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Chronic renal failure (CRF) or chronic kidney disease (CKD) is the end result of a gradual, progressive loss of kidney function. The loss of function may be so slow that you do not have symptoms until your kidneys have almost stopped working.
The final stage of chronic kidney disease is called end-stage renal disease (ESRD). At this stage, the kidneys are no longer able to remove enough wastes and excess fluids from the body. At this point, you would need dialysis or a kidney transplant.
Nursing Care Plans
Nursing Priorities
- Maintain homeostasis.
- Prevent complications.
- Provide information about disease process/prognosis and treatment needs.
- Support adjustment to lifestyle changes.
Discharge Goals
- Fluid/electrolyte balance stabilized.
- Complications prevented/minimized.
- Disease process/prognosis and therapeutic regimen understood.
- Dealing realistically with situation; initiating necessary lifestyle changes.
- Plan in place to meet needs after discharge.
1. Risk for Decreased Cardiac Output
Risk factors may include
- Fluid imbalances affecting circulating volume, myocardial workload, and systemic vascular resistance (SVR)
- Alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia)
- Accumulation of toxins (urea), soft-tissue calcification (deposition of calcium phosphate)
Possibly evidenced by
- Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.
Desired Outcomes
- Maintain cardiac output as evidenced by BP and heart rate within patient’s normal range; peripheral pulses strong and equal with prompt capillary refill time.
| Nursing Interventions |
Rationale |
| Auscultate heart and lung sounds. Evaluate presence of peripheral edema, vascular congestion and reports of dyspnea. |
S3 and S4 heart sounds with muffled tones, tachycardia, irregular heart rate, tachypnea, dyspnea, crackles, wheezes,edema and jugular distension suggest HF. |
| Assess presence and degree of hypertension: monitor BP; note postural changes (sitting, lying, standing). |
Significant hypertension can occur because of disturbances in the renin-angiotensin-aldosterone system (caused by renal dysfunction). Although hypertension is common, orthostatic hypotension may occur because of intravascular fluid deficit, response to effects of antihypertensive medications, or uremic pericardial tamponade. |
| Investigate reports of chest pain, noting location, radiation, severity (0–10 scale), and whether or not it is intensified by deep inspiration and supine position. |
Although hypertension and chronic HF may cause MI, approximately half of CRF patients on dialysis develop pericarditis, potentiating risk of pericardial effusion or tamponade. |
| Evaluate heart sounds (note friction rub), BP, peripheral pulses, capillary refill, vascular congestion, temperature, and sensorium or mentation. |
Presence of sudden hypotension, paradoxic pulse, narrow pulse pressure, diminished or absent peripheral pulses, marked jugular distension, pallor, and a rapid mental deterioration indicate tamponade, which is a medical emergency. |
| Assess activity level, response to activity. |
Weakness can be attributed to HF and anemia. |
| Monitor laboratory and diagnostic studies: |
| Electrolytes (potassium, sodium, calcium, magnesium), BUN and Cr; |
Imbalances can alter electrical conduction and cardiac function. |
| Chest x-rays. |
Useful in identifying developing cardiac failure or soft-tissue calcification. |
| Administer antihypertensive drugs such as prazosin (Minipress), captopril (Capoten), clonidine (Catapres), hydralazine (Apresoline). |
Reduces systemic vascular resistance and renin release to decrease myocardial workload and aid in prevention of HF and MI. |
| Prepare for dialysis. |
Reduction of uremic toxins and correction of electrolyte imbalances and fluid overload may limit and prevent cardiac manifestations, including hypertension and pericardial effusion. |
| Assist with pericardiocentesis as indicated. |
Accumulation of fluid within pericardial sac can compromise cardiac filling and myocardial contractility, impairing cardiac output and potentiating risk of cardiac arrest. |
2. Risk for Ineffective Protection
Risk factors may include
- Abnormal blood profile (suppressed erythropoietin production/secretion; decreased RBC production and survival; altered clotting factors; increased capillary fragility)
Possibly evidenced by
- Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.
Desired Outcomes
- Experience no signs/symptoms of bleeding/hemorrhage.
