Chronic Renal Failure Nursing Diagnosis & Care Plan

Chronic renal failure, also known as chronic kidney disease (CKD), is a progressive and irreversible deterioration of kidney function.

This condition requires comprehensive nursing care to manage symptoms, prevent complications, and improve the patient’s quality of life.

This article will explore the nursing diagnosis, interventions, and care plans for patients with chronic renal failure.

Causes (Related to)

Chronic renal failure can result from various conditions that damage the kidneys over time. Common causes include:

• Diabetes mellitus (both type 1 and type 2)
• Hypertension
• Glomerulonephritis
• Polycystic kidney disease
• Prolonged obstruction of the urinary tract
• Recurrent kidney infections
• Autoimmune disorders (lupus nephritis)
• Chronic use of certain medications (NSAIDs)

Signs and Symptoms (As evidenced by)

Chronic renal failure manifests with a wide range of signs and symptoms. During a physical assessment, a patient with chronic renal failure may present with one or more of the following:

Subjective: (Patient reports)

• Fatigue and weakness
• Decreased urine output
• Nausea and vomiting
• Loss of appetite
• Sleep disturbances
• Itchy skin
• Muscle cramps
• Edema in lower extremities

Objective: (Nurse assesses)

• Elevated blood pressure
• Pale or yellowed skin
• Dry, itchy skin
• Bruising easily
• Abnormal heart rhythm
• Shortness of breath
• Cognitive changes (confusion, difficulty concentrating)
• Lab values
• Elevated serum creatinine and blood urea nitrogen (BUN)
• Electrolyte imbalances (e.g., hyperkalemia, hyperphosphatemia)
• Anemia (low hemoglobin and hematocrit)
• Metabolic acidosis

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for chronic renal failure:

• The patient will maintain optimal fluid balance as evidenced by stable weight and absence of edema.
• The patient will demonstrate improved nutritional status within the agreed timeframe.
• The patient will report decreased fatigue and improved energy levels.
• The patient will maintain electrolyte levels within normal range.
• The patient will verbalize understanding of dietary restrictions and medication regimen.
• The patient will demonstrate techniques to manage pruritus effectively.
• The patient will report improved sleep patterns.
• The patient will maintain blood pressure within the target range.

Nursing Assessment

A comprehensive nursing assessment is the first step in providing care for a patient with chronic renal failure. The following section covers subjective and objective data related to chronic renal failure.

1. Monitor vital signs.
   Check blood pressure, heart rate, respiratory rate, and temperature regularly. Hypertension is common in CKD and can further damage the kidneys.
2. Assess fluid status.
   Monitor daily weights, intake and output, and presence of edema. Fluid overload is a common complication in CKD.
3. Evaluate skin integrity.
   Assess for dryness, itching, and any signs of infection. Uremic pruritus is a common symptom in CKD patients.
4. Assess nutritional status.
   Monitor appetite, dietary intake, and any gastrointestinal symptoms. Due to dietary restrictions and uremia, malnutrition is prevalent in CKD patients.
5. Evaluate respiratory status.
   Assess for shortness of breath, mainly when lying flat. Pulmonary edema can occur due to fluid overload.
6. Assess neurological status.
   Check for changes in mental status, confusion, or signs of uremic encephalopathy.
7. Monitor laboratory values.
   Check serum creatinine, BUN, electrolytes, hemoglobin, and hematocrit regularly. These values help assess kidney function and guide treatment.
8. Evaluate for anemia.
   Assess for pallor, fatigue, and shortness of breath. Anemia is common in CKD due to decreased erythropoietin production.
9. Assess pain levels.
   Chronic pain, particularly in the lower back or abdomen, can occur in CKD patients.
10. Evaluate psychosocial status.
    Assess for signs of depression, anxiety, or difficulty coping with the chronic illness.

Nursing Interventions

Nursing interventions are crucial for managing symptoms and preventing complications in patients with chronic renal failure. The following section outlines possible nursing interventions for this patient.

