Tuesday, October 19, 2010

Chronic renal failure CRF or end-stage renal disease, ESRD is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or kidney transplantation is performed. Chronic renal failure, or 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 or azotemia (retention of urea and other nitrogenous wastes in the blood). Few symptoms develop until after more than 75% of Glomerular filtration is lost. Then, the remaining normal parenchyma deteriorates progressively and symptoms worsen as renal function decreases. 

Pathophysiology of Chronic renal failure 
End result of the gradual, progressive destruction of nephrons and decrease in Glomerular Filtration Rate (GFR), resulting in loss of kidney function that produces major changes in all body systems. Chronic kidney disease (CKD), although ultimately irreversible, may be slowed by improved standardized blood tests and availability of new drugs to control blood pressure 

Stages of renal failure
Chronic kidney disease CKD stages correspond to the degree of nephron loss:

  • Decreased renal reserve, Glomerular Filtration Rate GFR may be normal; slightly higher than normal, stage I: greater than or equal to 90 mL/min/1.73 m2; or somewhat less than normal, stage II: 60 to 89 mL/min/1.73 m2. Kidney dysfunction is present, however, it may be undiagnosed due to lack of symptoms blood urea nitrogen/creatinine (BUN/Cr) ratio is normal and nephron loss at less than 75%.
  • Renal insufficiency, Nephron loss at 75% to 90%; GFR is moderately (stage III: 30 to 59 mL/min/1.73 m2) to severely (stage IV: 15 to 29 mL/min/1.73 m2) reduced. Slight elevation in BUN/Cr. Polyuria and nocturia present high output failure
  • Renal Failure (GFR 20% to 25% of normal)
  • End Stage Renal Disease (ESRD). Nephron loss at greater than 90% with a GFR of only 10% to 15% (stage V: less than 15 mL/min/1.73 m2). Fluid and electrolyte abnormalities, Azotemia and uremia present Dialysis required

Clinical Manifestations of Chronic renal failure

  • Gastrointestinal GI anorexia, nausea, vomiting, hiccups, ulceration of Gastrointestinal GI tract, and hemorrhage 
  • Cardiovascular hyperkalemic ECG changes, hypertension, pericarditis, pericardial effusion, pericardial tamponade 
  • Respiratory pulmonary edema, pleural effusions, pleural rub 
  • Neuromuscular fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma 
  • Metabolic and endocrine glucose intolerance, hyperlipidemia, sex hormone disturbances causing decreased libido, impotence, amenorrhea 
  • Fluid, electrolyte, acid base disturbances usually salt and water retention but may be sodium loss with dehydration, acidosis, hyperkalemia, hypermagnesemia, hypocalcemia 
  • Dermatologic pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost 
  • Skeletal abnormalities renal osteodystrophy resulting in osteomalacia 
  • Hematologic anemia, defect in quality of platelets, increased bleeding tendencies 
  • Psychosocial functions personality and behavior changes, alteration in cognitive processes

Etiology Causes Renal Failure Chronic CRF
Multiple causes;

  • Acute tubular necrosis (ATN) from unresolved acute renal failure (ARF) 
  • Chronic infections: glomerulonephritis, pyelonephritis, beta hemolytic streptococci infection 
  • Vascular diseases: hypertensive nephrosclerosis, renal artery stenosis, renal vein thrombosis, vasculitis 
  • Obstructive processes: long-standing renal calculi, Benign Prostatic Hyperplasia (BPH) 
  • Cystic disorders: polycystic or medullary kidney disease 
  • Collagen diseases: systemic lupus erythematosus (SLE) and collagen vascular disease 
  • Tumors: malignant (multiple myeloma) or benign 
  • Nephrotoxic agents: drugs, such as aminoglycosides, tetracyclines, contrast dyes, heavy metals 
  • Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism 
  • Long-standing systemic hypertension

Such comorbidities as diabetes and hypertension are responsible for more than 70% of all cases of End Stage Renal Disease ESRD. Highest incidence of End Stage Renal Disease ESRD occurs in individuals older than age 65 years. over the last decade, there has been a 98% increase in incidence in those aged 75 years and older

If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. Even in patient with life sustaining maintenance Renal dialysis or a kidney transplant, the patient may still have:

  • Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) 
  • Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis 
  • Hypertension due to sodium and water retention and malfunction of the rennin angiotensin aldosterone system 
  • Anemia due to decreased erythropoietin production, decreased Red Blood Cell RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis 
  • Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels 
  • Peripheral neuropathy, Restless leg syndrome, one of the first symptoms of peripheral neuropathy, causes pain, burning, and itching in the legs and feet. Eventually, this condition progresses to paresthesia and motor nerve dysfunction unless dialysis is initiated 
  • Sexual dysfunction 

Treatment Goal for Chronic renal failure CRF End Stage Renal Disease ESRD conservation of renal function as long as possible. Correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.

Treatment For Chronic renal failure CRF End Stage Renal Disease ESRD

  • Detection and treatment of reversible causes of renal failure (e.g. bring Diabetes Mellitus under control, treat hypertension) 
  • Dietary regulation low-protein diet supplemented with essential amino acids or their keto analogues to minimize uremic toxicity and to prevent wasting and malnutrition 
  • Fluid status maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume. Loop diuretics, such as furosemide only if some renal function remains, and fluid restriction can reduce fluid retention. 
  • A cardiac glycoside may be used to mobilize edema fluids; an antihypertensive, especially an angiotensin-converting enzyme inhibitor, to control blood pressure and associated edema. 
  • Treatment of associated conditions to improve renal dynamics 
  • Anemia recombinant human erythropoietin (Epo-gen), a synthetic hormone. Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells. 
  • Acidosis replacement of bicarbonate stores by infusion or oral administration of sodium bicarbonate 
  • Hyperkalemia restriction of dietary potassium; administration of cation exchange resin 
  • Phosphate retention decrease dietary phosphorus (chicken, milk, legumes, carbonated beverages); administer phosphate-binding agents because they bind phosphorus in the intestinal tract 
  • Drug therapy, surgery, and dialysis Maintenance renal dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management. Antiemetic taken before meals may relieve nausea and vomiting, and cimetidine, omeprazole, or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.
Nursing Assessment

  • Patient History, Obtain history of chronic disorders and underlying health status. The patient’s history may include a disease or condition that can cause renal failure, but he may not have any symptoms for a long time. Symptoms usually occur by the time the GFR is 20% to 35% of normal, and almost all body systems are affected. Assessment findings reflect involvement of each system; many findings reflect involvement of more than one system. The patient may report a history of Acute Renal Failure ARF 
  • Assess degree of renal impairment and involvement of other body systems by obtaining a review of systems and reviewing laboratory results. Patient’s description of any central nervous system (CNS) symptoms. Blurred vision is common. Patients may have impaired decision making and judgment, irritability, decreased alertness, insomnia, increased extremity weakness, and signs of increasing peripheral neuropathy (decreased sensation in the extremities, hands, and feet; pain; and burning sensations). 
  • CRF affects all body systems Perform thorough physical examination, including vital signs, cardiovascular, pulmonary, GI, neurologic, dermatologic, and musculoskeletal systems. Hypertension is usually noted in the patient with CRF and may indeed be its cause. Patients often have rapid, irregular heart rates; distended jugular veins; and if pericarditis is present, pericardial frictions rub and distant heart sounds. Respiratory symptoms include hyperventilation, Kussmaul breathing, Dyspnea, orthopnea, and pulmonary congestion. 
  • Assess psychosocial response to disease process including availability of resources and support network. Some patient may have personality and cognitive changes. Sexual dysfunction usually occur in patient with chronic renal failure, carefully assess of the patient’s capabilities, home situation, available support systems, financial resources, and coping abilities is important before any nursing interventions for Chronic Renal Failure CRF can be planned. 