- Maintain/demonstrate improvement in laboratory values.
| Nursing Interventions |
Rationale |
| Note reports of increasing fatigue, weakness. Observe for tachycardia, pallor of ski and mucous membranes, dyspnea, and chest pain. Plan patient activities to avoid fatigue. |
May reflect effects of anemia and cardiac response necessary to keep cells oxygenated. |
| Monitor level of consciousness and behavior. |
Anemia may cause cerebral hypoxia manifested by changes in mentation, orientation, and behavioral responses. |
| Evaluate response to activity, ability to perform tasks. Assist as needed and develop schedule for rest. |
Anemia decreases tissue oxygenation and increases fatigue, which may require intervention, changes in activity, and rest. |
| Limit vascular sampling, combine laboratory tests when possible. |
Recurrent or excessive blood sampling can worsen anemia. |
| Observe for oozing from venipuncture sites, bleeding, ecchymotic areas following slight trauma, petechiae; joint swelling or mucous membrane involvement (bleeding gums, recurrent epistaxis, hematemesis, melena, and hazy or red urine. |
Bleeding can occur easily because of capillary fragility and altered clotting functions and may worsen anemia. |
| Hematest GI secretions and stool for blood. |
Mucosal changes and altered platelet function due to uremia may result in gastric mucosal erosion and GI hemorrhage. |
| Provide soft toothbrush, electric razor; use smallest needle possible and apply prolonged pressure following injections or vascular punctures. |
Reduces risk of bleeding and hematoma formation. |
| Monitor laboratory studies: |
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| RBCs, Hb and Hct; |
Uremia (elevated ammonia, urea, other toxins) decreases production of erythropoietin and depresses RBC production and survival time. In CRF, Hb and Hct are usually low but tolerated; (patient may not be symptomatic until Hb is below 7). |
| Platelet count, clotting factors; |
Suppression of platelet formation and inadequate levels of factors III and VIII impair clotting and potentiate risk of bleeding. Note: Bleeding may become intractable in ESRD. |
| Prothrombin time (PT) level. |
Abnormal prothrombin consumption lowers serum levels and impairs clotting. |
| Administer fresh blood, packed RBCs (PRCs) as indicated. |
May be necessary when patient is symptomatic with anemia. PRCs are usually given when patient is experiencing fluid overload or receiving dialysis treatment. Washed RBCs are used to prevent hyperkalemia associated with stored blood. |
| Administer medications, as indicated: |
| Erythropoietin preparations (Epogen, EPO, Procrit); |
Corrects many of the symptoms of CRF resulting from anemia by stimulating the production and maintenance of RBCs, thus decreasing the need for transfusion. |
| Iron preparations: folic acid (Folvite), cyanocobalamin (Rubesol-1000); |
Useful in managing symptomatic anemia related to nutritional or dialysis-induced deficits. Note: Iron should not be given with phosphate binders because they may decrease iron absorption. |
| Cimetidine (Tagamet), ranitidine (Zantac); antacids; |
May be given prophylactically to reduce or neutralize gastric acid and thereby reduce the risk of GI hemorrhage. |
| Hemostatics or fibrinolysis inhibitors such as aminocaproic acid (Amicar); |
Inhibits bleeding that does not subside spontaneously or respond to usual treatment. |
| Stool softeners (Colace); bulk laxative (Metamucil). |
Straining to pass hard-formed stool increases likelihood of mucosal and rectal bleeding. |
3. Disturbed Thought Process
May be related to
- Physiological changes: accumulation of toxins (e.g., urea, ammonia), metabolic acidosis, hypoxia; electrolyte imbalances, calcifications in the brain
Possibly evidenced by
- Disorientation to person, place, time
- Memory deficit; altered attention span, decreased ability to grasp ideas
- Impaired ability to make decisions, problem-solve
- Changes in sensorium: somnolence, stupor, coma
- Changes in behavior: irritability, withdrawal, depression, psychosis
Desired Outcomes
- Regain/maintain optimal level of mentation.
- Identify ways to compensate for cognitive impairment/memory deficits.
| Nursing Interventions |
Rationale |
| Assess extent of impairment in thinking ability, memory, and orientation. Note attention span. |
Uremic syndrome’s effect can begin with minor confusion, irritability and progress to altered personality or inability to assimilate information and participate in care. Awareness of changes provides opportunity for evaluation and intervention. |
| Ascertain from SO patient’s usual level of mentation. |
Provides comparison to evaluate progression and resolution of impairment. |
| Provide SO with information about patient’s status. |
Some improvement in mentation may be expected with restoration of more normal levels of BUN, electrolytes, and serum pH. |
| Provide quiet or calm environment and judicious use of television, radio, and visitation. |
Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation. |
| Reorient to surroundings, person, and so forth. Provide calendars, clocks, outside window. |
Provides clues to aid in recognition of reality. |
| Present reality concisely, briefly, and do not challenge illogical thinking. |
Confrontation potentiates defensive reactions and may lead to patient mistrust and heightened denial of reality. |
| Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary. |
May aid in reducing confusion, and increases possibility that communications will be understood and remembered. |
| Establish a regular schedule for expected activities. |
Aids in maintaining reality orientation and may reduce fear and confusion. |
| Promote adequate rest and undisturbed periods for sleep. |
Sleep deprivation may further impair cognitive abilities. |
| Monitor laboratory studies such as BUN and Cr, serum electrolytes, glucose level, and ABGs (Po2, pH). |
Correction of elevations or imbalances can have profound effects on cognition or mentation. |
| Provide supplemental O2 as indicated. |
Correction of hypoxia alone can improve cognition. |
| Avoid use of barbiturates and opiates. |
Drugs normally detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion. |
| Prepare for dialysis. |
Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis. |
4. Risk for Impaired Skin Integrity
Risk factors may include
- Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy)
- Alterations in skin turgor (edema/dehydration)
- Reduced activity/immobility
- Accumulation of toxins in the skin
Possibly evidenced by
- Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.
