Renal Disease Nursing Diagnosis: A Comprehensive Guide for Nurses

Chronic Kidney Disease (CKD), also known as chronic renal failure (CRF), is marked by a gradual and irreversible decline in kidney function. The insidious nature of renal disease often means it progresses significantly before detection, owing to the kidneys’ remarkable ability to compensate for nephron loss. Many individuals with early CKD experience no overt symptoms, with manifestations typically emerging in the later, more advanced stages.

This article delves into the essential aspects of nursing diagnosis in renal disease, aiming to provide a robust understanding for healthcare professionals.

Stages of Chronic Kidney Disease: A Quick Overview

To effectively understand the nursing implications, it’s crucial to recognize the staging of CKD, which is determined by the Glomerular Filtration Rate (GFR):

• Stage 1: GFR ≥ 90 mL/min/1.73 m² (Normal or increased GFR)
• Stage 2: GFR 60-89 mL/min/1.73 m² (Mildly decreased GFR)
• Stage 3a: GFR 45-59 mL/min/1.73 m² (Moderately decreased GFR)
• Stage 3b: GFR 30-44 mL/min/1.73 m² (Moderately decreased GFR)
• Stage 4: GFR 15-29 mL/min/1.73 m² (Severely decreased GFR)
• Stage 5: GFR < 15 mL/min/1.73 m² (Kidney failure, End-Stage Renal Disease – ESRD)

As kidney function diminishes, the body’s ability to filter toxins is compromised, impacting various organ systems and potentially leading to irreversible damage. Stage 5 CKD, or End-Stage Renal Disease (ESRD), necessitates renal replacement therapy such as dialysis or kidney transplantation.

The Nursing Process in Renal Disease Management

The cornerstone of CKD management and treatment revolves around several key objectives: preserving existing kidney function, mitigating cardiovascular disease risks, preventing complications, and enhancing patient comfort. Nurses play a vital role in promoting health activities that can delay or prevent CKD onset and progression. Providing patients with accurate disease information and supporting their adherence to necessary lifestyle adjustments are crucial nursing responsibilities.

Comprehensive Nursing Assessment for Renal Disease

The initial step in nursing care is a thorough nursing assessment. This involves gathering comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects. We will explore both subjective and objective data pertinent to chronic kidney disease.

Gathering Subjective Data: Health History Review

1. Exploring General Symptoms: Clinical manifestations of CKD arise from the retention of metabolic waste products like creatinine, urea, phenols, electrolytes, and excess water. Symptom presentation varies based on CKD severity and may include:

• Fatigue
• Weakness
• Loss of Appetite
• Edema
• Shortness of Breath
• Changes in Urine Output

2. Identifying Risk Factors: Certain factors elevate the risk of developing CKD. Nurses should identify these risk factors during assessment:

• Advanced Age
• Specific Ethnicity (African-American, Native American, Asian American)
• Family History of Kidney Disease
• Pre-existing Kidney Structural Abnormalities

3. Detailed Medical History: CKD often develops as a consequence of underlying diseases or conditions that impair kidney function. Relevant medical history includes:

• Hypertension
• 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
• Recurrent Urinary Tract Infections
• Conditions Leading to Persistent Urine Reflux into Kidneys (Vesicoureteral Reflux)

4. Lifestyle and Environmental Factors: Specific lifestyle and environmental exposures can exacerbate kidney damage. Assessment should include:

• Exposure to Nephrotoxic Substances (mold, certain medications, arsenic, lead, etc.)
• Obesity
• Smoking

5. Medication Review: Many medications are processed and eliminated by the kidneys. It is critical to review the patient’s medication list, including over-the-counter and prescription drugs that can potentially harm the kidneys:

• Statins
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Opioids
• Antibiotics
• Antiretrovirals
• Antidiabetics and Insulin
• Antacids

Objective Data: Physical Assessment

1. Recognizing Asymptomatic Early Stages: Patients in early CKD stages (1-3) are often asymptomatic. Clinical signs of endocrine or metabolic imbalances related to fluid or electrolytes typically manifest in later stages (4-5). Early physical findings may be subtle, such as fatigue or minor edema in extremities.

2. Assessing for Metabolic Acidosis: In stages 4 and 5 CKD, severe kidney damage impairs toxin and waste product filtration, potentially leading to metabolic acidosis. Later-stage symptoms include:

• Oliguria or Anuria (reduced or absent urine output)
• Edema (generalized or peripheral)
• Muscle Cramps
• Nausea
• Loss of Appetite
• Shortness of Breath

3. Evaluating Fluid and Electrolyte Imbalances: Compromised kidney function 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: Anemia, characterized by a low red blood cell count, is a common CKD complication. Signs of anemia include:

• Fatigue
• Activity Intolerance
• Feeling Cold
• Pale Skin
• Difficulty Concentrating
• Lightheadedness or Dizziness
• Heart Palpitations

Diagnostic Procedures in Renal Disease

1. CKD Screening Tests: Initial CKD screening involves tests to assess kidney function:

• Urinalysis
• Urine Albumin-Creatinine Ratio (ACR)
• Serum Creatinine
• Estimated GFR (eGFR) using CKD-EPI equation

2. Blood Tests: Further serum blood tests provide insights into underlying conditions and CKD complications:

• Complete Blood Count (CBC)
• Basic Metabolic Panel (BMP)
• Serum Albumin Levels
• Lipid Profile

3. Bone Health Assessment: To assess for renal bone disease, the following tests are used:

• Serum Calcium and Phosphate
• 25-hydroxyvitamin D
• Alkaline Phosphatase
• Intact Parathyroid Hormone (PTH) Levels

4. Imaging Scans: Imaging techniques allow visualization of the 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 necessary when the diagnosis remains uncertain or to guide management based on the extent of renal involvement in diagnosed conditions.