Diagnostic Test Chronic Renal Failure CRF 

  • Complete blood count (CBC) anemia (a characteristic sign), Elevated serum creatinine, BUN, phosphorus. Decreased serum calcium, bicarbonate, and proteins, especially albumin. ABG levels low blood pH, low carbon dioxide, low bicarbonate. show elevated blood urea nitrogen, creatinine, and potassium levels; decreased arterial pH and bicarbonate levels, and low hemoglobin (Hb) levels and hematocrit (HCT). 
  • Computed tomography scan, Renal or abdominal X-ray, magnetic resonance imaging, or Ultrasonography shows reduced kidney size. 
  • Kidney biopsy allows histological identification of underlying pathology 

Nursing Diagnosis 
Common Nursing diagnosis that could be found in patient with Chronic Renal Failure CRF: 
Risk for decreased Cardiac Output 
Risk for ineffective Protection 
Disturbed Thought Processes 
Risk for impaired Skin Integrity 
Risk for impaired Oral Mucous Membrane 
Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 
Acute pain 
Disabled family coping 
Excess fluid volume 
Imbalanced nutrition: Less than body requirements
Impaired gas exchange 
Impaired oral mucous membrane 
Impaired urinary elimination 
Ineffective coping 
Ineffective sexuality patterns 
Ineffective tissue perfusion: Renal 
Interrupted family processes 
Risk for infection 
Risk for injury 

Nursing Intervention  

Nursing diagnosis 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) 

Desired Outcomes/Evaluation Criteria Client Will Circulation Status: 
Maintain cardiac output as evidenced by blood pressure (BP) and heart rate within client’s normal range; peripheral pulses strong and equal with prompt capillary refill time. 

Nursing Intervention Risk for decreased Cardiac Output: 

  • Auscultate heart and lung sounds. Evaluate presence of peripheral edema, vascular congestion, and reports of Dyspnea. Rationale S3/S4 heart sounds with muffled tones, tachycardia, irregular heart rate, Tachypnea, Dyspnea, crackles, wheezes, and edema or jugular distention suggest heart failure (HF). 
  • Assess presence and degree of hypertension Monitor Blood Pressure and note postural changes, such as sitting, lying, and standing. Rationale Significant hypertension can occur because of disturbances in the rennin 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 to 10 scale), and whether or not it is intensified by deep inspiration and supine position. Rationale: Although hypertension and chronic HF may cause myocardial infarction (MI), approximately half of CRF clients on dialysis develop pericarditis, potentiating risk of pericardial effusion and tamponade. 
  • Evaluate heart sounds for friction rub, BP, peripheral pulses, JVD, capillary refill, and mentation. Rationale: Presence of sudden hypotension with paradoxical pulse, narrow pulse pressure, diminished or absent peripheral pulses, marked JVD, pallor, and a rapid mental deterioration indicate tamponade, which is a medical emergency. 
  • Assess activity level and response to activity. Rationale: Weakness can be attributed to heart failure and anemia. 
  • Collaborate in treatment of underlying disease or conditions, where possible. Rationale Delaying or halting progression of CRF in early stages can be aided by interventions, such as controlling BP, managing diabetes, treating hyperlipidemia, and avoiding toxins such as NSAIDs, intravenous (IV) contrast dye, amino glycosides, and so on. 
  • Administer oxygen, as indicated. Rationale: Cardiac function can be improved with use of oxygen if client is severely anemic or metabolic acidosis and electrolyte abnormalities are causing Dysrhythmias. 
  • Prepare for renal replacement therapy, such as hemodialysis. Rationale: Reduction of uremic toxins and correction of electrolyte imbalances and fluid overload may limit or prevent cardiac manifestations, including hypertension and pericardial effusion. 

Nursing Diagnosis Risk for ineffective Protection 
Risk factors may include: 

  • Abnormal blood profile decreased RBC production and survival, altered clotting factors (suppressed erythropoietin production or secretion). 
  • Increased capillary fragility 

Desired Outcomes/Evaluation Criteria Client Will 

  • Experience no signs and symptoms of bleeding or hemorrhage. 
  • Maintain or demonstrate improvement in laboratory values. 

