Nursing Diagnosis for Renal: A Comprehensive Guide for Healthcare Professionals

Chronic Kidney Disease (CKD), also known as chronic renal failure (CRF), is a condition marked by the gradual and irreversible decline in kidney function. Due to the remarkable adaptability of the kidneys, significant nephron loss often occurs before kidney disease is detected. In the early stages of CKD, patients frequently exhibit no symptoms, and recognition may be delayed until the disease progresses.

Stages of Chronic Kidney Disease

CKD progression is categorized into stages based on the glomerular filtration rate (GFR):

• Stage 1: GFR at 90 mL/min/1.73 m² or higher (normal or increased kidney function)
• Stage 2: GFR between 60 and 89 mL/min/1.73 m² (mildly reduced kidney function)
• Stage 3a: GFR between 45 and 59 mL/min/1.73 m² (moderately reduced kidney function)
• Stage 3b: GFR between 30 and 44 mL/min/1.73 m² (moderately reduced kidney function)
• Stage 4: GFR between 15 and 29 mL/min/1.73 m² (severely reduced kidney function)
• Stage 5: GFR less than 15 mL/min/1.73 m² (kidney failure requiring dialysis)

As kidney function deteriorates, the kidneys become less effective at filtering toxins, impacting other organ systems and potentially causing irreversible damage. End-stage renal disease (ESRD), the final stage of CKD, necessitates dialysis or kidney transplantation.

The Nursing Process in Renal Care

The primary objectives in managing and treating CKD are to preserve remaining kidney function, minimize cardiovascular disease risks, prevent complications, and enhance patient comfort. Nurses play a vital role in promoting health activities that can delay or prevent CKD onset. Educating patients about CKD and encouraging adherence to necessary lifestyle adjustments are crucial nursing responsibilities.

Nursing Assessment for Renal Patients

The initial step in nursing care involves a comprehensive nursing assessment to collect physical, psychosocial, emotional, and diagnostic data. This section will detail subjective and objective data relevant to chronic kidney disease assessment.

Reviewing Health History for Renal Conditions

1. Investigate General Symptoms: Clinical signs of CKD arise from the retention of substances like creatinine, urea, phenols, electrolytes, and water. Symptom presentation varies based on CKD severity and may include:

• Fatigue
• Weakness
• Appetite loss
• Edema
• Dyspnea
• Changes in urination patterns

2. Identify Risk Factors for Renal Disease: Certain factors increase CKD susceptibility:

• Advanced age
• Ethnicity (African-American, Native American, Asian American)
• Family history of kidney disease
• Congenital kidney or urinary tract malformations

3. Document Medical History Relevant to Renal Function: CKD typically develops secondary to other conditions. Diseases and conditions that can lead to CKD include:

• Hypertension
• Diabetes Mellitus
• Cardiovascular disease
• Glomerulonephritis and polycystic kidney disease
• Hereditary kidney diseases
• Urinary tract obstructions (e.g., kidney stones)
• Cancer, particularly of the urinary tract
• Recurrent kidney infections (pyelonephritis)
• Recurrent urinary tract infections (UTIs)
• Vesicoureteral reflux

4. Evaluate Lifestyle and Environmental Factors: Specific lifestyle and environmental exposures can exacerbate kidney damage:

• Exposure to nephrotoxic agents (e.g., mold, certain medications, heavy metals like arsenic and lead)
• Obesity
• Smoking

5. Analyze Medication History: The kidneys metabolize and eliminate many drugs. Certain over-the-counter (OTC) and prescription medications can be nephrotoxic:

• Statins
• Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
• Antibiotics, especially aminoglycosides and vancomycin
• Antiretroviral medications
• Antidiabetic drugs and insulin
• Antacids containing aluminum or magnesium

Physical Examination in Renal Nursing

1. Recognize Asymptomatic Early Stages: Patients in CKD stages 1-3 are often asymptomatic. Metabolic or endocrine imbalances related to fluid and electrolyte regulation usually become clinically apparent in stages 4-5. Initial symptoms might be non-specific, such as fatigue and peripheral edema.

