Chronic Renal Failure (CRF), also known as Chronic Kidney Disease (CKD), denotes a gradual and irreversible decline in kidney function. The kidneys, known for their remarkable adaptability, often mask the early stages of kidney disease until significant nephron loss occurs. Consequently, individuals with early CKD frequently exhibit no symptoms, and the condition might go unnoticed until it reaches more advanced stages.
Stages of Chronic Kidney Disease
CKD staging is determined by the Glomerular Filtration Rate (GFR), a key indicator of kidney function:
- 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 requiring dialysis or transplant)
As kidney function worsens, their ability to filter toxins diminishes, impacting other organ systems and potentially causing irreversible damage. Stage 5 CKD culminates in End-Stage Renal Disease (ESRD), necessitating dialysis or kidney transplantation for survival.
The Nursing Process in Renal Failure Care
The primary objectives in managing CKD are to preserve existing kidney function, mitigate cardiovascular risks, prevent complications, and enhance patient comfort. Nurses play a pivotal role in promoting health and preventing CKD onset and progression. Educating patients about the disease process and encouraging adherence to necessary lifestyle adjustments are crucial nursing responsibilities in renal failure care planning.
Nursing Assessment for Renal Failure
The initial step in providing effective nursing care is a comprehensive nursing assessment. This involves gathering physical, psychosocial, emotional, and diagnostic data. Below, we explore subjective and objective data relevant to chronic kidney disease, essential for formulating a robust [Renal Failure Care Plan Nursing Diagnosis](renal failure care plan nursing diagnosis).
Review of Health History in Renal Failure
1. General Symptoms Inquiry: Clinical manifestations of CKD arise from the body’s retention of waste products like creatinine, urea, phenols, electrolytes, and excess water. Symptom severity varies with CKD stage and may include:
- Fatigue and weakness
- Loss of appetite
- Edema (swelling in legs, ankles, feet, or face)
- Shortness of breath (dyspnea)
- Changes in urination patterns (increased or decreased frequency, especially at night)
2. Risk Factor Identification: Certain factors elevate the risk of developing CKD:
- Advanced age
- Race/Ethnicity: African Americans, Native Americans, and Asian Americans are at higher risk.
- Family history of kidney disease
- Congenital kidney or urinary tract defects
3. Medical History Review: CKD often stems from underlying diseases or conditions that impair kidney function. Conditions linked to CKD include:
- Hypertension (High blood pressure)
- Diabetes (Type 1 and Type 2)
- Cardiovascular disease
- Glomerulonephritis and Polycystic Kidney Disease (existing kidney diseases)
- Inherited kidney diseases
- Prolonged urinary tract obstructions (e.g., kidney stones)
- Cancer
- Recurrent kidney infections (pyelonephritis)
- Recurrent urinary tract infections (UTIs)
- Vesicoureteral reflux (urine backflow to kidneys)
4. Lifestyle and Environmental Assessment: Specific lifestyle and environmental elements can exacerbate kidney damage:
- Exposure to nephrotoxic substances (e.g., mold, heavy metals like arsenic and lead, certain medications)
- Obesity
- Smoking
5. Medication Review: Many drugs are processed by the kidneys. Certain over-the-counter (OTC) and prescription medications can be nephrotoxic:
- Statins (certain types)
- Pain relievers (NSAIDs like ibuprofen and naproxen, and opioids)
- Antibiotics (aminoglycosides, vancomycin)
- Antiretrovirals
- Antidiabetic medications and insulin
- Antacids containing aluminum or magnesium
Physical Assessment in Renal Failure
1. Asymptomatic Early Stages: Patients in CKD stages 1-3 often show no symptoms. Metabolic and endocrine changes, and fluid/electrolyte imbalances typically become apparent in stages 4-5. Early symptoms may be subtle, such as fatigue and peripheral edema.