Desired Outcomes
- Maintain intact skin.
- Demonstrate behaviors/techniques to prevent skin breakdown/injury.
| Nursing Interventions |
Rationale |
| Inspect skin for changes in color, turgor, vascularity. Note redness, excoriation. Observe for ecchymosis, purpura. |
Indicates areas of poor circulation or breakdown that may lead to decubitus formation and infection. |
| Monitor fluid intake and hydration of skin and mucous membranes. |
Detects presence of dehydration or overhydration that affect circulation and tissue integrity at the cellular level. |
| Inspect dependent areas for edema. Elevate legs as indicated. |
Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. |
| Change position frequently; move patient carefully; pad bony prominences with sheepskin, elbow or heel protectors. |
Decreases pressure on edematous, poorly perfused tissues to reduce ischemia. |
| Provide soothing skin care. Restrict use of soaps. Apply ointments or creams (lanolin, Aquaphor). |
Baking soda, cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin. |
| Keep linens dry, wrinkle-free. |
Reduces dermal irritation and risk of skin breakdown. |
| Investigate reports of itching. |
Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products such as phosphate crystals (associated with hyperparathyroidism in ESRD). |
| Recommend patient use cool, moist compresses to apply pressure (rather than scratch) pruritic areas. Keep fingernails short; encourage use of gloves during sleep if needed. |
Alleviates discomfort and reduces risk of dermal injury. |
| Suggest wearing loose-fitting cotton garments. |
Prevents direct dermal irritation and promotes evaporation of moisture on the skin. |
| Provide foam or flotation mattress. |
Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis. |
5. Risk for Impaired Oral Mucous Membrane
Risk factors may include
- Lack of/or decreased salivation, fluid restrictions
- Chemical irritation, conversion of urea in saliva to ammonia
Possibly evidenced by
- Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.
Desired Outcomes
- Maintain integrity of mucous membranes.
- Identify/initiate specific interventions to promote healthy oral mucosa.
| Nursing Interventions |
Rationale |
| Inspect oral cavity; note moistness, character of saliva, presence of inflammation, ulcerations, leukoplakia. |
Provides opportunity for prompt intervention and prevention of infection. |
| Provide fluids throughout 24-hr period within prescribed limit. |
Prevents excessive oral dryness from prolonged period without oral intake. |
| Offer frequent mouth care and rinse with 0.25% acetic acid solution; provide gum, hard candy, breath mints between meals. |
Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea. |
| Encourage good dental hygiene after meals and at bedtime. Recommend avoidance of dental floss. |
Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding. |
| Recommend patient stop smoking and avoid lemon or glycerine products or mouthwash containing alcohol. |
These substances are irritating to the mucosa and have a drying effect, potentiating discomfort. |
| Provide artificial saliva as needed (Ora-Lube). |
Prevents dryness, buffers acids, and promotes comfort. |
| Administer medications as indicated such as antihistamines: cyproheptadine (Periactin). |
May be given for relief of itching. |
6. Deficient Knowledge
May be related to
- Lack of exposure/recall, information misinterpretation
- Cognitive limitation
Possibly evidenced by
- Questions/request for information, statement of misconception
- Inaccurate follow-through of instructions, development of preventable complications
Desired Outcomes
- Verbalize understanding of condition/disease process and potential complications.
- Verbalize understanding of therapeutic needs.
- Correctly perform necessary procedures and explain reasons for the actions.
- Demonstrate/initiate necessary lifestyle changes.