2. Detect Metabolic Acidosis: In stages 4 and 5 CKD, severely compromised kidneys fail to adequately filter waste and toxins, potentially leading to metabolic acidosis. Later-stage CKD symptoms include:

• Oliguria or anuria
• Edema
• Muscle cramps
• Nausea
• Anorexia
• Shortness of breath

3. Identify Fluid and Electrolyte Imbalances: Impaired kidney function disrupts fluid and electrolyte balance, leading to:

• Hypertension
• Peripheral edema
• Pulmonary edema
• Hyperkalemia
• Hyperphosphatemia

4. Monitor for Anemia Signs: Anemia, a common CKD complication, results from reduced erythropoietin production. Anemia manifestations include:

• Fatigue
• Activity intolerance
• Cold intolerance
• Pallor
• Cognitive difficulties
• Lightheadedness or dizziness
• Palpitations

Diagnostic Procedures for Renal Evaluation

1. Conduct CKD Screening: Kidney function assessment involves:

• Urinalysis to detect protein, blood, and other abnormalities.
• Urine albumin-creatinine ratio (ACR) to quantify proteinuria.
• Serum creatinine measurement.
• Estimated GFR calculation using the CKD-EPI equation.

2. Perform Blood Tests: Additional blood tests to evaluate underlying conditions and complications include:

• Complete blood count (CBC) to assess for anemia and infection.
• Basic metabolic panel (BMP) to evaluate electrolytes, glucose, and BUN/creatinine.
• Serum albumin levels to assess nutritional status.
• Lipid profile to evaluate cardiovascular risk.

3. Assess Bone Health: Renal bone disease diagnosis may involve:

• Serum calcium and phosphate levels.
• 25-hydroxyvitamin D level.
• Alkaline phosphatase level.
• Intact parathyroid hormone (PTH) levels.

4. Prepare for Imaging Studies: Renal and surrounding organ imaging can be performed using:

• Renal ultrasonography.
• Retrograde pyelography.
• Computed tomography (CT) scan.
• Magnetic resonance imaging (MRI).
• Renal radionuclide scanning.

5. Prepare for Kidney Biopsy (if necessary): Percutaneous kidney biopsy is indicated when the diagnosis remains unclear after initial workup or to guide management based on renal involvement severity in diagnosed conditions.

Nursing Interventions for Renal Patients

Nursing interventions and comprehensive care are critical for patient recovery and management of CKD. The following sections outline essential nursing interventions for patients with chronic kidney disease.

Slowing Renal Disease Progression

1. Manage Underlying Conditions: While existing kidney damage is irreversible, managing underlying causes is crucial for slowing CKD progression and reducing complications. Key management strategies include:

• Blood pressure control.
• Diabetes management (HbA1c target).
• Weight management.
• Avoidance of nephrotoxic substances.
• Management of hyperlipidemia.

2. Blood Pressure Management: CKD patients with hypertension should aim for blood pressure below 130/80 mmHg. Medications like ACE inhibitors or angiotensin II receptor blockers are used to lower blood pressure and protect kidney function.

3. Protein Restriction: Limiting protein intake can help slow proteinuria progression. Protein intake should be individualized, considering protein type and quantity, in consultation with a nephrologist and dietitian.

4. NSAID Avoidance Education: NSAIDs are nephrotoxic and should be avoided by CKD patients. Patient education on alternatives for pain management is essential.

5. Smoking Cessation Support: Smoking accelerates ESRD progression. Smoking cessation significantly reduces the risk of kidney failure.

6. Fluid Retention Management: Fluid retention is common in CKD, contributing to hypertension and edema. Loop diuretics can be used to promote diuresis.

7. Erythropoiesis Stimulation: Erythropoietin-stimulating agents (ESAs) promote red blood cell production, alleviating anemia symptoms.

8. Cholesterol Management: Statins are used to manage cholesterol levels and reduce cardiovascular disease risk in CKD patients.

9. Bone Health Maintenance: Vitamin D and calcium supplementation can reduce fracture risk and prevent renal bone disease. Phosphate binders help control hyperphosphatemia and prevent vascular calcification.

10. Electrolyte Balance Management: CKD patients are at risk for electrolyte imbalances, including hyperphosphatemia, hypocalcemia, hyperkalemia, and hyponatremia. Management involves medications, supplements, and dietary modifications.

Initiating Renal Replacement Therapy

1. Dialysis and Transplantation Discussion: Patients with CKD experiencing severe complications like metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable fluid overload, and malnutrition require renal replacement therapy (RRT).

2. Palliative and Conservative Care Options: For patients who decline RRT, palliative and conservative care focuses on symptom management, comfort, and quality of life.

3. Vascular Access Preparation for Hemodialysis: When hemodialysis is planned, surgical creation of vascular access is necessary:

• Arteriovenous (AV) graft: A synthetic tube connects an artery and vein, usable within weeks.
• AV fistula: Surgically joining an artery and vein, the preferred access due to patency and low infection risk, but requires months to mature.

4. Peritoneal Dialysis Education: Peritoneal dialysis (PD) may be suitable for some patients, offering home-based dialysis. A catheter is placed in the abdomen, and dialysate is infused into the peritoneal cavity to filter waste.

