such as phosphate binders, calcium supplements, and potassium-lowering agents. Ensure proper timing of phosphate binders with meals.
- Monitor for Signs and Symptoms of Imbalances: Assess for signs of hyperkalemia (muscle weakness, cardiac arrhythmias), hypokalemia (muscle weakness, fatigue), hyperphosphatemia (itching, bone pain), hypocalcemia (muscle cramps, tetany).
- Dialysis Adequacy: Collaborate with the dialysis team to ensure dialysis treatments are effective in managing electrolyte imbalances.
3. Risk for Infection
Nursing Diagnosis: Risk for Infection related to invasive dialysis access and compromised immune system.
Related Factors:
- Invasive dialysis access (catheter, fistula, graft)
- Frequent healthcare access (dialysis center)
- Compromised immune system due to ESRD and uremia
- Malnutrition
- Co-morbidities (e.g., diabetes)
As Evidenced By (Risk Diagnosis – Evidenced by risk factors):
- Dialysis access device (catheter, fistula, graft)
- Frequent dialysis treatments
- ESRD diagnosis and associated immune suppression
- History of infections
Expected Outcomes:
- Patient will remain free from infection at dialysis access site and systemically.
- Patient will demonstrate proper dialysis access care and hygiene.
- Patient will identify signs and symptoms of infection and report them promptly.
Nursing Interventions:
- Access Site Care: Strict adherence to aseptic technique during dialysis access care. Educate patient and family on proper access site care, including hand hygiene, dressing changes, and monitoring for signs of infection.
- Monitor Access Site: Regularly assess dialysis access site for signs of infection: redness, warmth, swelling, pain, drainage.
- Systemic Infection Monitoring: Monitor for systemic signs of infection: fever, chills, elevated white blood cell count.
- Preventative Measures: Promote good hygiene, handwashing, and vaccination (e.g., influenza, pneumococcal).
- Antibiotic Administration: Administer antibiotics as prescribed for confirmed infections.
- Education on Infection Prevention: Educate patient and family on infection prevention strategies, including avoiding exposure to illness, proper hygiene, and early reporting of signs of infection.
4. Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to dietary restrictions, uremic symptoms, and dialysis treatment.
Related Factors:
- Dietary restrictions (protein, potassium, phosphorus, sodium, fluid)
- Anorexia, nausea, vomiting due to uremia
- Metabolic acidosis
- Protein loss during dialysis
- Decreased appetite and altered taste
As Evidenced By:
- Weight loss
- Muscle wasting
- Decreased serum albumin levels
- Weakness, fatigue
- Anorexia, nausea, vomiting
- Dietary intake less than recommended daily allowance
Expected Outcomes:
- Patient will maintain adequate nutritional status as evidenced by stable weight, improved serum albumin levels, and adequate dietary intake.
- Patient will adhere to renal diet recommendations.
- Patient will report improved appetite and reduced uremic symptoms affecting nutrition.
Nursing Interventions:
- Nutritional Assessment: Comprehensive nutritional assessment including dietary history, weight, BMI, serum albumin, and pre-albumin levels.
- Renal Diet Education: Provide thorough education on renal diet, emphasizing protein management, and restrictions of potassium, phosphorus, sodium, and fluids. Work with a registered dietitian for individualized meal planning.
- Appetite Stimulation: Strategies to manage nausea and improve appetite: antiemetics as prescribed, small frequent meals, oral hygiene, and pleasant meal environment.
- Nutritional Supplements: Consider nutritional supplements as prescribed to meet protein and calorie needs, especially for patients experiencing malnutrition.
- Monitor Nutritional Status: Regularly monitor weight, serum albumin, and pre-albumin levels to assess nutritional status and adjust interventions as needed.
- Dialysis Dietitian Consultation: Refer patient to a registered dietitian specializing in renal diets for ongoing nutritional counseling and support.
5. Fatigue
Nursing Diagnosis: Fatigue related to physiological effects of ESRD and dialysis treatment.
Related Factors:
- Anemia
- Uremia and accumulation of toxins
- Electrolyte imbalances
- Fluid overload
- Dialysis procedure itself
- Psychological factors (depression, anxiety)
- Sleep disturbances
As Evidenced By:
- Verbal reports of fatigue or exhaustion
- Decreased physical endurance
- Inability to maintain usual routines
- Lethargy, drowsiness
- Increased rest periods
- Lack of motivation
Expected Outcomes:
- Patient will report reduced fatigue levels.
- Patient will participate in activities of daily living and desired activities to the extent possible.
- Patient will identify and manage factors contributing to fatigue.
Nursing Interventions:
- Fatigue Assessment: Assess fatigue levels using a standardized fatigue scale. Explore contributing factors, including anemia, sleep patterns, and psychological distress.
- Anemia Management: Administer erythropoiesis-stimulating agents (ESAs) as prescribed to manage anemia, a major contributor to fatigue in ESRD. Monitor hemoglobin levels.
- Optimize Dialysis Adequacy: Ensure dialysis treatments are adequate in removing uremic toxins, which can contribute to fatigue.
- Energy Conservation: Teach energy conservation techniques to help patients manage fatigue and prioritize activities.
- Promote Rest and Sleep: Encourage adequate rest and sleep. Address sleep disturbances through lifestyle modifications or medical interventions if needed.
- Exercise and Activity: Encourage gentle exercise and physical activity as tolerated to improve energy levels and overall well-being.
- Psychological Support: Address psychological factors like depression and anxiety that can exacerbate fatigue. Provide emotional support and referrals for counseling if needed.
