End – Stage Renal Disease

Description* Chronic renal failure, or end-stage renal

disease (ESRD), is a progressive, irreversible, deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia.

Signs and Symptoms* Cardiovascular: hypertension, pitting edema

(feet, hands, sacrum), periorbital edema, pericardial friction rub, engorged neck veins, pericarditis, pericardial effusion, pericardial tamponade, hyperkalemia, hyperlipidemia.

* Integumentary: gray-bronze skin color, dry flaky skin, pruritus, ecchymosis, purpura , thin brittle nails, coarse thinning hair.

* Pulmonary: crackles; thick, tenacious sputum; depressed cough reflex,: pleuritic pain; shortness of breath; tachypnea; Kussmaul-type respirations; uremic pneumonitis (“uremic lung”)

* Gastrointestinal: ammonia odor to breath (fetor uremicus), metallic taste, mouth ulcerations and bleeding, anorexia, nausea and vomiting, hiccups, constipation or diarrhea, bleeding from gastrointestinal tract.

* Neurologic: weakness and fatigue, confusion, inability to concentrate, disorientation, tremors, seizures, asterixis, restlessness of legs, burning of soles of feet, behavior changes.

* Musculoskeletal: muscle cramps, loss of muscle strength, renal osteodystrophy, bone pain, fractures, foot drop.

* Reproductive: amenorrhea, testicular atrophy, infertility, decrease libido.

* Hematologic: anemia, thrombocytopenia.

Diagnostic Procedures

* Blood tests ( to determine blood cell counts, electrolytes levels, and kidney function.

* Urine tests

* Chest x-ray – a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

* Bone scan- a nuclear imaging method to evaluate any degenerative and/ or arthritic changes in joints; to detect bone diseases and tumors; to determine the cause of bone pain or inflammation.

* Renal ultrasound- a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is use to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst or other obstruction or abnormalities.

* Electrocardiogram (ECG or EKG- a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.

*Kidney biopsy- a procedure in which tissue samples are removed ( with a needle or during surgery) from the body for examination under a microscope; to determine if cancer or other abnormal cells are present.

Nursing ManagementAssessment:

*Assess fluid status and help patient limit fluid intake to prescribed limit.

*Assess nutritional status and address factors contributing to nutritional imbalance.

* Assess patient’s understanding about the condition and it treatment, explain renal function, and assist patient to identify ways to incorporate lifestyle changes related to illness and treatment.

* Assess factors contributing to fatigue.

* Assess patient’s and family’s responses and reaction o illness and treatment. Encourage open discussion of concerns about changes produced by diasease and treatment.

* Assess for and monitor collaborative problems (eg, hyperkalemia, pericarditis, pericardial effusion and pericardial tamponade, hypertension, anemia ,bone disease, and metastatic calcifications.

* Complication can be prevented or delayed by administering prescribed antihypertensive, cardiovascular agents, anticonvulsants, erythropoietin, iron supplements, phosphate-binding agents, and calcium supplements.

* Dietary interventions needed with careful regulation of protein intake, fluid intake to balance fluid losses and sodium intake and with some restriction of potassium.

Medical Management

* Protein is restricted; protein must be of high biologic value (dairy products, eggs, meats.

* Vitamin supplementation.

* Fluid allowance is 500 to 600 mL of fluid or more than 24- hour urine output.

* Adequate intake of calories and vitamins is ensured. Calories are supplied with carbohydrates and fats to prevent wasting.

Pharmacologic Management

*Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids or calcium carbonate; both must be given with food.

*Hypertension is managed by intravascular volume control and antihypertensive medication.

* Heart failure and pulmonary edema are treated with fluid restriction, low-sodium diet, diuretics, inotropic agents, and dialysis.

* Metabolic acidosis is treated, if necessary, with sodium bicarbonate supplements or dialysis.

*Hyperkalemia is treated with dialysis; medications are monitored for potassium content; patient is placed on potassium-restricted diet; Kayexelate is administered as needed.

*Patient is observed for early evidence of neurologic abnormalities.

*The onset of seizures,type,duration,and general effect on patient are recorded; physician is notified immediately and patient is protected from injury with padded side rails.

* Intravenous diazepam or phenytoin is administered to control seizure.

* Anemia is treated with recombinant human erythropoietin; hematocrit is monitored frequently.

* Heparin is adjusted as necessary to prevent clotting of dialysis lines during treatments.

* Serum iron and transferrin levels are monitored to assess iron states.

* Blood pressure and serum potassium levels are monitored.

*Patient is referred to a dialysis and transplantation center early in the course of progressive renal disease. Dialysis is initiated when patient cannot maintain a reasonable lifestyle with conservative treatment.

Other Nursing Interventions Managing Excess Fluid Volume

*Assess fluid status and identify potential sources of imbalanced.

*Monitor patient’s progress and complication with treatment regimen.

Promoting Balance Nutrition

* Implement a dietary program to ensure proper nutritional intake within the limits of the treatment regimen.

* Provide a referral for a nutritional consultation.

Educating the patient and Family

Teaching Patient’s Self-Care

* Provide ongoin g explanations and information to patient and family concerning ESRD, treatment options, and potential complications.

*Teach patient and family what problems to report: signs of worsening renal failure, hyperkalemia, assess problems.

* Provide medication teaching and show patient undergoing hemodialysis how to assess vascular access for patency and precaution to take.

Continuing Care

*Provide assistance and emotional support to patient and family in dealing with dialysis and it’s long term implications.

*Stress the importance of follow-up examinations and treatment.

*Refer patient to home care nurse for continued monitoring and support.

NURSING CARE PLAN

Nursing diagnosisIneffective tissue perfusion related to decreased cardiac output as evidenced by BP=80/40 mmhg, nausea,vomoting, diaphoresis and pr=120bpm.

“grabe lingin ulo ku day” as verbalized by the client.

GoaLWithin 1 hour of nursing interventions, client will be able to maintain adequate

tissue perfusion.

InterventionsIndependent:Monitor vital signs

especially BP.

Elevate head of bed and maintain head/neck in midline or neutral position.

Provide baseline for comparison to follow and evaluate response to interventions.

To promote circulation and to increase gravitational blood flow.

Encourage quiet, restful atmosphere.

Emphasize necessity for smoking cessation.

Conserves energy and lower tissue oxygen demand.

Smoking promote vasoconstriction of blood vessels and may further compromise perfusion.

Encourage use of relaxation activities.

Dependent:Administer

medication as prescribed by the doctor.

*mannitol

To decrease tension level.

Osmotic diuretic that increases BP.

EvaluationAfter 1 hour of nursing intervention,

goal fully met as evidenced by BP=110/80mmhg, PR=80bpm,absence of nausea, vomiting, and diaphoresis.

“la nah galingin ulo ko.” as verbalized by the client.