Chronic kidney disease (CKD) or chronic renal failure (CRF) is characterized by a progressive and irreversible loss of kidney function.
Since the kidneys are highly adaptive organs, kidney disease is often not identified until there is a considerable loss of nephrons. Patients with early CKD are often asymptomatic, and symptoms may not be recognized until later stages.
In this article:
- Stages of Chronic Kidney Disease
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plan
- Imbalanced Nutrition: Less Than Body Requirements
- Impaired Urinary Elimination
- Risk for Decreased Cardiac Output
- Risk for Electrolyte Imbalance
Stages of Chronic Kidney Disease
CKD is categorized into stages based on the patient’s glomerular filtration rate (GFR):
- Stage 1: Normal or increased GFR (rate greater than or equal to 90)
- Stage 2: Mild decrease in GFR (rate between 60-89)
- Stage 3a: Moderate decrease in GFR (rate between 45-59)
- Stage 3b: Moderate decrease in GFR (rate between 30-44)
- Stage 4: Severe decrease in GFR (rate between 15-29)
- Stage 5: Kidney failure requiring dialysis (GFR less than 15)
As the kidneys further deteriorate and lose their ability to filter out toxins, other organ systems become affected, and irreversible damage may occur. The final stage of CKD is end-stage renal disease (ESRD), which requires dialysis and kidney transplant.
Nursing Process
The preservation of existing kidney function, reduction of cardiovascular disease risks, prevention of complications, and promotion of the patient’s comfort are the primary goals of CKD management and treatment.
Nurses are responsible for encouraging health promotion activities that can delay and prevent the onset of CKD. Providing accurate information about the disease process and encouraging the patient to adhere to lifestyle modifications are within the scope of the nurse.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to chronic kidney disease.
Review of Health History
1. Ask about the patient’s general symptoms.
The clinical manifestations of CKD often occur due to retained creatinine, urea, phenols, electrolytes, and water and can vary depending on the severity. Symptoms include:
- Fatigue
- Weakness
- Loss of appetite
- Edema
- Shortness of breath
- Changes in urine output
2. Identify the patient’s risk factors.
The following risk factors increase the incidence of CKD:
- Older age
- African-American, Native American, or Asian American ethnicity
- Family history of kidney disease
- Kidney structure defects
3. Record the patient’s medical history.
CKD happens when a disease or condition compromises kidney function. The following conditions and diseases can lead to CKD:
- Hypertension
- Diabetes
- Cardiovascular disease
- Existing kidney disease (such as glomerulonephritis and polycystic kidney disease)
- Inherited kidney disease
- Conditions that result in prolonged urinary tract blockage (such as kidney stones)
- Cancer
- Recurrent kidney infection
- Recurrent urinary tract infection
- Conditions that lead to persistent urine backflow to the kidneys (such as vesicoureteral reflux)
4. Assess the patient’s lifestyle and environment.
Specific lifestyle and environmental factors may worsen kidney damage. These include:
5. Review the patient’s medication list.
Many drugs are metabolized and eliminated through the kidneys. The following over-the-counter and prescription medicines can harm the kidneys:
- Statins
- Pain medications (NSAIDs and opioids)
- Antibiotics
- Antiretrovirals
- Antidiabetics and insulin
- Antacids
Physical Assessment
1. Patients may be asymptomatic in early stages.
Most patients with CKD stages 1-3 have no symptoms. Endocrine or metabolic changes in water or electrolyte balance typically become clinically evident in stages 4-5. Early symptoms may include fatigue and swelling in the hands and feet.