- Participate in treatment regimen.
| Nursing Interventions |
Rationale |
| Review disease process and prognosis and future expectations. |
Provides knowledge base from which patient can make informed choices. |
| Review dietary restrictions, including: |
| Phosphorus (carbonated drinks, processed foods, poultry, corn, peanuts) and magnesium (whole grain products, legumes); |
Retention of phosphorus stimulates the parathyroid glands to shift calcium from bones (renal osteodystrophy ) , and accumulation of magnesium can impair neuromuscular function and mentation. |
| Fluid and sodium restrictions when indicated. |
If fluid retention is a problem, patient may need to restrict intake of fluid to 1100 cc (or less) and restrict dietary sodium. If fluid overload is present, diuretic therapy or dialysis will be part of the regimen. |
| Discuss other nutritional concerns such as regulating protein intake according to level of renal function (generally 0.6 – 0.7g per k of body weight per day of good quality protein, such as meat, eggs). |
Metabolites that accumulate in blood derive almost entirely from protein catabolism; as renal function declines, proteins may be restricted proportionately. Too little protein can result in malnutrition. Note: Patient on dialysis may not need to be as vigilant with protein intake. |
| Encourage adequate calorie intake, especially from carbohydrates in the nondiabetic patient. |
Spares protein, prevents wasting, and provides energy. Note: Use of special glucose polymer powders can add calories to enhance energy level without extra food or fluid intake. |
| Discuss drug therapy, including use of calcium supplements and phosphate binders such as aluminum hydroxide antacids (Amphojel, Basalgel) and avoidance of magnesium antacids (Mylanta, Maalox, Gelusil); vitamin D. |
Prevents serious complications (reducing phosphate absorption from the GI tract and supplying calcium to maintain normal serum levels, reducing risk of bone demineralization or fractures, tetany); however, use of aluminum – containing products should be monitored because accumulation in the bones potentiates osteodystrophy. Magnesium products potentiate risk of hypermagnesemia. Note: Supplemental vitamin D may be required to facilitate calcium absorption. |
| Stress importance of reading all product labels (drugs and food) and not taking medications without prior approval of healthcare provider. |
It is difficult to maintain electrolyte balance when exogenous intake is not factored into dietary restrictions, (hypercalcemia can result from routine supplement use in combination with increased dietary intake of calcium – fortified foods and medications containing calcium). |
| Review measures to prevent bleeding and hemorrhage, (use of soft toothbrush, electric razor); avoidance of constipation, forceful blowing of nose, strenuous exercise and contact sports. |
Reduces risks related to alteration of clotting factors and decreased platelet count. |
| Instruct in self – observation and self-monitoring of BP, including scheduling rest period before taking BP, using same arm or position. |
Incidence of hypertension is increased in CRF, often requiring management with antihypertensive drugs, necessitating close observation of treatment effects (vascular response to medication). |
| Caution against exposure to external temperature extremes (heating pad or snow). |
Peripheral neuropathy may develop, especially in lower extremities (effects of uremia, electrolyte and acid-base imbalances), impairing peripheral sensation and potentiating risk of tissue injury. |
| Establish routine exercise program within limits of individual ability; intersperse adequate rest periods with activities. |
Aids in maintaining muscle tone and joint flexibility. Reduces risks associated with immobility (including bone demineralization ) , while preventing fatigue. |
| Address sexual concerns. |
Physiological effects of uremia and antihypertensive therapy may impair sexual desire and performance. |
| Identify available resources as indicated. Stress necessity of medical and laboratory follow- up. |
Close monitoring of renal function and electrolyte balance is necessary to adjust dietary prescription, treatment or make decisions about possible options such as dialysis and transplantation. |
| Identify signs and symptoms requiring immediate medical evaluation (Low -grade fever, chills, changes in characteristics of urine and sputum, tissue swelling and drainage, oral ulcerations; |
Depressed immune system, anemia, malnutrition all contribute to increased risk of infection. |
| Numbness and tingling of digits, abdominal and muscle cramps, carpopedal spasms; |
Uremia and decreased absorption of calcium may lead to peripheral neuropathies. |
| Joint swelling and tenderness, decreased ROM, reduced muscle strength; |
Hyperphosphatemia with corresponding calcium shifts from the bone may result in deposition of the excess calcium phosphate as calcifications in joints and soft tissues. Symptoms of skeletal involvement are often noted before impairment in organ function is evident. |
| Headaches, blurred vision, periorbital and sacral edema, “red eyes”; |
Suggestive of development and poor control of hypertension, or changes in eyes caused by calcium. |
| Review strategies to prevent constipation, including stool softeners (Colace) and bulk laxatives (Metamucil) but avoiding magnesium products (milk of magnesia). |
Reduced fluid intake, changes in dietary pattern, and use of phosphate – binding products often result in constipation that is not responsive to nonmedical interventions.Use of products containing magnesium increases risk of hypermagnesemia. |
Other Possible Nursing Care Plans
- Fluid Volume excess—compromised regulatory mechanism.
- Fatigue—decreased metabolic energy production/dietary restriction, anemia, increased energy requirements, e.g., fever/
- inflammation, tissue regeneration.
- Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, decisional conflicts: patient value system; health beliefs, cultural influences; powerlessness; economic difficulties; family conflict; lack of/refusal of support systems.
- Hopelessness—deteriorating physiological condition, long-term stress, prolonged activity limitations.
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