End Stage Renal Disease Nursing Diagnosis and Nursing Care Plan

End Stage Renal Disease Nursing Care Plans Diagnosis and Interventions

The fifth and last stage of the progression of chronic kidney disease (CKD) is end-stage kidney disease (ESKD), often known as kidney failure. A few of the risk factors for developing chronic kidney disease, which may eventually lead to end-stage renal failure, include diabetes, high blood pressure, heart illness, drug addiction, urinary tract obstructions, family history, inflammation, and some genetic diseases.

Furthermore, untreated chronic kidney disease can advance to the point of end-stage disease if it is not appropriately managed. As kidney failure worsens, patients may suffer a wide range of symptoms. These include bone discomfort, skin and nail changes, drowsiness, fatigue, decreased urine or the inability to urinate, dry skin, itchy skin, headaches, weight loss, nausea, and easy bruising.

Dialysis or a kidney transplant is required for survival when the kidneys can no longer filter the blood of waste and excess fluid.

End-Stage Renal Disease Symptoms and Signs

Early on in the end-stage renal disease, the patient may not exhibit any symptoms or signs. Signs and symptoms that chronic kidney disease is developing into end-stage renal disease include:

  • Nausea
  • Vomiting
  • Loss of appetite
  • Fatigue and weakness
  • Changes in frequency of urination
  • If fluid accumulates around the heart’s lining, chest pain may result.
  • Breathlessness if pulmonary fluid accumulates
  • Swelling of feet and ankles
  • Hard to control high blood pressure
  • Headaches
  • Difficulty sleeping
  • Decreased mental sharpness
  • Muscle twitches and cramps
  • Persistent itching
  • Metallic taste

Cause of End-Stage Renal Disease

Numerous medical conditions that affect the kidneys might lead to renal disease. The harm may occur all at once or gradually over years. Kidney failure may eventually result from kidney disease.

  • Type 1 or type 2 diabetes
  • High blood pressure
  • Glomerulonephritis, an inflammation in the filtration unit of the kidneys
  • Inflammation of the kidney’s tubules and surrounding tissues is known as interstitial nephritis
  • There are additional inherited kidney diseases, like polycystic kidney disease.
  • persistent obstruction of the urinary tract caused by diseases like enlarged prostate, kidney stones, or certain malignancies
  • The disorder is known as vesicoureteral reflux, which causes urine to back up into the kidneys
  • Recurrent kidney infection also called pyelonephritis
  • Autoimmune diseases
  • Birth defects that affect the growth and development of kidneys
  • Severe and repetitive infections like urinary tract infections

Risk Factors to End-Stage Renal Disease

There is a chance that end-stage renal disease will develop more quickly in chronic kidney disease due to several factors, including:

  • Diabetes with poor blood sugar control
  • Glomeruli-related kidney disease affects the kidney structures responsible for removing waste products from the blood.
  • Polycystic kidney disease
  • High blood pressure
  • Tobacco use
  • Family history of kidney failure
  • Older age
  • Consumption of drugs that could harm the kidney

Complications of End-Stage Renal Disease

Once kidney damage has been done, it cannot be undone. Nearly any part of the body may experience potential complications, which can include:

  • Fluid retention, which can result in hypertension, fluid in the lungs, and edema in the arms and legs
  • Hyperkalemia – a sudden increase in blood potassium levels that may be fatal and compromise the function of the heart,
  • Heart disease
  • Bone fracture risk is increased by weak bones.
  • Anemia
  • Erectile dysfunction, or diminished sex desire
  • Decreased immune response, increasing the vulnerability to infection
  • Pericarditis is an inflammation of the sac-like membrane that covers the heart
  • Problems in pregnancy that put both the mother and the fetus in danger
  • Malnutrition
  • The end-stage renal disease causes irreversible kidney deterioration that will eventually make dialysis or a kidney transplant necessary to survive.

Diagnosis of End-Stage Renal Disease


Medical professionals could inquire about the patient’s personal and family medical history to diagnose end-stage renal disease. Physical and neurological examinations will be performed, in addition to additional testing like:

  • Blood tests. These will help determine the level of waste products in the blood, such as urea and creatinine.
  • Urine test. This testing is to check the presence of the protein albumin in the urine.
  • Imaging tests such as an ultrasound, MRI, or CT scan. These are ordered to evaluate the kidneys and search for unusual areas that may be used.
  • Removal of a sample of kidney tissue (biopsy). The sample is collected and then examined under a microscope to determine the type of kidney disease the patient has and the extent of the damage there is.