2. Assess for the presence of metabolic acidosis.
Stage 4 and 5 CKD means the kidneys are severely damaged and are unable to filter out toxins and waste products. This can lead to serious conditions like metabolic acidosis. Symptoms of later stages of CKD include:
- Oliguria or anuria (little to no urine output)
- Edema
- Muscle cramps
- Nausea
- Loss of appetite
- Shortness of breath
3. Determine alterations in fluid and electrolyte balance.
The following are complications of the kidney’s inability to filter electrolytes and water:
- Hypertension
- Peripheral edema
- Pulmonary edema
- Hyperkalemia
- Hyperphosphatemia
4. Monitor for signs of anemia.
Anemia, or low red blood cell (RBC) count, is a complication of CKD. The following signs characterize anemia:
- Fatigue
- Activity intolerance
- Feeling cold
- Pale skin
- Difficulty concentrating
- Lightheadedness or dizziness
- Heart palpitations
Diagnostic Procedures
1. Perform CKD screening.
CKD screening includes the following tests to assess kidney function:
- Urinalysis
- Urine albumin-creatinine ratio (ACR)
- Serum creatinine
- Estimation of GFR using the CKD-EPI equation
2. Perform blood tests.
Additional serum tests include the following to assess for underlying conditions or complications:
- Complete blood count (CBC)
- Basic metabolic panel
- Serum albumin levels
- Lipid profile
3. Determine the bone status.
The following tests can provide a diagnosis of renal bone disease:
- Serum calcium and phosphate
- 25-hydroxyvitamin D
- Alkaline phosphatase
- Intact parathyroid hormone (PTH) levels
4. Prepare the patient for imaging scans.
Imaging scans can be done to assess the kidneys and the organs around them. The following options are available to the healthcare provider:
- Renal ultrasonography
- Retrograde pyelography
- Computed tomography (CT) scan
- Magnetic resonance imaging (MRI)
- Renal radionuclide scanning
5. Prepare the patient for a kidney biopsy if needed.
Percutaneous kidney biopsy is recommended when the diagnosis is still uncertain following the required workup or to guide management in already-diagnosed conditions based on the severity of renal involvement.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with chronic kidney disease.
Delay Progression of Kidney Disease
1. Treat underlying conditions.
Existing kidney damage is irreversible. However, the key to reducing complications and slowing the progression of renal disease is to treat the underlying cause, such as:
- Managing blood pressure
- Controlling diabetes (HbA1C <7%)
- Losing weight
- Avoiding nephrotoxic substances
- Managing high cholesterol
2. Set a blood pressure goal.
CKD patients with hypertension should maintain their blood pressure below 130/80 mmHg. Administer medications (such as ACE inhibitors or angiotensin II receptor blockers) to lower blood pressure and protect the function of the kidneys.
3. Restrict protein.
Restricting protein has been demonstrated to delay the progression of proteinuria. Protein consumption has to be determined in terms of type and quantity. Collaborate with the nephrologist and dietitian for recommended protein intake for the patient.
4. Advise on NSAIDs.
NSAIDs are nephrotoxic, and patients with CKD should be educated on avoiding these medications.
5. Encourage smoking cessation.
Smokers progress to ESRD sooner than nonsmokers. Quitting smoking decreases the risk of kidney failure.
6. Relieve fluid retention.
Fluid retention is common in patients with chronic renal disease and may result in high blood pressure and edema. Loop diuretics can induce diuresis.
7. Promote RBC production.
Erythropoietin hormone supplements promote the production of additional red blood cells. This could lessen anemia-related symptoms.
8. Maintain the cholesterol levels within the acceptable range.
Encourage the use of statin medications to decrease cholesterol. These medications protect against coronary artery disease in patients with CKD.
9. Strengthen the bones.
Vitamin D and calcium supplements can lessen the risk of fractures and help avoid weak bones. Administer phosphate binders to reduce the amount of phosphate in the blood and shield the blood vessels from injury by calcium deposits (calcification).
10. Treat electrolyte imbalances.
Patients with CKD are at risk for hyperphosphatemia, hypocalcemia, hyperkalemia, and hyponatremia and may require medications, supplements, and dietary restrictions to balance electrolytes.
Initiate Renal Replacement Treatment
1. Discuss dialysis and transplantation.
Patients with CKD who experience serious complications like metabolic acidosis, hyperkalemia, pericarditis, encephalopathy, intractable fluid retention, and malnutrition will need renal replacement therapy.
2. Inform the patient about their options.
Patients who do not desire renal replacement treatment should receive information about palliative and conservative care management. Symptom management promotes comfort and quality of life.
