Definition
Chronic renal failure (CRF), also known as chronic kidney disease (CKD), is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. CRF can develop insidiously over many years, or it may result from an episode of a cure renal failure from which the client has not recovered.
Nursing Goal
The nursing goal for client’s with CRF is to prevent further complications and supportive care. Client education is also critical as this is a chronic disease and thus requires long-term treatment.
Fluid Volume Excess
Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR, nephron hypertrophied leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria.
Assessment
Patient may manifest:
- Edema
- Hypertension
- Weight gain
- Pulmonary congestion (SOB, DOB)
- Oliguria
- Distended jugular vein
- Changes in mental status
Diagnosis
- Fluid Volume Excess R/T decrease glomerular filtration rate and sodium retention
Planning
- Patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess
- Patient will manifest stabilize fluid volume AEB balance I & O, normal VS, stable weight, and free from signs of edema.
| Nursing Interventions | Rationale |
|---|---|
| Establish rapport | To gain patient’s trust and cooperation. |
| Monitor and record vital signs | To assess precipitating and causative factors. |
| Assess possible risk factors | To obtain baseline data |
| Monitor and record vital signs. | To obtain baseline data |
| Assess patient’s appetite | To note for presence of nausea and vomiting |
| Note amount/rate of fluid intake from all sources | To prevent fluid overload and monitor intake and output |
| Compare current weight gain with admission or previous stated weight | To monitor fluid retention and evaluate degree of excess |
| Auscultate breath sounds | For presence of crackles or congestion |
| Record occurrence of dyspnea | To evaluate degree of excess |
| Note presence of edema. | To determine fluid retention |
| Measure abdominal girth for changes. | May indicate increase in fluid retention |
| Evaluate mentation for confusion and personality changes. | May indicate cerebral edema. |
| Observe skin mucous membrane. | To evaluate degree of fluid excess. |
| Change position of client timely. | To prevent pressure ulcers. |
| Review lab data like BUN, Creatinine, Serum electrolyte. | To monitor fluid and electrolyte imbalances |
| Restrict sodium and fluid intake if indicated | To lessen fluid retention and overload. |
| Record I&O accurately and calculate fluid volume balance | To monitor kidney function and fluid retention. |
| Weigh client | Weight gain indicates fluid retention or edema. |
| Encourage quiet, restful atmosphere. | To conserve energy and lower tissue oxygen demand. |
| Promote overall health measure. | To promote wellness. |
Acute Pain
Pain is a discomfort that is caused by the stimulation of the nerve endings. Any trauma that the kidney experience (by any causes or factors) perceive by the body as a threat, the body releases cytokine and prostaglandin causing pain which is felt by the patient at his flank area.
Assessment
Patient may manifest:
- Facial Grimaces
- Guarding behaviors
- Costovertebral pain/ Flank pain
- Limited ROM
- Body weakness
- Facial Mask
- Narrowed Focus
- Sleep Disturbance
- Diaphoresis
- RR & BP changes
Diagnosis
- Acute Pain
Planning
- Patient will demonstrate use of relaxation skills to relieve pain.
- Patient will report relief/control of pain.