Nursing Interventions for Renal Disease

Effective nursing interventions are crucial for managing CKD and improving patient outcomes.

Strategies to Delay CKD Progression

1. Address Underlying Conditions: While existing kidney damage is irreversible, managing the underlying causes is key to slowing progression and reducing complications. This includes:

• Blood Pressure Management
• Diabetes Control (HbA1c monitoring and management)
• Weight Management
• Avoiding Nephrotoxic Substances
• Managing Hyperlipidemia

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

3. Protein Restriction: Dietary protein restriction can slow proteinuria progression. The type and amount of protein need to be individualized, often in consultation with a nephrologist and dietitian.

4. NSAID Education: NSAIDs are nephrotoxic and should be avoided by CKD patients. Patient education on this is crucial.

5. Smoking Cessation: Smoking accelerates CKD progression to ESRD. Smoking cessation is strongly recommended.

6. Managing Fluid Retention: Fluid retention in CKD can lead to hypertension and edema. Loop diuretics can be used to promote diuresis.

7. Erythropoietin-Stimulating Agents (ESAs): ESAs promote red blood cell production, mitigating anemia-related symptoms.

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

9. Bone Health Support: Vitamin D and calcium supplements, along with phosphate binders, are used to prevent bone disease and vascular calcification.

10. Electrolyte Balance Management: Medications, supplements, and dietary modifications are used to manage electrolyte imbalances like hyperphosphatemia, hypocalcemia, hyperkalemia, and hyponatremia.

Renal Replacement Therapy (RRT) Initiation

1. Dialysis and Transplantation Discussion: For patients with severe CKD complications, RRT becomes necessary. Nurses should initiate discussions about dialysis and kidney transplantation options.

2. Palliative and Conservative Care: For patients who decline RRT, information about palliative and conservative care focused on symptom management and quality of life is essential.

3. Vascular Access Preparation: For planned hemodialysis, surgical creation of vascular access is needed. Options include:

• Arteriovenous (AV) Graft
• AV Fistula (preferred option)

4. Peritoneal Dialysis Education: Peritoneal dialysis (PD) is another dialysis modality that may be suitable for some patients, offering home-based therapy.

5. Kidney Transplant Considerations: Kidney transplantation, from living or deceased donors, requires lifelong immunosuppression. Patient eligibility requires meeting specific health criteria.

6. Psychosocial Support: A CKD diagnosis can be emotionally challenging. Nurses should provide emotional support, answer questions, and address misconceptions.

7. Interdisciplinary Collaboration: CKD management requires a team approach involving nephrologists, dietitians, cardiologists, endocrinologists, social workers, and transplant teams.

Renal Disease Nursing Care Plans: Addressing Key Diagnoses

Nursing care plans are vital for prioritizing assessments and interventions based on identified nursing diagnoses. Here are examples of care plans for common nursing diagnoses in CKD.

Nursing Care Plan: Excess Fluid Volume

Nursing Diagnosis: Excess Fluid Volume

Related Factors: Kidney dysfunction, decreased urine output, sodium retention, inappropriate fluid intake, compromised regulatory mechanisms.

Evidenced By: Altered mental status, adventitious breath sounds, pulmonary congestion, edema, imbalanced intake and output, jugular vein distension, oliguria.

Expected Outcomes:

• Patient will be free from edema and maintain clear lung sounds without dyspnea.
• Patient will maintain balanced fluid intake and output.

Assessments:

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

Interventions:

1. Daily Weight Monitoring: 1 kg weight gain ≈ 1 liter fluid retention. Use same scale, time, and clothing for accuracy.
2. Fluid Restriction: Restrict oral, IV, and enteral fluids as indicated to prevent overload.
3. Diuretics: Administer diuretics as prescribed to increase urinary fluid elimination.
4. Edema Care: Reposition patient q2h to prevent pressure ulcers; elevate edematous extremities to improve circulation and reduce swelling.
5. Dialysis Preparation: Prepare patient for dialysis if indicated (stage 5 CKD).

Alt text: Lower extremity edema in a patient with renal disease, highlighting fluid retention.

Nursing Care Plan: Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related Factors: Disease process, malabsorption, metabolic acidosis, chronic inflammation, food aversion, dialysis.

Evidenced By: Constipation, diarrhea, weight loss, nausea, vomiting, altered nutritional markers, poor appetite, low energy, muscle wasting.