3. Prepare the patient for vascular access creation.
When hemodialysis is anticipated, vascular access will need to be surgically created.
- An AV (arteriovenous) graft is created by surgically implanting a tube into the arm to connect the artery and vein. An AV graft can be utilized within days to weeks.
- An AV fistula is the recommended vascular access. The AV fistula has a good incidence of patency, and infections are rare, though fistulas take time to mature and cannot be used for months.
4. Educate on peritoneal dialysis.
This dialysis option may be ideal for some patients depending on their kidney function, overall health, and ability to perform their own dialysis at home. With PD, a catheter is inserted into the abdomen, and the dialysate flows into the peritoneum, which acts as a natural filter to remove waste products.
5. Anticipate a possible kidney transplant.
Both living and deceased donors can provide kidneys for transplant. Transplantation will require lifelong medication to prevent the body from rejecting the new kidney. To qualify, the patient must meet certain requirements, such as good general health and no use of drugs or cigarettes.
6. Support the patient in coping with a chronic disease.
It can be unsettling for the patient to receive a chronic renal disease diagnosis. Give the patient time to adjust and accept the diagnosis. Answer their inquiries and eliminate any misconceptions.
7. Collaborate with the interdisciplinary team.
Nephrologists are the providers who manage and guide the treatment of patients with CKD. The nurse may also collaborate with dieticians who create meal plans specific for patients on renal diets. Additional healthcare providers may include cardiologists, endocrinologists, social workers, and the transplant team.
Nursing Care Plan
Once the nurse identifies nursing diagnoses for chronic kidney disease, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for chronic kidney disease.
Excess Fluid Volume
Excess fluid volume is common in patients with CRF because the kidneys are not functioning to remove excess fluids and waste products from the body. When there is excess fluid, complications can arise including swelling, hypertension, and heart problems.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Kidney dysfunction
- Decreased urine output
- Sodium retention
- Inappropriate fluid Intake
- Compromised regulatory mechanism
As evidenced by:
- Altered mental status
- Adventitious breath sounds
- Pulmonary congestion
- Altered pulmonary artery pressure
- Altered urine specific gravity
- Edema
- Imbalanced intake and output
- Jugular vein distension
- Oliguria
Expected outcomes:
- Patient will remain free of edema and maintain clear lung sounds without evidence of dyspnea.
- Patient will maintain balanced intake and output.
Assessment:
1. Assess lung sounds.
Adventitious lung sounds such as rales or crackles and dyspnea signal a complication of fluid retention.
2. Assess and monitor the patient’s intake and output.
The patient’s intake and output should be well documented to help detect imbalances and fluid overload. Damaged kidneys cannot produce as much urine.
3. Assess laboratory values.
BUN and creatinine assess renal function. GFR is determined by the creatinine level and shows how well the kidneys are filtering. Electrolytes are also assessed.
Interventions:
1. Monitor the patient’s weight daily.
It is estimated that 1 kg (2.2 lbs) of weight gained is equivalent to 1 liter of fluid retained. Monitoring the patient’s weight daily must be performed using the same scale during the same time of the day while the patient is wearing the same type of clothing for accurate results.
2. Restrict fluids as indicated.
When restricting fluid intake in patients with CFR, all forms of fluid intake must be considered including oral, intravenous, and enteral sources. Fluid restriction is indicated to prevent and reduce fluid overload.
3. Administer medications as indicated.
Diuretics are often prescribed to patients with CRF to increase urinary elimination of fluids and reduce retention and further complications.
4. Provide care to edematous extremities as needed.
Patients with CRF often exhibit lower extremity edema or anasarca due to excess fluid retention. Reposition the patient every two hours to prevent the development of pressure ulcers and elevate affected extremities to improve blood flow and reduce swelling.
5. Prepare the patient for dialysis as indicated.
Patients with stage 5 renal failure will require dialysis. Dialysis nurses are trained to provide hemodialysis or peritoneal dialysis.