1. Manage fluid balance.
   Monitor fluid intake and output, weigh patient daily, and educate on fluid restrictions if necessary. This helps prevent fluid overload and its complications.
2. Administer medications as prescribed.
   This may include antihypertensives, phosphate binders, erythropoiesis-stimulating agents, and vitamin D supplements. Ensure proper timing and dosage, especially for medications that are cleared.
3. Provide dietary education.
   Teach the patient about dietary restrictions, particularly protein, potassium, phosphorus, and sodium intake. Consult with a renal dietitian for individualized meal planning.
4. Monitor and manage electrolyte imbalances.
   Regularly check electrolyte levels and implement interventions (administering calcium gluconate for hyperkalemia).
5. Implement infection prevention measures.
   Educate the patient on proper hand hygiene and signs of infection. Due to compromised immune function, CKD patients are at increased risk of infections.
6. Manage anemia.
   Administer erythropoiesis-stimulating agents and iron supplements as prescribed. Monitor hemoglobin levels regularly.
7. Provide skin care.
   Implement measures to relieve itching, such as moisturizers and recommend cool baths. Teach the patient to avoid scratching to prevent skin breakdown.
8. Manage pain.
   Administer pain medications as prescribed and teach non-pharmacological pain management techniques.
9. Provide emotional support.
   Offer counseling or refer to support groups to help the patient cope with the chronic illness.
10. Prepare for renal replacement therapy.
    If appropriate, educate the patient about dialysis options (hemodialysis or peritoneal dialysis) and kidney transplantation.
11. Promote exercise.
    Encourage regular physical activity within the patient’s capabilities to improve overall health and manage symptoms like fatigue.
12. Educate about medication adherence.
    Stress the importance of taking medications as prescribed and the potential consequences of non-adherence.

Nursing Care Plans

The following section provides five examples of nursing care plans for chronic renal failure.

Care Plan #1: Fluid Volume Excess

Nursing Diagnosis: Fluid Volume Excess related to decreased kidney function as evidenced by edema, weight gain, and elevated blood pressure.

Related factors/causes:

• Impaired kidney function leads to decreased urine output
• Sodium and water retention
• Inadequate fluid restrictions

Nursing Interventions and Rationales:

1. Monitor daily weights and compare them.
   Rationale: Sudden weight gain can indicate fluid retention.
2. Assess for peripheral edema and pulmonary congestion.
   Rationale: These are signs of fluid overload that may require immediate intervention.
3. Educate the patient on fluid restrictions and the importance of adherence.
   Rationale: Patient understanding can improve compliance with fluid restrictions.
4. Administer diuretics as prescribed.
   Rationale: Diuretics can help manage fluid overload by increasing urine output.
5. Monitor intake and output strictly.
   Rationale: This helps in assessing fluid balance and the effectiveness of interventions.

Desired Outcomes:

• The patient will maintain a weight within 0.5 kg of dry weight.
• The patient will demonstrate an understanding of fluid restrictions.
• The patient will show reduced signs of fluid overload (decreased edema, normal blood pressure).

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Care Plan #2: Imbalanced Nutrition: Less than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to dietary restrictions and uremic symptoms as evidenced by weight loss, poor appetite, and low albumin levels.

Related factors/causes:

• Dietary restrictions (protein, potassium, phosphorus)
• Uremic symptoms (nausea, vomiting, altered taste sensation)
• Medication side effects

Nursing Interventions and Rationales:

1. Assess nutritional status, including weight, appetite, and dietary intake.
   Rationale: This provides baseline data and helps monitor progress.
2. Consult with a renal dietitian for individualized meal planning.
   Rationale: A specialized diet can meet nutritional needs while adhering to necessary restrictions.
3. Administer antiemetics as prescribed to manage nausea.
   Rationale: Controlling nausea can improve appetite and food intake.
4. Encourage small, frequent meals.
   Rationale: This can improve food intake in patients with poor appetite.
5. Monitor serum albumin and pre-albumin levels.
   Rationale: These are indicators of nutritional status.