Nursing Assessment for Dialysis Patients
A comprehensive nursing assessment is crucial for identifying appropriate nursing diagnoses and planning effective care for dialysis patients. This assessment should include:
1. Review of Health History:
- ESRD History: Stage of CKD, cause of kidney failure, duration of dialysis, type of dialysis (hemodialysis, peritoneal dialysis), dialysis schedule.
- Medical History: Co-morbidities (diabetes, hypertension, heart failure), past medical and surgical history.
- Medication History: Current medications, including prescription, over-the-counter, and herbal supplements. Pay attention to nephrotoxic medications and medications requiring renal dose adjustment.
- Allergies: Medications, food, latex, etc.
- Psychosocial History: Support system, coping mechanisms, emotional status, financial concerns, living situation.
2. Physical Assessment:
- Vital Signs: Blood pressure (pre- and post-dialysis), heart rate, respiratory rate, temperature, oxygen saturation.
- Fluid Status: Weight, edema (location and severity), lung sounds (rales, crackles), jugular vein distention, intake and output.
- Cardiovascular: Heart sounds, peripheral pulses, signs of heart failure.
- Respiratory: Respiratory rate and effort, breath sounds, cough.
- Gastrointestinal: Appetite, nausea, vomiting, bowel sounds, abdominal distention.
- Neurological: Mental status, level of consciousness, reflexes, peripheral neuropathy.
- Integumentary: Skin color, temperature, moisture, turgor, presence of pruritus, ecchymosis, dialysis access site assessment (for infection, bleeding, bruit and thrill in fistulas/grafts).
- Musculoskeletal: Muscle strength, muscle cramps, bone pain.
3. Diagnostic Data Review:
- Laboratory Values: eGFR, BUN, creatinine, electrolytes (sodium, potassium, calcium, phosphorus, bicarbonate), complete blood count (hemoglobin, hematocrit, platelets), serum albumin, lipid profile, parathyroid hormone (PTH).
- Dialysis Records: Dialysis flow sheets, ultrafiltration volumes, pre- and post-dialysis weights, access flow rates (for hemodialysis).
- Imaging Studies: Kidney ultrasound, echocardiogram, chest X-ray as indicated.
Nursing Interventions for Dialysis Patients
Nursing interventions for patients on dialysis are multifaceted and aimed at managing complications, optimizing dialysis therapy, and enhancing quality of life. Key interventions include:
1. Dialysis Management:
- Hemodialysis:
- Pre-dialysis assessment: vital signs, weight, access site assessment, patient condition.
- Intra-dialysis monitoring: vital signs, patient comfort, monitoring for complications (hypotension, muscle cramps, nausea, headache).
- Post-dialysis assessment: vital signs, weight, access site assessment, patient condition, medication administration.
- Access care: ensuring patency of vascular access (fistula, graft, catheter), aseptic technique during cannulation and dressing changes, monitoring for complications.
- Peritoneal Dialysis:
- Pre-dialysis assessment: vital signs, weight, catheter site assessment, patient condition.
- Monitoring during exchanges: inflow, dwell, and outflow volumes and characteristics, patient comfort, monitoring for complications (peritonitis, catheter leakage).
- Post-dialysis assessment: vital signs, weight, catheter site assessment, patient condition, medication administration.
- Catheter care: maintaining aseptic technique during catheter care, dressing changes, monitoring for signs of infection.
2. Medication Management:
- Administer medications as prescribed, including:
- Erythropoiesis-stimulating agents (ESAs) for anemia.
- Phosphate binders to control hyperphosphatemia.
- Vitamin D analogs and calcium supplements for hypocalcemia and hyperparathyroidism.
- Antihypertensives to manage blood pressure.
- Potassium-lowering agents for hyperkalemia.
- Antiemetics for nausea and vomiting.
- Analgesics for pain.
- Monitor medication effectiveness and side effects.
- Provide patient education on medications, including purpose, dosage, administration, and potential side effects.
3. Dietary and Fluid Management:
- Implement and reinforce renal diet recommendations.
- Provide education on fluid restrictions and sodium, potassium, and phosphorus limitations.
- Collaborate with a registered dietitian to develop individualized meal plans.
- Monitor dietary adherence and provide ongoing support and counseling.
4. Psychosocial Support:
- Assess patient’s emotional and psychological well-being.
- Provide emotional support and counseling to address anxiety, depression, and coping challenges related to chronic illness and dialysis treatment.
- Facilitate access to support groups and resources for patients and families.
- Promote patient autonomy and involvement in care decisions.
5. Patient Education:
- Provide comprehensive education on ESRD, dialysis treatment, medication management, diet and fluid restrictions, access care, and self-management strategies.
- Assess patient’s learning needs and tailor education to their level of understanding.
- Use various teaching methods (verbal, written, visual aids).
- Evaluate patient understanding and reinforce teaching as needed.
Conclusion
Nursing diagnoses provide a structured framework for understanding and addressing the complex healthcare needs of patients on dialysis. By focusing on key diagnoses such as Excess Fluid Volume, Electrolyte Imbalance, Risk for Infection, Imbalanced Nutrition, and Fatigue, nurses can deliver targeted and effective care. Comprehensive assessment, meticulous monitoring, and patient-centered interventions are essential to optimize outcomes and enhance the quality of life for individuals undergoing dialysis. This guide serves as a foundation for nurses to strengthen their expertise in caring for this unique and challenging patient population.