Treatment for End-Stage Renal Disease

Treatments for end-stage renal illness include:

  • Kidney transplant – In a kidney transplant, a healthy kidney from a living or deceased donor is surgically implanted into a patient whose kidneys are no longer functioning correctly. When it comes to treating end-stage renal illness, a kidney transplant is frequently referred to as a lifetime of dialysis. The patient no longer requires dialysis after a successful kidney transplant since the new kidney filters the blood.
  • Dialysis – Dialysis takes up the kidneys’ role in maintaining the body’s equilibrium. Kidney function is unaffected. There are two typical categories:
    • Hemodialysis: Blood is drawn from the body, processed, and then returned to it via a device known as a hemodialyzer. Blood must be transferred using blood arteries in the arm, according to medical professionals.
    • Peritoneal dialysis: While the blood is still inside the body, this procedure cleans it. First, medical professionals insert a plastic tube into the stomach. The surplus fluid and garbage are then collected by a solution that is pumped in. After the cleaning, they remove the solution.
  • Supportive care – The patient can choose palliative or supportive care to help manage the symptoms and feel better if the patient decides without dialysis or a kidney transplant. Palliative care can potentially be combined with dialysis or a kidney transplant. Kidney failure advances without either dialysis or a transplant, ultimately resulting in death. Death can happen suddenly, slowly over months or years. Supportive care may consist of symptom management, comfort-preserving measures, and end-of-life preparation.

Prevention of End Stage Renal Disease

Maintaining control over the illnesses that harm the kidneys, particularly high blood pressure or diabetes, is the best way to prevent end-stage renal disease. The kidney damage will be minimized if the following are employed:

  • Avoid items that have salt added. By avoiding products with added salt, such as many convenience foods like frozen dinners, canned soups, and fast food, the patient can reduce the amount of sodium consumed daily. Salty snack foods, canned vegetables, processed meats, and cheeses are examples of additional salt-containing foods.
  • Pick foods with less potassium. The patient must eat low-potassium food selections at each meal. Bananas, oranges, potatoes, spinach, and tomatoes are examples of foods high in potassium.
  • Eat fewer proteins.  A person should monitor how many grams of protein are required daily. Lean meats, eggs, milk, cheese, and beans are examples of high-protein foods. Foods low in protein include fruits, vegetables, pieces of bread, and cereals.
  • Keep blood pressure at normal range. Preferably below 140/90 or ask the physician what the best blood pressure target is for the person.
  • Managing diabetes properly. Stay in the target blood sugar range as much as possible.

Nursing Diagnosis for End-Stage Renal Disease

Nursing Care Plan for End Stage Renal Disease 1

Risk for Decreased Cardiac Output

Nursing Diagnosis: Risk for Decreased Cardiac Output related to  urea accumulation,  fluid imbalances, electrolyte imbalances, and hypoxia secondary to ESRD

Desired Outcome:  The patient will maintain the patient’s blood pressure and heart rate within the normal range while maintaining strong, equal peripheral pulses and an adequate capillary refill time.

Nursing Interventions for End Stage Renal DiseaseRationale
Auscultate for the patient’s lung and heart sounds. Analyze any peripheral edema, vascular congestion, and dyspnea complaints.Tachycardia, irregular heart rate, tachypnea, dyspnea, crackles, wheezes, edema, jugular distension, and muffled S3 and S4 heart sounds are indicative of heart failure.
Monitor the patient’s blood pressure and take note of any changes following their posture (sitting, lying, standing) to detect the presence and severity of hypertension.   Renin-angiotensin-aldosterone system issues might result in significant hypertension (caused by renal dysfunction). Orthostatic hypotension can happen even while hypertension is frequently present due to intravascular fluid deficiency, a patient’s reaction to the effects of antihypertensive drugs, or uremic pericardial tamponade.  
Examine complaints of chest discomfort, noting its location, radiation, severity (on a scale of 1 to 10), and whether or not it is aggravated by deep inhalation or lying down.  Approximately half of ESRD patients on dialysis develop pericarditis, which increases the risk of pericardial effusion or tamponade even if hypertension and chronic heart failure might induce myocardial infarction.
Observe and monitor diagnostic and laboratory tests: 
BUN, Cr, and electrolytes (potassium, sodium, calcium, and magnesium)Electrical conduction and heart function can be affected by imbalances. chest x-rays  
Chest X-rayHelpful in spotting soft tissue calcification or impending heart failure.
Administer  antihypertensive medications as prescribed    Reduces renin release and systemic vascular resistance to lessen cardiac stress and help avoid heart failure and myocardial infarction.
Prepare the patient for dialysis.By lowering uremic toxins, addressing electrolyte imbalances, and reducing fluid retention, cardiovascular symptoms like hypertension and pericardial effusion may be controlled and prevented.
As needed, assist with pericardiocentesis.A buildup of fluid within the pericardial sac can impede cardiac output and myocardial contractility, increasing the risk of cardiac arrest.