Nursing Intervention: 

  • Note reports of increasing fatigue and weakness. Observe for tachycardia, pallor of skin and mucous membranes, Dyspnea, and chest pain. Plan client activities to avoid fatigue. Rationale May reflect effects of anemia and cardiac response necessary to keep cells oxygenated. 
  • Monitor level of consciousness (LOC) and behavior. Rationale Anemia may cause cerebral hypoxia manifested by changes in mentation, orientation, and behavioral responses. 
  • Evaluate response to activity and ability to perform tasks. Assist as needed and develop schedule for rest. Rationale Anemia decreases tissue oxygenation and increases fatigue, which may require intervention, changes in activity, and rest. 
  • Observe for oozing from venipuncture sites, bleeding or ecchymosis areas following slight trauma, petechiae, and joint swelling or mucous membrane involvement bleeding gums, recurrent epitasis, hematemesis, melena, and hazy or red urine. Rationale Bleeding can occur easily because of capillary fragility and altered clotting functions and may worsen anemia. 
  • Provide soft toothbrush and electric razor. Use smallest needle possible and apply prolonged pressure following injections or vascular punctures. Rationale Reduces risk of bleeding and hematoma formation. 
  • Administer fresh blood and packed red cells (PRCs), as indicated. Rationale May be necessary when client is symptomatic with anemia. PRCs are usually given when client is experiencing fluid overload or receiving dialysis treatment. Washed RBCs are used to prevent hyperkalemia associated with stored blood. 
  • Administer medications, as indicated, for example: Erythropoietin preparations (Epogen, EPO, Procrit) Rationale Stimulates the production and maintenance of RBCs, thus decreasing the need for transfusion. Iron preparations, such as folic acid and cyanocobalamin Rationale Useful in managing symptomatic anemia related to nutritional and dialysis-induced deficits. Note: Iron should not be given with phosphate binders because they may decrease iron absorption. Cimetidine, ranitidine, and antacids Rationale 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 Rationale Inhibits bleeding that does not subside spontaneously or respond to usual treatment. Stool softeners, such as Colace and bulk laxative, such as Metamucil Rationale straining to pass hard formed stool increases likelihood of mucosal or rectal bleeding. 

Nursing Diagnosis Disturbed Thought Processes 
May be related to: Physiological changes accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances; calcifications in the brain 
Desired Nursing Outcomes Evaluation Criteria Client Will: 
  • Regain or maintain optimal level of mentation. 
  • Identify ways to compensate for cognitive impairment and memory deficits. 

Nursing Intervention nursing diagnosis Disturbed Thought Processes: 
  • Assess extent of impairment in thinking ability, memory, and orientation. Rationale Uremic syndrome’s effect can begin with minor confusion or irritability and progress to altered personality, inability to assimilate information or participate in care. Awareness of changes provides opportunity for evaluation and intervention. 
  • Provide quiet, calm environment and judicious use of TV, radio, and visitation. Rationale Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation. 
  • Reorient to surroundings, person, and so forth. Provide calendars, clocks, and outside window. Rationale Provides clues to aid in recognition of reality. 
  • Present reality concisely and briefly, and do not challenge illogical thinking. Rationale Confrontation potentiates defensive reactions and may lead to client mistrust and heightened denial of reality. 
  • Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary. Rationale May aid in reducing confusion and increases possibility that communications will be understood and remembered. 
  • Establish a regular schedule for expected activities. Rationale Aids in maintaining reality orientation and may reduce fear and confusion. 
  • Promote adequate rest and undisturbed periods for sleep Rationale Sleep deprivation may further impair cognitive abilities. 
  • Provide supplemental oxygen (O2) as indicated. Rationale Correction of hypoxia alone can improve cognition. 
  • Avoid use of barbiturates and opiates. Rationale Drugs normally detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion. 

Nursing diagnosis Risk for impaired Skin Integrity 
Risk factors may include: 
  • Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy) 
  • Changes in fluid status; alterations in skin turgor edema 
  • Reduced activity, immobility Accumulation of toxins in the skin 

Desired Outcomes/Evaluation Criteria Client Will: 
  • Maintain intact skin. 
  • Risk Management 
  • Demonstrate behaviors and techniques to prevent skin breakdown or injury. 