Imbalanced Nutrition: Less Than Body Requirements
Patients with chronic kidney disease experience malnutrition due to various reasons from the disease process and dialysis.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process
- Malabsorption
- Metabolic acidosis
- Chronic inflammation
- Food aversion
- Dialysis
As evidenced by:
- Constipation
- Diarrhea
- Weight loss
- Nausea
- Vomiting
- Alterations in nutritional markers
- Poor appetite
- Low energy levels
- Muscle wasting
Expected outcomes:
- Patient will report an adequate appetite level.
- Patient will demonstrate electrolytes and protein levels within acceptable limits.
Assessment:
1. Assess the patient’s eating pattern and factors contributing to imbalanced nutrition.
Understanding the patient’s eating habits, appetite, and factors contributing to imbalanced nutrition can help provide baseline information for comparison and determine appropriate interventions to prevent further deterioration of the patient’s nutritional status. Uremic effects, metabolic acidosis, reduced nutrient absorption, protein loss during dialysis, chronic inflammation, and oxidative stress are possible causes of reduced appetite and malnutrition.
2. Assess and review laboratory results.
Decreased serum albumin is present in patients with CKD who are also experiencing imbalanced nutrition due to protein loss via the urine, decreased synthesis, and fluid shifts. Low vitamin D and calcium levels can preface weakened bones and fractures. Electrolytes may be increased or decreased.
3. Assess the patient’s hydration status and daily weight.
Patients in the later stages of CKD will be sensitive to fluid intake and may experience edema if sodium and water cannot be excreted. A sudden increase in weight often signals fluid retention.
Interventions:
1. Encourage the patient to avoid foods high in potassium, sodium, and phosphorus.
As CKD worsens, nutritional needs change. Avoiding foods high in potassium, sodium, and phosphorus can control hypertension, protect the heart, and prevent weakened bones.
2. Encourage the patient to eat the right amount and type of protein.
A low-protein diet is often indicated for patients with CKD. Excessive protein can make the kidneys work harder in filtering waste products. Patients not receiving dialysis should consume 0.6-0.8g/kg of protein per day, while patients on dialysis can consume 1 -1.2g/kg per day.
3. Instruct the patient to limit alcohol intake.
Drinking too much alcohol places additional strain on the kidney’s filtering function and accelerates the progression of CKD.
4. Instruct the patient to limit intake of saturated and trans fat.
Limiting saturated and trans fat intake can lower fat buildup in the blood vessels, heart, and kidneys. Monounsaturated and polyunsaturated fats found in olive, avocado, and flaxseed oil are healthier alternatives to trans and saturated fats.
5. Increase fiber.
Constipation is a common complaint with CKD. 20-25 g of fiber for women and 30-38 g for men is recommended to prevent constipation and maintain a balance of healthy bacteria in the gut.
6. Refer the patient to a renal dietitian.
A renal dietician can recommend a specialized diet for patients with CKD, ensuring careful consideration of the patient’s nutritional status, fluid needs, and kidney health.
Impaired Urinary Elimination
Impaired urinary elimination is common in patients with CRF as the kidneys lose their ability to filter waste products through urine production.
Oliguria or low urine output is characterized by urine excretion of less than 20 ml per hour or less than 400 ml per day. This is considered one of the earliest signs of impaired renal function.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Chronic kidney disease
As evidenced by:
- Oliguria
- Dysuria
- Urinary retention
- Urinary incontinence
Expected outcomes:
- Patient will produce at least 400 mL of urine per 24 hours.
- Patient will not experience complications from oliguria.
Assessment:
1. Assess the patient’s urinary elimination patterns and problems.
Understanding the patient’s normal urinary elimination patterns can help formulate the best approach to promoting healthy elimination patterns.
2. Assess urine characteristics.
Assess the amount, color, clarity, and odor of urine for additional complications such as infection.
Interventions:
1. Administer diuretics as indicated.
Diuretics promote urinary elimination and prevent fluid overload in patients with CRF.
2. Administer fluids with caution.
Fluid therapy can help with promoting urinary elimination but can cause worsening fluid retention and electrolyte imbalances. Monitor closely.
3. Educate on expectations.
With CRF, urine production may increase and decrease. Educate the patient that as the disease progresses urine production will slow and may stop completely.