2. Metabolic Acidosis Assessment: Stages 4 and 5 CKD indicate severe kidney damage and impaired waste and toxin filtration, potentially leading to metabolic acidosis. Symptoms of later CKD stages include:
- Oliguria or anuria (significantly reduced or absent urine output)
- Generalized edema
- Muscle cramps
- Nausea and vomiting
- Anorexia (loss of appetite)
- Shortness of breath
3. Fluid and Electrolyte Imbalance Evaluation: Kidney dysfunction disrupts fluid and electrolyte balance, leading to complications like:
- Hypertension
- Peripheral edema
- Pulmonary edema
- Hyperkalemia (high potassium)
- Hyperphosphatemia (high phosphate)
- Hypocalcemia (low calcium)
4. Anemia Monitoring: Anemia, a common CKD complication, results from reduced erythropoietin production. Signs of anemia include:
- Persistent fatigue
- Activity intolerance
- Cold intolerance
- Pallor (pale skin)
- Difficulty concentrating
- Lightheadedness or dizziness
- Heart palpitations
Diagnostic Procedures for Renal Failure
1. CKD Screening: Screening tests to assess kidney function are vital, especially for at-risk individuals:
- Urinalysis (detects protein, blood, and other abnormalities)
- Urine albumin-creatinine ratio (ACR) (measures albumin levels in urine, indicating kidney damage)
- Serum creatinine (blood test to assess kidney function)
- Estimated GFR (eGFR) using CKD-EPI equation (calculated from serum creatinine, age, race, and sex)
2. Blood Tests: Additional serum tests help assess underlying conditions and CKD complications:
- Complete blood count (CBC) (evaluates red blood cells for anemia, white blood cells for infection)
- Basic metabolic panel (BMP) (measures electrolytes, glucose, BUN, creatinine)
- Serum albumin levels (assesses nutritional status and protein loss)
- Lipid profile (evaluates cholesterol and triglycerides, important for cardiovascular risk in CKD)
3. Bone Status Assessment: Renal bone disease is a frequent CKD complication. Tests to evaluate bone health include:
- Serum calcium and phosphate levels
- 25-hydroxyvitamin D level (vitamin D deficiency is common in CKD)
- Alkaline phosphatase (enzyme elevated in bone disorders)
- Intact parathyroid hormone (PTH) levels (elevated PTH indicates secondary hyperparathyroidism in CKD)
4. Imaging Scans: Kidney imaging provides structural and functional information:
- Renal ultrasonography (non-invasive, assesses kidney size, shape, and obstructions)
- Retrograde pyelography (X-ray of urinary tract after dye injection)
- Computed tomography (CT) scan (detailed cross-sectional images)
- Magnetic resonance imaging (MRI) (detailed soft tissue images, avoids radiation)
- Renal radionuclide scanning (nuclear medicine scan to assess kidney function and blood flow)
5. Kidney Biopsy: Percutaneous kidney biopsy is considered when diagnosis remains unclear after initial workup or to guide management based on disease severity. It involves taking a small kidney tissue sample for microscopic examination.
Nursing Interventions for Renal Failure
Nursing interventions are critical in managing renal failure, focusing on slowing disease progression and mitigating complications. The following interventions are crucial components of a renal failure care plan.
Delaying Renal Failure Progression
1. Managing Underlying Conditions: While existing kidney damage is irreversible, addressing the root cause is key to slowing progression and reducing complications. This involves:
- Blood pressure control: Maintaining blood pressure below 130/80 mmHg is vital for CKD patients with hypertension.
- Diabetes management: Strict glycemic control (HbA1c < 7%) is essential for diabetic nephropathy.
- Weight management: Weight loss for obese patients reduces kidney stress.
- Nephrotoxic substance avoidance: Limiting exposure to harmful substances.
- Cholesterol management: Lowering high cholesterol levels.
2. Blood Pressure Goals: Antihypertensive medications, particularly ACE inhibitors or angiotensin II receptor blockers (ARBs), are often prescribed to lower blood pressure and protect kidney function in CKD patients.
3. Protein Restriction: Reducing protein intake can slow proteinuria progression. The type and amount of protein should be individualized in consultation with a nephrologist and dietitian. Typically, a moderately low protein diet is recommended in earlier CKD stages, with adjustments as the disease progresses and especially if dialysis is initiated.