5. Kidney Transplant Considerations: Kidney transplantation, from living or deceased donors, offers improved survival and quality of life. Lifelong immunosuppression is required post-transplant. Patient selection involves criteria such as general health and adherence to medical recommendations.

6. Psychosocial Support: A CKD diagnosis can be emotionally challenging. Nurses provide support, education, and address patient concerns to facilitate adjustment and acceptance.

7. Interdisciplinary Collaboration: CKD management involves a multidisciplinary team including nephrologists, nurses, dietitians, cardiologists, endocrinologists, social workers, and transplant teams.

Renal Nursing Care Plans and Diagnoses

Once nursing diagnoses for chronic kidney disease are identified, nursing care plans prioritize assessments and interventions for short-term and long-term care goals. Examples of nursing care plans for chronic kidney disease are detailed below.

Excess Fluid Volume in Renal Failure

Excess fluid volume is a common issue in CRF because of the kidneys’ inability to remove excess fluids and waste. This can lead to complications such as edema, hypertension, and cardiac issues.

Nursing Diagnosis: Excess Fluid Volume

Related to:

• Kidney dysfunction
• Decreased urine production (oliguria)
• Sodium and water retention
• Excessive fluid intake
• Impaired regulatory mechanisms

As evidenced by:

• Altered mental status
• Adventitious breath sounds (crackles, wheezes)
• Pulmonary congestion
• Altered pulmonary artery pressure
• Altered urine specific gravity
• Edema (peripheral, pulmonary)
• Imbalanced intake and output
• Jugular venous distention (JVD)
• Oliguria

Expected Outcomes:

• Patient will maintain clear lung sounds and be free from edema and dyspnea.
• Patient will maintain balanced fluid intake and output.

Assessments:

1. Auscultate Lung Sounds: Adventitious lung sounds (rales/crackles) and dyspnea indicate fluid retention complications.
2. Monitor Intake and Output: Accurate I&O monitoring is crucial to detect imbalances and fluid overload. Impaired kidneys produce less urine.
3. Review Laboratory Values: BUN, creatinine, GFR, and electrolytes assess renal function and fluid balance.

Interventions:

1. Daily Weight Monitoring: 1 kg weight gain equates to approximately 1 liter of fluid retention. Consistent daily weights using the same scale and conditions are essential.
2. Fluid Restriction: Restrict oral, IV, and enteral fluid intake as prescribed to prevent and manage fluid overload.
3. Administer Diuretics: Loop diuretics are commonly prescribed to increase urinary fluid elimination and reduce fluid retention.
4. Edema Care: Manage edema in extremities by repositioning every two hours to prevent pressure ulcers and elevating extremities to improve venous return and reduce swelling.
5. Dialysis Preparation: Prepare patients with stage 5 renal failure for dialysis as indicated to remove excess fluid.

Imbalanced Nutrition: Less Than Body Requirements in Renal Disease

Malnutrition is common in CKD due to disease processes and dialysis.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related to:

• Disease process (uremia)
• Malabsorption
• Metabolic acidosis
• Chronic inflammation
• Food aversions
• Dialysis-related nutrient losses

As evidenced by:

• Constipation
• 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.

Assessments:

1. Evaluate Eating Patterns and Contributing Factors: Assess dietary habits, appetite, and factors contributing to malnutrition (uremia, acidosis, decreased nutrient absorption, dialysis losses, inflammation, oxidative stress).
2. Review Laboratory Results: Low serum albumin indicates protein malnutrition. Monitor vitamin D, calcium, and electrolytes.
3. Hydration Status and Daily Weight: Monitor for fluid overload, especially in later CKD stages. Sudden weight gain may indicate fluid retention.

Interventions:

1. Dietary Restrictions: Advise patients to limit potassium, sodium, and phosphorus intake to manage hypertension, protect the heart, and prevent bone disease.
2. Protein Management: Recommend appropriate protein intake (lower protein for pre-dialysis, higher for dialysis patients) in consultation with a dietitian.
3. Limit Alcohol Intake: Excessive alcohol further burdens kidney function.
4. Limit Saturated and Trans Fats: Reduce intake of unhealthy fats to lower cardiovascular risk. Encourage healthier fats like monounsaturated and polyunsaturated fats.
5. Increase Fiber Intake: Recommend 20-38g of fiber daily to manage constipation common in CKD.
6. Renal Dietitian Referral: Refer patients to a renal dietitian for individualized dietary plans tailored to CKD stage, nutritional status, and fluid needs.