| Nursing Interventions | Rationale |
|---|---|
| Establish rapport. | To get the cooperation of the patient and SO. |
| Monitor and record vital signs. | To obtain baseline data. |
| Assess pt’s general condition | To obtain baseline data |
| Accept patient’s description of pain. | Pain is a subjective experience and cannot be felt by other. |
| Perform a comprehensive assessment of pain ( location , onset, characteristics, frequency) | To be able to compare changes from previous reports to rule out worsening of underlying condition/developing complications |
| Determine possible pathophysiology and causes of pain | To know underlying condition that leads to pain and possible management that would not further aggravate pain. |
| Assess patient’s perception along with behavioral and physiological responses. | To know clients attitude towards pain and use of specific pain and medication. |
| Perform pain assessment each time pan occurs, note and investigate changes from previous report. | To rule out worsening of underlying condition / development of complication. |
| Assess patient’s description of pain. | To acknowledge the pain experience convey acceptance of client’s response to pain. |
| Observe nonverbal cues including how client walks, holds body, sits, facial expressions, cool fingertips/ toes, which can mean constricted vessels | Observation may/ may not be congruent with verbal reports indicating need for further evaluation. |
| Assess for referral pain as appropriate | To help determine possibility of underlying condition or organ dysfunction requiring treatment. |
| Review patient’s previous experiences with pain and methods found either helpful or unhelpful for pain control in the past. | To rule out worsening of pain due to methods used. |
| Explore method for alleviation/ control of pain. | Timely intervention is more likely to be successful in alleviating pain. |
| Encourage verbalization of feelings about the pain. | To allow out let for emotions and enhance coping mechanism. |
| Provide quite environment, calm activities and adequate rest reinforce | To prevent fatigue and lessen stimuli. |
| Provide comfort measures such as back rub, change position, use of heat/ cold. | To provide non-pharmacologic pain management. |
| Instruct/encourage use of relaxation exercise such as focused breathing. | This is a form of relaxation technique that helps decrease level of pain. |
| Encourage diversional activities such as TV and socialization with others. | Provides diversionary activities that help block the perception of pain by the brain. |
| Assist with self-care activities. | To able to perform ADL’s and maintain good hygiene. |
| Assist in treatment of underlying disease process causing pain. | Evaluate effectiveness of therapies. |
| Provide for individualized physical therapy/ exercise program that can be continued by the client discharge refer to physical therapist. | To continue therapeutic effect and wellness for the patient |
| Administer analgesics as ordered. | Pharmacologic mgmt for pain |
Altered Renal Tissue Perfusion
For optimal cell functioning the kidney excrete potentially harmful nitrogenous product-Urea, Creatinine, Uric Acid but because of the loss of kidney excretory functions there is impaired excretion of nitrogenous waste product causing in increase in Laboratory result of BUN, Creatinine, Uric Acid Level.
Assessment
- Increase in Lab results (BUN, Creatinine, Uric Acid Level)
- Oliguria
- Anuria
- Edema
- Pulmonary Congestion
- Hypertension
- Hematuria
Diagnosis
- Altered Renal Perfusion RT Glomerular Malfunction
Planning
- Patient will demonstrate participation in his/her recommended treatment program.
- Patient will demonstrate behavior/lifestyle changes to prevent complications
| Nursing Interventions | Rationale |
|---|---|
| Establish rapport | To get the cooperation of the patient and SO. |
| Monitor and record vital signs. | To obtain baseline data |
| Assess patient’s general condition. | To obtain baseline data. |
| Determine factors related to individual situation and note situation that can affect all body system. | To assess causative and contributing factors |
| Note characteristic of urine: measure urine specific gravity. | To assess for hematuria and proteinuria and renal impairment. |
| Ascertain usual voiding pattern | To compare with current situation. |
| Note presence, location intensity duration of pain. | May indicate pain on affected organ |
| Note mentation status and review lab result such as BUN and creatinine levels. | increase BUN and creatinine levels may alter mentation |
| Monitor BP, ascertain patient’s usual range. | GFR may increase rennin and raise BP. |
| Observe for dependent generalized edema. | To note degree of impairment of renal function. |
| Measure urine output on a regular schedule and weigh daily. | To assess renal perfusion and function. |
| Provide diet restriction as indicated, while providing adequate calories. | Calories to meet body’s need while restriction of protein helps limit BUN. |
| Encourage discussion of feelings regarding prognosis or long term effects of discussion. | To decrease anxiety about condition and correct his wrong ideas about condition. |
| Identify necessary changes in lifestyle and assist client to incorporate disease management to ADLs. | To promote wellness and prevent further progression of complication. |
| Assess patient emotional/psychological factors affecting the current situation. | Stress or depression may be increasing the effect of an illness or depression might be the result of being forced into inactivity. |
| Establish realistic activity goal with patient. | Enhance commitments to promoting optical outcomes. |
| Give information about positive signs of improvement such as improve vital signs/ circulation. | To provide encouragement. |
| Provide physiologic support. Maintain calm attitude but admit concerns if questioned by the client/SO. | Honestly can be reassuring when so much activity or worries are apparent to the client or SO. |
| Review expectations of the patient/SO. | To establish individual goals. |
| Give patient information that provides evidence of daily/weekly progress. | To sustain motivation. |
| Encourage patient to maintain positive attitude; suggest use of relaxation technique such as guided imagery as appropriate. | To enhance sense of well being. |
| Administer medication as ordered. | For faster recovery. It is used to treat the client’s disease condition. |
| Promote overall health measure. | To promote wellness. |
Impaired Urinary Elimination
Renal Failure is a problem which results to loss of kidney functions and as GFR decrease, the kidney cannot excrete nitrogenous product and fluid causing impaired in Urinary elimination and together with prolonged use of medications such as NSAIDs this will lead to further kidney destruction which may thus decreasing the glomerular filtration and destroying of the remaining nephrons. This will result into inability of the kidney to concentrate urine which makes the patient to have a nursing diagnosis of impaired urinary elimination.