Nursing Care Plan for End Stage Renal Disease 2

Disturbed Thought Process

Nursing Diagnosis: Disturbed Thought Process related to Physiological modifications including the buildup of toxins (such as urea and ammonia), metabolic acidosis, hypoxia, electrolyte imbalances, and brain calcifications secondary to ESRD as evidenced by a lack of orientation to time, place, and people, deficits in memory, attention span, and conceptual understanding, impaired capacity for decision-making and problem-solving, sensory and behavioral changes

Desired Outcomes: 

  • The patient will regain/maintain mental acuity at its best.
  • The patient will determine how to make up for memory or cognitive impairments.
Nursing Interventions for End Stage Renal DiseaseRationale
Analyze the degree of cognitive, memory, and orienting impairment. Take note of the attention span.The effects of the uremic syndrome can start as mild disorientation and irritation and proceed to personality changes or an inability to process knowledge and take part in care. Being aware of changes offers the chance for evaluation and intervention.
Find out the patient’s typical degree of mentation from his/her significant other.Enables comparison to assess the evolution and recovery of disability.
Monitor the patient’s laboratory tests including BUN and Cr, serum electrolytes, glucose levels, and ABGs (Po2, pH).On cognition or mentation, correction of elevations or imbalances can have a significant impact.
Give more oxygen as directed.Addressing hypoxia alone can enhance cognition.
Reorient the patient to the environment, people, etc. Provide calendars, clocks, and an exterior window.Provide hints to help the patient recognize reality.
Present facts succinctly and without challenging erroneous thoughts.    Confrontation amplifies defensive responses, increases patients’ mistrust of the health professional, and intensifies their rejection of reality.
Use straightforward, succinct language to convey information and directions. Direct, yes-or-no inquiries are best. If required, explain everything again.May help to clear up confusion and improve the likelihood that messages will be recalled.
Create a consistent timetable for the activities intended to occur.Helps keep one’s perspective on reality and might help calm anxiety and perplexity.
Encourage appropriate rest and uninterrupted sleep times.Lack of sleep may make cognitive capacities even worse.
Opiates and barbiturates should not be used.Confusion will worsen as a result of the extended half-life and cumulative effects of drugs that are typically detoxified in the kidneys.

Nursing Care Plan for End Stage Renal Disease 3

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge

Desired Outcomes:  Deficient Knowledge related to lack of awareness/recall, incorrect information interpretation, cognitive constraint secondary to ESRD as evidenced by questions, information requests, or statements of misconception, incorrect execution of instructions, and the emergence of preventable complications

Desired Outcomes:

  • The patient will explain in words how they interpret the condition/course of the disease and any potential complications.
  • The patient will explain how they understand the demands of therapy.
  • The patient will execute the necessary steps correctly and justify their decisions.
  • The patient will make the essential lifestyle adjustments.
  • The patient will take part in the treatment plan.
Nursing Interventions for End Stage Renal DiseaseRationale
Review with the patient the disease’s course, its prognosis, and its outlook.Provides the patient with information so that they can make informed choices about ESRD.  
Review the following dietary restrictions: Phosphorus (found in carbonated beverages, processed foods, poultry, corn, and peanuts) and magnesium (found in whole grain products, and legumes)  Phosphorus retention causes the parathyroid glands to release calcium from the bones (causes renal osteodystrophy), and magnesium buildup can affect mental and neuromuscular health.
Limitations on sodium and fluid intake when necessary.  If fluid retention is a concern, the patient may need to limit their fluid consumption to 1100 cc (or less) and reduce their sodium intake. Dialysis or diuretic therapy will be used as part of the treatment plan if there is fluid overload.
Review with the patient additional dietary issues, such as adjusting protein consumption following renal function (generally 0.6 – 0.7g per k of body weight per day of good quality protein, such as meat, and eggs).Protein catabolism is nearly exclusively responsible for the metabolites that build up in blood; when renal function degrades, proteins may be reduced accordingly. Malnutrition may come from a lack of protein. Note: Patients receiving dialysis might not need to watch their protein intake as closely.
Encourage the patient to consume enough calories, primarily from carbohydrates.Protein is saved, waste is avoided, and energy is produced. Note: By using specific glucose polymer powders, one can increase their energy level without consuming more food or liquids.
Stress the value of reading the labels on all products, including food and medication, and the need to seek a doctor’s permission before taking any medication.When dietary limits do not take exogenous consumption into account, it is challenging to maintain electrolyte balance. Regular supplement use combined with increasing dietary calcium-fortified food intake and calcium-containing drugs can lead to hypercalcemia.
Discuss medication management, including the usage of calcium supplements, phosphate binders such as aluminum hydroxide antacids, vitamin D, and the avoidance of magnesium antacids.Prevents serious complications (reduces phosphate absorption from the GI tract, supplies calcium to maintain normal serum levels, lowers the risk of bone demineralization or fractures, and reduces tetany); However, the use of aluminum-containing products should be monitored because accumulation in the bones amplifies osteodystrophy. Products containing magnesium increase the risk of hypermagnesemia. Note: To aid calcium absorption, more vitamin D may be needed.
Review ways to avoid bleeding and hemorrhaging, such as using a soft toothbrush and an electric razor, and avoid constipation, blowing the nose too hard, strenuous exercise, and contact sports.Lowers the risk of clotting factor changes and a drop in platelet count.
Teach how to self-observe and self-monitor their blood pressure, including scheduling a period of rest before taking a reading using the same arm or posture.  The prevalence of hypertension is increased in CRF, necessitating care with antihypertensive medications and needing thorough monitoring of treatment outcomes (vascular response to medication).