Intervention Nursing diagnosis Risk for impaired Skin Integrity: 
  • Inspect skin for changes in color, turgor, and vascularity. Note redness and excoriation. Observe for ecchymosis and purpura. Rationale Indicates areas of poor circulation and early breakdown that may lead to decubitus formation and infection. 
  • Monitor fluid intake and hydration of skin and mucous membranes. Rationale Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level. 
  • Inspect dependent areas for edema. Elevate legs, as indicated. Rationale Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. 
  • Change position frequently, move client carefully, pad bony prominences with sheepskin, and use elbow and heel protectors. Rationale Decreases pressure on edematous, poorly perfused tissues to reduce ischemia. 
  • Provide soothing skin care, restrict use of soaps, and apply ointments or creams such as lanolin or Aquaphor. Rationale Baking soda and cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin. 
  • Keep linens dry and wrinkle free. Rationale Reduces dermal irritation and risk of skin breakdown. 
  • Investigate reports of itching. Rationale 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 client use cool, moist compresses to apply pressure to, rather than scratch, pruritic areas. Keep fingernails short; encourage use of gloves during sleep, if needed. Rationale Alleviates discomfort and reduces risk of dermal injury. 
  • Suggest wearing loose-fitting cotton garments. Rationale Prevents direct dermal irritation and promotes evaporation of moisture on the skin. 
  • Provide foam or flotation mattress. Rationale Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis. 

Nursing Diagnosis 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 

Desired Outcomes/Evaluation Criteria Client Will 
  • Maintain Oral Health 
  • Maintain integrity of mucous membranes. 
  • Identify and initiate specific interventions to promote healthy oral mucosa. 

Nursing Intervention Nursing diagnosis Risk for impaired Oral Mucous Membrane: 
  • Inspect oral cavity: note moistness, character of saliva, presence of inflammation, ulcerations, and leukoplakia. Rationale Provides opportunity for prompt intervention and prevention of infection. 
  • Provide fluids throughout 24-hour period within prescribed limit. Rationale Prevents excessive oral dryness from prolonged period without oral intake. 
  • Offer frequent mouth care or rinse with 0.25% acetic acid solution. Provide gum, hard candy, or breathe mints between meals. Rationale 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. Rationale Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding. 
  • Recommend client stop smoking and avoid lemon and glycerin products or mouthwash containing alcohol. Rationale These substances are irritating to the mucosa and have a drying effect, potentiating discomfort. 
  • Provide artificial saliva as needed, such as Oral-Lube. Rationale Prevents dryness, buffers acids, and promotes comfort. 

Patient Teaching Discharge and Home Healthcare Guidelines 
Patient teaching discharge and home healthcare guidelines for patient with Chronic Renal Failure CRF End Stage Renal Disease ESRD. CRF or ESRD are disorders that affect the patient’s total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. To promote adherence to the therapeutic program, and Encourage all people with the following risk factors to obtain screening for chronic kidney disease: elderly people, ethnic minorities, diabetics, and people with hypertension, those with autoimmune disease, and those with family history of kidney disease. Nurses may need to work collaboratively with social services to arrange for the patient’s dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important. 
Patient Teaching Discharge and Home Healthcare Guidelines Chronic Renal Failure CRF 
  • Teach the patient how to take his medications and what adverse effects to watch for. Suggest taking diuretics in the morning so that sleep isn’t disturbed. Topics to cover include reason for the procedure; complications; signs and symptoms of the related disease; how to check for bleeding, electrolyte imbalance, and changes in blood pressure; diet; exercise; and the use of equipment. 
  • In patient that requires dialysis, instruct him on how to adjust his medication schedule as needed in relation to dialysis care plan. 
  • Instruct the anemic patient to conserve energy by resting frequently. 
  • Tell the patient to report leg cramps or excessive muscle twitching. 
  • Explained to patients and family the importance of keeping follow-up appointments to have his electrolyte levels monitored. 
  • Explained to patients and family to avoid high-sodium and high-potassium foods. Encourage adherence to fluid and protein restrictions. To prevent constipation, stress the need for exercise and sufficient dietary fiber. 
  • Eat food before drinking fluids to alleviate dry mouth. If the patient requires dialysis, remember that he and family members are under extreme stress. 
  • If the facility doesn’t offer a course on dialysis nurses need to teach the patient and family members. 
  • A patient undergoing dialysis is under a great deal of stress, as is his family. Refer them to appropriate counseling agencies for assistance in coping with chronic renal failure. 
  • Demonstrate how to care for the shunt, fistula, or other vascular access device and how to perform meticulous skin care. Discourage activity that might cause the patient to bump or irritate the access site. 
  • Suggest that the patient wear a medical identification bracelet or carry pertinent information with him. 
  • Weigh self every morning to avoid fluid overload. 
  • Drink limited amounts of fluids only when thirsty. 
  • Measure allotted fluids, and save some for ice cubes; sucking on ice is thirst quenching. 
  • Use hard candy or chewing gum to moisten mouth.