4. NSAID Avoidance: Educate patients about the nephrotoxic effects of NSAIDs and advise against their use. Alternative pain management strategies should be explored.
5. Smoking Cessation: Smoking accelerates ESRD progression. Emphasize smoking cessation benefits and provide resources to help patients quit.
6. Fluid Retention Management: Loop diuretics (e.g., furosemide) help manage fluid retention, a common issue in CKD, which can lead to hypertension and edema.
7. Erythropoietin-Stimulating Agents (ESAs): ESAs (e.g., erythropoietin, darbepoetin) stimulate red blood cell production, alleviating anemia symptoms. Iron supplementation is often necessary for ESA therapy to be effective.
8. Cholesterol Management: Statins are used to manage hyperlipidemia and reduce cardiovascular risk in CKD patients.
9. Bone Health Management: Vitamin D and calcium supplements can strengthen bones and prevent fractures. Phosphate binders are administered to reduce hyperphosphatemia and prevent vascular calcification.
10. Electrolyte Imbalance Correction: Medications, supplements, and dietary modifications are used to manage electrolyte imbalances common in CKD, such as hyperphosphatemia, hypocalcemia, hyperkalemia, and hyponatremia. Dietary restrictions often involve limiting potassium, phosphorus, and sodium intake.
Initiating Renal Replacement Therapy
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. Palliative and Conservative Care: For patients who choose not to pursue renal replacement therapy, palliative and conservative care focuses on symptom management, comfort, and quality of life.
3. Vascular Access Creation for Hemodialysis: If hemodialysis is planned, timely surgical creation of vascular access is essential.
- Arteriovenous (AV) Graft: A synthetic tube surgically connects an artery and vein, usable within weeks.
- Arteriovenous (AV) Fistula: The preferred access, surgically connecting an artery and vein directly. Fistulas have better patency and lower infection rates but require months to mature before use.
4. Peritoneal Dialysis Education: Peritoneal dialysis (PD) is a home-based dialysis option. A catheter is inserted into the abdomen, and dialysate solution is infused into the peritoneal cavity, using the peritoneum as a natural filter.
5. Kidney Transplantation Considerations: Transplantation offers the best long-term outcomes. Kidneys can come from living or deceased donors. Lifelong immunosuppression is required post-transplant to prevent rejection. Patients must meet specific health criteria to be transplant candidates.
6. Psychosocial Support: A CKD diagnosis can be emotionally challenging. Nurses provide emotional support, allowing patients time to adjust, answering questions, and addressing misconceptions.
7. Interdisciplinary Collaboration: Effective CKD management requires a multidisciplinary team including nephrologists, nurses, dietitians, cardiologists, endocrinologists, social workers, and transplant specialists. Dietitians create personalized renal diets, while social workers address psychosocial and financial needs.
Renal Failure Nursing Care Plans and Diagnoses
Once nursing diagnoses are identified, nursing care plans guide prioritized assessments and interventions, setting both short-term and long-term care goals. Examples of nursing care plans for chronic kidney disease are detailed below, focusing on key nursing diagnoses relevant to renal failure care plan.
Excess Fluid Volume in Renal Failure
Excess fluid volume is a common concern in renal failure as impaired kidneys fail to effectively remove fluids and waste. Fluid overload can lead to complications such as edema, hypertension, and heart failure.
Nursing Diagnosis: Excess Fluid Volume related to kidney dysfunction, decreased urine output, sodium retention, inappropriate fluid intake, and compromised regulatory mechanisms.
As evidenced by:
- Altered mental status
- Adventitious breath sounds (rales/crackles)
- Pulmonary congestion
- Altered pulmonary artery pressure (if monitored)
- Altered urine specific gravity
- Edema (peripheral, pulmonary)
- Imbalanced intake and output
- Jugular vein distension (JVD)
- Oliguria
Expected Outcomes:
- Patient will maintain clear lung sounds without dyspnea and remain free of edema.
- Patient will demonstrate balanced fluid intake and output.
Assessments:
1. Auscultate Lung Sounds: Adventitious sounds like rales or crackles and dyspnea indicate fluid retention complications.