4. Prevent infections.
Patients who are receiving dialysis due to severe CFR are at risk for infections from dialysis catheters and fistulas. Monitor for fever and abdominal pain.
Risk for Decreased Cardiac Output
As kidney function declines, sodium retention and extracellular volume expand, resulting in peripheral edema, pulmonary edema, and hypertension. As this occurs, compensatory mechanisms kick in, causing decreased cardiac output to promote kidney perfusion.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Altered contractility
- Altered afterload
- Altered heart rate
- Altered preload
- Altered heart rhythm
- Altered stroke volume
- Fluid imbalance affecting circulating volume and myocardial workload
- Accumulation of toxins 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 be free from symptoms of decreased cardiac output, such as dyspnea, dysrhythmias, or activity intolerance.
Assessment:
1. Assess and monitor the patient’s blood pressure.
Hypertension is present in patients with CKD due to alterations of the renin-angiotensin-aldosterone system. Orthostatic hypotension also occurs due to intravascular deficits.
2. Assess for chest pain, its location, severity, and intensity.
Cardiovascular complications are common in patients with CKD and are mostly caused by coronary vasospasm, fluid buildup in the lungs, and inflammation of the pericardium.
3. Assess the patient’s laboratory studies.
CKD causes a significant imbalance in the patient’s fluid and electrolyte levels, especially potassium. Hyperkalemia increases the patient’s risk of disrupting the electrical signals of the myocardium, resulting in dysrhythmias and compromised perfusion throughout the body.
4. Assess for signs and symptoms of decreased cardiac output.
Decreased cardiac output can manifest as fatigue, dyspnea, orthopnea, edema, and decreased peripheral pulses. Early identification of symptoms enables prompt treatment and intervention.
Interventions:
1. Administer medications as indicated.
Antihypertensive drugs specifically, ace inhibitors and angiotensin II receptor blockers, are given to reduce the patient’s blood pressure, preserve kidney function, and reduce further complications of decreased cardiac output.
2. Closely monitor fluid status and restrict fluids as indicated.
CKD requires strict fluid management to preserve kidney function, prevent complications, and reduce the risk of decreased cardiac output. Diuretics may be necessary to rid the body of excess fluid.
3. Monitor ejection fraction.
CKD is a risk factor in the development of heart failure, which is evidenced by increased or decreased central venous pressure. The nurse can monitor the patient’s ejection fraction as an indicator of cardiac functioning.
4. Assist and prepare the patient for dialysis.
Dialysis is often indicated for patients with end-stage CKD as this can help reduce and eliminate uremic toxins, correct electrolyte imbalances, control fluid status, and prevent complications, including decreased cardiac output, hypertension, and pericardial effusion.
Risk for Electrolyte Imbalance
Patients with CRF are at risk of developing electrolyte imbalance due to impaired kidney function. This condition is often complicated by decreased sodium and calcium and increased potassium, magnesium, and phosphate.
Nursing Diagnosis: Risk for Electrolyte Imbalance
Related to:
- Renal failure
- 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.
Assessment:
1. Assess laboratory data.
Abnormal electrolyte panels indicate the progression of CRF.
2. Assess and monitor vital signs.
Imbalances in electrolytes can often lead to complications like respiratory failure and dysrhythmias observed through vital signs and EKGs.
Interventions:
1. Administer lactulose.
Hyperkalemia is the most common electrolyte imbalance in CRF and has the potential to cause serious cardiac arrhythmias. Lactulose promotes the fecal excretion of electrolytes as well as ammonia, urea, and creatinine.
2. Administer loop diuretics.
Loop diuretics are potassium-wasting and will rid the body of potassium. Loop diuretics are most beneficial when used with thiazide.
3. Provide or restrict nutrition based on lab work.
Electrolytes are found in many foods and fluids. Restrict intake when levels are high or provide additional sources if deficient.
4. Educate the patient about signs of high potassium and other risks.
Patients with CRF are susceptible to hyperkalemia and hyponatremia. Hyperkalemia can cause muscle weakness, restlessness, cramping, and a slow heart rate. Hyponatremia can cause muscle cramps, nausea, disorientation, and alterations in mental status.
References
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