Expected Outcomes:

• Patient will report adequate appetite.
• Patient will demonstrate electrolytes and protein levels within acceptable limits.

Assessments:

1. Eating Patterns and Contributing Factors: Understand eating habits, appetite, and factors causing nutritional imbalance (uremic effects, acidosis, malabsorption, dialysis-related protein loss, inflammation).
2. Laboratory Results: Assess serum albumin (protein status), vitamin D, calcium, and electrolytes.
3. Hydration Status and Daily Weight: Monitor for fluid sensitivity and edema. Sudden weight gain indicates fluid retention.

Interventions:

1. Dietary Restrictions (Potassium, Sodium, Phosphorus): Limit foods high in these electrolytes to manage hypertension, protect heart, and prevent bone weakening.
2. Protein Intake Management: Low-protein diet often indicated. Non-dialysis patients: 0.6-0.8g/kg/day; Dialysis patients: 1-1.2g/kg/day.
3. Limit Alcohol Intake: Alcohol adds strain to kidney function and accelerates CKD progression.
4. Limit Saturated and Trans Fats: Reduce unhealthy fat intake to protect blood vessels, heart, and kidneys. Encourage healthier fats (monounsaturated, polyunsaturated).
5. Increase Fiber Intake: Promote fiber intake (20-38g/day) to prevent constipation.
6. Renal Dietitian Referral: Consult a renal dietitian for specialized dietary guidance.

Alt text: A renal dietitian providing dietary guidance to a patient, emphasizing nutritional management in renal disease.

Nursing Care Plan: Impaired Urinary Elimination

Nursing Diagnosis: Impaired Urinary Elimination

Related Factors: Chronic kidney disease.

Evidenced By: Oliguria, dysuria, urinary retention, urinary incontinence.

Expected Outcomes:

• Patient will produce at least 400 mL urine per 24 hours.
• Patient will not experience complications from oliguria.

Assessments:

1. Urinary Elimination Patterns: Assess normal patterns to tailor interventions for healthy elimination.
2. Urine Characteristics: Assess urine amount, color, clarity, odor for infection or other complications.

Interventions:

1. Diuretics: Administer diuretics as prescribed to promote urinary elimination and prevent fluid overload.
2. Cautious Fluid Administration: Fluid therapy needs careful monitoring to avoid worsening fluid retention and electrolyte imbalances.
3. Patient Education on Expectations: Educate patient on fluctuating urine production in CKD, with eventual decline in later stages.
4. Infection Prevention: Monitor for infection in dialysis patients with catheters/fistulas (fever, abdominal pain).

Nursing Care Plan: Risk for Decreased Cardiac Output

Nursing Diagnosis: Risk for Decreased Cardiac Output

Related Factors: Altered contractility, afterload, heart rate, preload, rhythm, stroke volume, fluid imbalance, toxin accumulation, soft-tissue calcification.

Evidenced By: Risk diagnosis – no signs/symptoms yet. Interventions are preventative.

Expected Outcomes:

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

Assessments:

1. Blood Pressure Monitoring: Assess for hypertension (RAAS alterations) and orthostatic hypotension (intravascular deficits).
2. Chest Pain Assessment: Evaluate chest pain (location, severity) for cardiovascular complications (vasospasm, pulmonary edema, pericarditis).
3. Laboratory Studies: Monitor electrolytes, especially potassium, as hyperkalemia increases dysrhythmia risk.
4. Signs/Symptoms of Decreased Cardiac Output: Assess for fatigue, dyspnea, orthopnea, edema, decreased peripheral pulses for early intervention.

Interventions:

1. Medication Administration: Administer antihypertensives (ACEIs/ARBs) to manage BP, protect kidneys, and reduce cardiac output risks.
2. Fluid Management: Strict fluid management and diuretics as needed to prevent complications.
3. Ejection Fraction Monitoring: Monitor ejection fraction as indicator of cardiac function and heart failure risk.
4. Dialysis Preparation: Prepare for dialysis in ESRD to remove toxins, correct imbalances, control fluids, and prevent cardiac complications.

Nursing Care Plan: Risk for Electrolyte Imbalance

Nursing Diagnosis: Risk for Electrolyte Imbalance

Related Factors: Renal failure, kidney dysfunction.

Evidenced By: Risk diagnosis – no signs/symptoms yet. Interventions are preventative.

Expected Outcomes:

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

Assessments:

1. Laboratory Data: Monitor electrolyte panels for CRF progression.
2. Vital Signs Monitoring: Electrolyte imbalances can cause dysrhythmias and respiratory failure, reflected in vital signs and ECG.

Interventions:

1. Lactulose Administration: Lactulose promotes fecal excretion of potassium and other waste products to manage hyperkalemia.
2. Loop Diuretics: Administer loop diuretics (potassium-wasting) to lower potassium levels.
3. Dietary Management: Adjust diet based on electrolyte levels – restrict intake if high, supplement if deficient.
4. Patient Education on Hyperkalemia/Hyponatremia: Educate on signs of electrolyte imbalances (muscle weakness, cramps, nausea, disorientation).

References

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