2. Monitor Intake and Output (I&O): Accurate I&O monitoring is crucial for detecting fluid imbalances and overload. Damaged kidneys produce less urine.
3. Review Laboratory Values: BUN and creatinine assess renal function. GFR, derived from creatinine, indicates kidney filtration capacity. Electrolyte levels should also be monitored for imbalances related to fluid overload.
Interventions:
1. Daily Weight Monitoring: Daily weights, using the same scale, time, and clothing, are essential. A 1 kg (2.2 lbs) weight gain approximates 1 liter of fluid retention.
2. Fluid Restriction: Restrict fluids as prescribed, considering all sources (oral, IV, enteral). Fluid restriction prevents and manages fluid overload.
3. Administer Diuretics: Diuretics (e.g., loop diuretics) are often prescribed to promote urinary fluid elimination and reduce fluid retention and related complications.
4. Edema Care: Provide care for edematous extremities. Reposition patients every two hours to prevent pressure ulcers and elevate affected limbs to enhance venous return and reduce swelling.
5. Dialysis Preparation: Prepare patients for dialysis as indicated, especially in stage 5 renal failure. Dialysis nurses are specialized in hemodialysis and peritoneal dialysis.
Imbalanced Nutrition: Less Than Body Requirements in Renal Failure
Malnutrition is frequent in CKD due to disease processes and dialysis.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to disease process, malabsorption, metabolic acidosis, chronic inflammation, food aversions, and dialysis.
As evidenced by:
- Constipation or Diarrhea
- Unintentional weight loss
- Nausea and Vomiting
- Alterations in nutritional markers (e.g., decreased albumin, prealbumin)
- Poor appetite
- Low energy levels
- Muscle wasting
Expected Outcomes:
- Patient will report improved appetite.
- Patient will demonstrate electrolytes and protein levels within acceptable ranges.
Assessments:
1. Eating Patterns and Contributing Factors: Assess dietary habits, appetite, and factors contributing to malnutrition (uremic toxins, metabolic acidosis, malabsorption, protein loss in dialysis, inflammation, oxidative stress). This provides baseline data and guides interventions.
2. Review Laboratory Results: Decreased serum albumin indicates malnutrition and protein loss. Low vitamin D and calcium suggest risk of bone disease. Electrolyte imbalances should also be assessed.
3. Hydration Status and Daily Weight: Monitor hydration status and daily weight, as fluid sensitivity and edema are common in later CKD stages. Sudden weight gain may indicate fluid retention.
Interventions:
1. Dietary Restrictions: Advise patients to limit foods high in potassium, sodium, and phosphorus to manage hypertension, protect the heart, and prevent bone weakening.
2. Protein Management: Recommend appropriate protein intake. Low-protein diets are often indicated in CKD (0.6-0.8g/kg/day for non-dialysis patients, 1-1.2g/kg/day for dialysis patients), as excessive protein increases kidney workload.
3. Limit Alcohol Intake: Excessive alcohol consumption puts extra strain on kidneys and can accelerate CKD progression.
4. Limit Unhealthy Fats: Advise limiting saturated and trans fats to reduce cardiovascular risks. Encourage healthier monounsaturated and polyunsaturated fats.
5. Increase Fiber Intake: Recommend 20-38g of fiber daily (individualized for gender and needs) to prevent constipation, a common CKD complaint, and promote gut health.
6. Renal Dietitian Referral: Refer patients to a renal dietitian for personalized dietary plans considering nutritional status, fluid needs, and kidney health.
Impaired Urinary Elimination in Renal Failure
Impaired urinary elimination is common in renal failure as kidneys lose their filtering capacity and urine production is affected. Oliguria (urine output <400ml/day or <20ml/hour) is an early sign of renal impairment.
Nursing Diagnosis: Impaired Urinary Elimination related to chronic kidney disease.
As evidenced by:
- Oliguria
- Dysuria (painful urination – less common in CKD but possible with UTIs)
- Urinary retention (can occur, especially if underlying obstruction)
- Urinary incontinence (less directly related to CKD itself, but can be a comorbidity)
Expected Outcomes:
- Patient will produce at least 400 mL of urine per 24 hours (if residual renal function allows).