Assessment
Patient may manifest:
- Increase in Lab results (BUN, Creatinine, Uric Acid Level)
- Oliguria
- Anuria
- Hesitancy
- Urinary Retention
Diagnosis
- Impaired Urinary Elimination R/T failing glomerular filtration AEB Impaired excretion of nitrogenous products secondary to Renal Failure
Planning
- Patient will verbalize understanding of condition
- Patient will participate in measures to correct/compensate for defects
| Nursing Interventions | Rationale |
|---|---|
| Establish rapport. | To get the cooperation of the patient and SO. |
| Monitor and record vital signs. | To obtain baseline data. |
| Assess pt’s general condition | To know what problem and interventions should be prioritize. |
| Review for laboratory test for changes in renal function. | To assess for contributing or causative factors. |
| Establish realistic activity goal with client. | Enhance commitments to promoting optimal outcomes. |
| Determine clients pattern of elimination | To assess degree of interference. |
| Palpate bladder | To assess retention |
| Investigate pain, noting location | To investigate extent of interference |
| Determine client’s usual daily fluid intake | To help determine level of hydration. |
| Note condition of skin and mucous membranes, color of urine. | To assess level of hydration. |
| Observe for signs of infection | To help in treating urinary alterations |
| Encourage to verbalize fear/concerns | Open expression allows client to deal with feelings and begin problem solving. |
| Emphasize the need to adhere with prescribe diet | To prevent aggravation of disease condition. |
| Emphasize importance of having good hygiene. | To promote wellness. |
| Emphasize importance of adhering to treatment regimen | To promote wellness |
Altered Nutrition: Less than Body Requirements
Due restricted foods and prescribed dietary regimen, an individual experiencing renal problem cannot maintain ideal body weight and sufficient nutrition. At the same time patients may experience anemia due to decrease erythropoietic factor that cause decrease in production of RBC causing anemia and fatigue
Assessment
- Anorexia
- Anemia
- Fatigue
- Reported inadequate food intake less than recommended daily allowance
Diagnosis
- Altered Nutrition: Less than body Requirement R/T Catabolic state, Anorexia and Malnutrition 2O to Renal Failure
Planning
- Patient will display normalization of laboratory values and be free of signs of malnutrition.
- Patient will demonstrate behaviors, lifestyle change to regain and maintain an appropriate weight.
| Nursing Interventions | Rationale |
|---|---|
| Establish rapport | To gain patient’s trust. |
| Assess general appearance and monitor vital signs. | To establish baseline data. |
| Identify patient at risk for malnutrition. | To assess contributing factors. |
| Ascertain understanding of individual nutritional needs. | To determine what information to provide the patient. |
| Assess weight, age, body build, strength, rest level. | To provide comparative baseline. |
| Assist in developing individualized regimen. | To control underlying factors. |
| Provide diet modification as indicated. | To establish a nutritional plans. |
| Determine whether patient prefers more calories in a meal. | To establish a nutritional plans. |
| Avoid high in sodium-rich food. | To prevent further increase in sodium level. |
| Promote relaxing environment. | To enhance intake. |
| Provide oral care. | To prevent further spread of dental caries. |
| Provide safety. | To prevent injury. |
| Maintain bed rest. | To decrease metabolic demand. |
| Change position every 2 hours. | To prevent ulcerations. |
| Position the bed into semi-fowler’s position. | To enhance lung expansion. |
| Limit fluid intake as ordered. | To prevent water retention. |
| Encourage to do Passive range of motion exercise. | To have proper circulation of blood. |
| Encourage early ambulation. | To prevent muscle atrophy. |
| Regulate Intravenous line as Ordered. | To maintain hydration status. |
| Administer Medications as ordered. | To prompt treatment. |
Other Possible Nursing Care Plans
- Hyperthermia due to possible infection or activation of inflammatory process.
- Impaired skin integrity due to edema.
- Deficient Knowledge