Desired Outcomes:

• The patient will demonstrate weight gain or maintenance within the goal range.
• The patient will report improved appetite and food intake.
• The patient will show improved nutritional markers (e.g., albumin levels).

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Care Plan #3: Activity Intolerance

Nursing Diagnosis: Activity Intolerance related to fatigue and anemia as evidenced by shortness of breath with minimal exertion and verbalized exhaustion.

Related factors/causes:

• Anemia due to decreased erythropoietin production
• Uremic toxins affecting muscle function
• Fluid overload leads to decreased oxygen exchange

Nursing Interventions and Rationales:

1. Assess fatigue levels and tolerance to activities.
   Rationale: This provides baseline data and helps in planning appropriate interventions.
2. Administer erythropoiesis-stimulating agents and iron supplements as prescribed.
   Rationale: These medications can help manage anemia and improve energy levels.
3. Encourage regular, moderate exercise within the patient’s capabilities.
   Rationale: Regular exercise can improve overall strength and endurance.
4. Teach energy conservation techniques.
   Rationale: This can help the patient manage daily activities without excessive fatigue.
5. Monitor hemoglobin and hematocrit levels regularly.
   Rationale: These values help assess the effectiveness of anemia management.

Desired Outcomes:

• The patient will report increased energy levels and decreased fatigue.
• The patient will demonstrate improved tolerance to daily activities.
• The patient will maintain hemoglobin levels within the target range.

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Care Plan #4: Disturbed Sleep Pattern

Nursing Diagnosis: Disturbed Sleep Pattern related to uremic symptoms and psychological stress as evidenced by difficulty falling asleep, frequent waking, and daytime drowsiness.

Related factors/causes:

• Uremic pruritus causing nighttime discomfort
• Anxiety and stress related to chronic illness
• Electrolyte imbalances affecting sleep-wake cycle

Nursing Interventions and Rationales:

1. Assess sleep patterns and factors affecting sleep.
   Rationale: This helps identify specific causes of sleep disturbance.
2. Implement measures to relieve pruritus (e.g., cool baths, moisturizers).
   Rationale: Reducing itching can improve sleep comfort.
3. Teach relaxation techniques and sleep hygiene practices.
   Rationale: These can help improve sleep and reduce anxiety.
4. Administer sleep medications as prescribed, considering renal clearance.
   Rationale: Pharmacological interventions may be necessary for severe sleep disturbances.
5. Encourage regular physical activity during the day.
   Rationale: Exercise can improve sleep quality and reduce daytime fatigue.

Desired Outcomes:

• The patient will report improved sleep quality and duration.
• The patient will demonstrate the use of relaxation techniques before bedtime.
• The patient will report decreased daytime drowsiness.

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Care Plan #5: Ineffective Coping

Nursing Diagnosis: Ineffective Coping related to chronic illness demands as evidenced by verbalized feelings of hopelessness and difficulty adhering to treatment regimen.

Related factors/causes:

• Complexity of treatment regimen
• Fear of disease progression and complications
• Limited social support

Nursing Interventions and Rationales:

1. Assess the patient’s understanding of the disease and treatment plan.
   Rationale: This helps identify knowledge gaps and misconceptions.
2. Provide education about the disease process, treatment options, and self-management strategies.
   Rationale: Improved understanding can enhance coping abilities.
3. Refer to support groups or counseling services.
   Rationale: Peer support and professional counseling can provide emotional support and coping strategies.
4. Encourage the involvement of family members in care planning.
   Rationale: Family support can improve adherence and emotional well-being.
5. Teach problem-solving skills for managing treatment-related challenges.
   Rationale: This empowers the patient to handle difficulties more effectively.

Desired Outcomes:

• The patient will verbalize an improved ability to cope with the disease and its treatment.
• The patient will demonstrate adherence to the treatment regimen.
• The patient will utilize support systems effectively.

References

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