Impaired Urinary Elimination in Chronic Renal Failure

Impaired urinary elimination is a hallmark of CRF as kidneys lose their ability to filter waste and produce urine effectively. Oliguria (urine output <400 mL/day) is an early sign of renal dysfunction.

Nursing Diagnosis: Impaired Urinary Elimination

Related to:

• Chronic kidney disease

As evidenced by:

• Oliguria
• Dysuria
• Urinary retention
• Urinary incontinence (less common but can occur)

Expected Outcomes:

• Patient will produce at least 400 mL of urine per 24 hours (if still producing urine).
• Patient will not experience complications from oliguria.

Assessments:

1. Assess Urinary Elimination Patterns: Understand baseline urinary habits to guide interventions.
2. Assess Urine Characteristics: Monitor urine amount, color, clarity, and odor for signs of infection or other issues.

Interventions:

1. Administer Diuretics: Diuretics may be used cautiously to promote urinary elimination and manage fluid overload.
2. Cautious Fluid Administration: Fluid therapy requires careful monitoring to avoid worsening fluid retention and electrolyte imbalances.
3. Patient Education on Disease Progression: Educate patients that urine production will likely decrease as CKD progresses, potentially ceasing completely.
4. Infection Prevention: Monitor for infection in dialysis patients, especially at catheter or fistula sites. Assess for fever and abdominal pain.

Risk for Decreased Cardiac Output in Renal Patients

Declining kidney function leads to sodium retention and fluid volume expansion, causing edema, pulmonary edema, and hypertension, increasing cardiac workload and potentially decreasing cardiac output.

Nursing Diagnosis: Risk for Decreased Cardiac Output

Related to:

• Altered myocardial contractility
• Increased afterload (hypertension, fluid overload)
• Altered heart rate or rhythm (electrolyte imbalances)
• Increased preload (fluid retention)
• Fluid imbalance and increased myocardial workload
• Accumulation of uremic toxins and vascular calcification

As evidenced by:

Risk diagnosis – no current signs/symptoms present.

Expected Outcomes:

• Patient will maintain vital signs within normal limits.
• Patient will remain free from symptoms of decreased cardiac output (dyspnea, dysrhythmias, activity intolerance).

Assessments:

1. Monitor Blood Pressure: Assess for hypertension and orthostatic hypotension.
2. Assess for Chest Pain: Evaluate chest pain characteristics (location, severity, intensity) as cardiovascular complications are common in CKD.
3. Review Laboratory Studies: Monitor electrolytes, especially potassium, as hyperkalemia can cause dysrhythmias.
4. Assess for Decreased Cardiac Output Symptoms: Identify early signs like fatigue, dyspnea, orthopnea, edema, and diminished peripheral pulses.

Interventions:

1. Administer Medications: Antihypertensives (ACE inhibitors, ARBs) are crucial to manage blood pressure and protect cardiac and renal function.
2. Fluid Management: Closely monitor and restrict fluids as indicated. Diuretics may be needed to manage fluid overload.
3. Monitor Ejection Fraction: Assess ejection fraction as an indicator of cardiac function and risk for heart failure.
4. Dialysis Preparation: Prepare patients for dialysis as indicated to remove uremic toxins, correct electrolyte imbalances, and manage fluid overload, thereby reducing cardiac strain.

Risk for Electrolyte Imbalance in Renal Insufficiency

Patients with CRF are at high risk for electrolyte imbalances due to impaired kidney function, commonly involving sodium, potassium, calcium, magnesium, and phosphate.

Nursing Diagnosis: Risk for Electrolyte Imbalance

Related to:

• Renal failure
• Kidney dysfunction

As evidenced by:

Risk diagnosis – no current signs/symptoms present.

Expected Outcomes:

• Patient will maintain normal serum potassium, sodium, calcium, magnesium, and phosphorus levels.

Assessments:

1. Review Laboratory Data: Monitor electrolyte panels regularly to detect imbalances.
2. Monitor Vital Signs and ECG: Electrolyte imbalances can cause dysrhythmias and respiratory compromise, reflected in vital signs and ECG changes.

Interventions:

1. Administer Lactulose: Lactulose can help lower potassium levels by promoting fecal excretion of potassium and other waste products.
2. Administer Loop Diuretics: Loop diuretics promote potassium excretion in urine.
3. Dietary Management: Adjust dietary intake of electrolytes based on lab results (restrict high-electrolyte foods or supplement deficiencies).
4. Patient Education on Hyperkalemia and Hyponatremia: Educate patients about signs and symptoms of hyperkalemia (muscle weakness, cramps, slow heart rate) and hyponatremia (muscle cramps, nausea, confusion).

References

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