Nursing Care Plan for End Stage Renal Disease 4

Risk for Infection

Nursing Diagnosis: Risk for Infection related to metabolic acidosis, pulmonary edema, uremia, and loss of appetite secondary to ESRD

Desired Outcome: The patient will not manifest a temperature remaining below 99 degrees Fahrenheit, a normal WBC count, and/or negative urine and/or blood cultures

Nursing Interventions for End Stage Renal DiseaseRationale
As the ESRD worsens, monitor changes in body temperature, respiratory system, and urine system.Explains the existence of infection brought on by a chronic condition that is progressing as well as how it is affecting all systems.
Examine lab findings for infection (elevated WBC and positive blood cultures).To both avoid and treat an infection that may be secondary to ESRD.
Safeguard cultures of sputum or urine for analysis.Identifies the presence, kind, and specific antibiotic sensitivity of the microorganisms causing the infection.
When necessary, perform proper hand washing and practice medical or surgical asepsis. Teach the patient how to wash their hands properly and how to dispose of used tissues and items.Stops the spread of diseases to the patient.
Administer antibiotics as directed (specify drug, dose, route, and times).Antibiotics aid in preventing or treating an infection.
Teach the patient to take daily baths, wipe their bottoms after using the restroom from front to back, and wear loose cotton underwear.To help prevent the growth of bacteria. Patients can assist in preventing infection by being informed.

Nursing Care Plan for End Stage Renal Disease 5

Impaired Urinary Elimination

Nursing Diagnosis: Impaired Urinary Elimination related to loss of kidney function, decrease in glomerular filtration rate, and accumulation of nitrogenous products and fluid secondary to ESRD as evidenced by the increase in laboratory results (BUN, Creatinine, Uric Acid Level), anuria, oliguria, hesitancy, and urinary retention

Desired Outcomes: 

  • The patient will exhibit actions and methods to avoid urine infection and retention.
  • The patient will determine what is causing the incontinence.
  • The patient will not experience urinary leakage or bladder dilation and will maintain a healthy I&O.
  • The patient will explain the rationale for receiving treatment.
  • The patient will express understanding of the disease through words.
Nursing Interventions for End Stage Renal DiseaseRationale
Assess and monitor the patient’s voiding pattern (frequency and amount). Compare the fluid intake and urine production and monitor the specific gravity of the patient’s urine.Identifies the features of bladder function such as the effectiveness of bladder emptying, renal function, and fluid balance. The main cause of mortality issues with the urinary system.
Check for overflow and feel the bladder to check for distension.Bladder dysfunction comes in several forms, but it can cause reflux incontinence and pee retention by impairing the ability of the bladder to contract and the sphincter to relax. Note: Autonomic dysreflexia may be triggered by bladder distension.
Take note of any reports of urine frequency, urgency, burning, incontinence, nocturia, or stream size or force. Urinate, then feel the patient’s bladder.This reveals the level of elimination interference or might point to a bladder infection. Fullness over the bladder after a void indicates insufficient emptying or retention and calls for medical attention.
Review the patient’s medication regimen, including any prescribed, OTC, and illicit drugs.Numerous substances, including cannabis and various antispasmodics, antidepressants, and narcotic analgesics, as well as OTC pharmaceuticals with anticholinergic or alpha agonist characteristics, might interfere with bladder emptying.
Analyze the patient’s typical urinary pattern and incontinence episodes.Many people only experience incontinence in the morning after their bladders have collected a lot of urine overnight.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna Curran. RN, BSN, PHN

Anna Curran. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse.

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