- Patient will not experience complications from oliguria (e.g., fluid overload, electrolyte imbalance).
Assessments:
1. Urinary Elimination Patterns: Assess normal voiding patterns to identify deviations and guide interventions.
2. Urine Characteristics: Monitor urine amount, color, clarity, and odor to detect potential infections or other complications.
Interventions:
1. Administer Diuretics: Diuretics promote urinary elimination and prevent fluid overload in CKD.
2. Cautious Fluid Administration: Fluid therapy can support elimination but may worsen fluid retention and electrolyte imbalances. Close monitoring is vital.
3. Patient Education on Expectations: Educate patients that urine production patterns may fluctuate in CKD, and as the disease progresses, urine output will likely decrease and may cease entirely.
4. Infection Prevention: Dialysis patients are at higher risk for infections related to catheters and fistulas. Monitor for fever and abdominal pain.
Risk for Decreased Cardiac Output in Renal Failure
Declining kidney function causes sodium retention and fluid volume expansion, leading to edema and hypertension. Compensatory mechanisms can then reduce cardiac output to maintain kidney perfusion, paradoxically increasing risk for decreased cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output related to altered contractility, afterload, heart rate, preload, rhythm, stroke volume, fluid imbalance, toxin accumulation, and soft-tissue calcification.
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
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. Blood Pressure Monitoring: Monitor blood pressure for hypertension (due to RAAS alterations) and orthostatic hypotension (due to intravascular volume deficits).
2. Chest Pain Assessment: Assess for chest pain (location, severity, intensity) as cardiovascular complications are common in CKD (coronary vasospasm, pulmonary edema, pericarditis).
3. Review Laboratory Studies: Monitor electrolytes, especially potassium. Hyperkalemia can disrupt myocardial electrical signals, causing dysrhythmias and reduced cardiac output.
4. Assess for Decreased Cardiac Output Signs: Monitor for fatigue, dyspnea, orthopnea, edema, decreased peripheral pulses – early signs of reduced cardiac output.
Interventions:
1. Administer Medications: Antihypertensives (ACE inhibitors, ARBs) are used to control blood pressure, protect kidney function, and reduce cardiac output complications.
2. Fluid Management: Strict fluid management, including fluid restriction, is crucial to preserve kidney function, prevent complications, and reduce decreased cardiac output risk. Diuretics may be needed.
3. Ejection Fraction Monitoring: Monitor ejection fraction (if available) as a cardiac function indicator. CKD is a heart failure risk factor.
4. Dialysis Preparation: Prepare patients for dialysis in ESRD, as dialysis removes uremic toxins, corrects electrolyte imbalances, manages fluid status, and prevents cardiac complications.
Risk for Electrolyte Imbalance in Renal Failure
Patients with renal failure are at high risk for electrolyte imbalances due to impaired kidney regulation. Common imbalances include hyperkalemia, hyperphosphatemia, hypocalcemia, and hyponatremia.
Nursing Diagnosis: Risk for Electrolyte Imbalance related to renal failure and kidney dysfunction.
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
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 and manage imbalances. Abnormalities indicate CKD progression.
2. Monitor Vital Signs and EKG: Electrolyte imbalances can cause dysrhythmias and respiratory compromise, reflected in vital signs and EKG changes.
Interventions:
1. Administer Lactulose: Lactulose promotes fecal excretion of potassium, ammonia, urea, and creatinine, helping manage hyperkalemia.
2. Administer Loop Diuretics: Loop diuretics promote potassium excretion, beneficial in hyperkalemia management, especially when combined with thiazide diuretics.
3. Dietary Management: Adjust diet based on lab results. Restrict potassium, phosphorus, and sodium intake when levels are elevated. Provide supplements if deficiencies exist (e.g., calcium, vitamin D).
4. Patient Education on Electrolyte Imbalance Signs: Educate patients about hyperkalemia (muscle weakness, cramping, slow heart rate) and hyponatremia (muscle cramps, nausea, disorientation, mental status changes) symptoms, and when to seek medical attention.