Sunday, October 17, 2010

Dialysis treatment replaces the function of the Renal/kidneys, which normally serve as the body’s natural filtration system. Dialysis is performed as critical life support when someone suffers acute or chronic kidney failure. Process that substitutes for kidney function by removing excess fluid and accumulated endogenous or exogenous toxins. It is a mechanical way to cleanse the blood and balance body fluids and chemicals when the kidneys are not able to perform these essential functions. Because kidney function can be reversible in some cases, dialysis can provide temporary support until renal function is restored. Dialysis may also be used in irreversible or chronic kidney shutdown when transplantation is the medical goal and the patient is waiting for donated kidneys. Some critically ill patients, with life-threatening illnesses, such as cancer or severe heart disease, are not candidates for transplantation and dialysis may be the only option for treating what is called End Stage Renal Disease (ESRD).Type of fluid and solute removal depends on the client’s underlying Pathophysiology, current hemodynamic status, vascular access, availability of equipment and resources, and healthcare providers’ training. There are two types of dialysis treatment: hemodialysis and peritoneal dialysis 
Two primary types of Renal/kidneys dialysis 

Peritoneal Dialysis 

  • Continuous Ambulatory Peritoneal Dialysis: Continuous ambulatory peritoneal dialysis (CAPD) is a form of intracorporeal dialysis that uses the peritoneum for the semi permeable membrane. 
  • Continuous cyclic peritoneal dialysis (CCPD). Also called automated peritoneal dialysis (APD), CCPD is an overnight treatment that uses a machine to drain and refill the abdominal cavity; CCPD takes 10 to 12 hours per session. 
  • Intermittent peritoneal dialysis (IPD). This hospitalbased treatment is performed several times a week. A machine administers and drains the dialysate solution, and sessions can take 12 to 24 hours. 

Hemodialysis is a process of cleansing the blood of accumulated waste products. It is used for patients with end-stage renal failure or for acutely ill patients who require short-term dialysis. The treatment involves circulating the patient’s blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. Two needles are inserted into the patient’s vein, or access site, and are attached to the ECC, which consists of plastic blood tubing, a filter known as a dialyzer (artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a chemical bath that is used to draw waste products out of the blood. 


  • Treatment for acute renal failure (ARF) or chronic end-stage renal disease (ESRD) 
  • Emergency removal of toxins due to drug overdose, acute life-threatening hyperkalemia, severe acidosis, and uremia 

Choice of dialysis is determined by three main factors. 
Type of renal failure (acute or chronic) 
Client’s particular physical condition 
Access to dialysis resources 

Nursing assessment for renal dialysis Refer to Acute Renal Failure or Chronic Renal Failure, for assessment here
Primary focus is at the community level at the dialysis center, although inpatient acute stay may be required during initiation of therapy. 

Nursing Diagnoses That Could Be Found In Patient with Renal Dialysis 

  • Imbalanced Nutrition: Less than Body Requirements 
  • Impaired physical Mobility 
  • Self-Care Deficit 
  • Risk for Constipation 
  • Risk for disturbed Thought Processes 
  • Anxiety [specify level]/Fear 
  • Disturbed Body Image/situational low Self-Esteem
  • Deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs 

Nursing Care Plan for patient with Renal Dialysis Nursing diagnosis Imbalanced Nutrition Less than Body Requirements May be related to Gastrointestinal (GI) disturbances (result of uremia or medication side effects)—anorexia, nausea, vomiting, and stomatitis Sensation of feeling full—abdominal distention during continuous ambulatory peritoneal dialysis (CAPD) Dietary restrictions bland, tasteless food; lack of interest in food Loss of peptides and amino acids (building blocks for proteins) during dialysis 

Nursing Interventions

  1. Monitor food and fluid ingested and calculate daily caloric intake. Rationale Identifies nutritional deficits and therapy needs, which are extremely variable, depending on client’s age, stage of renal disease, other coexisting conditions, and the type of dialysis being planned 
  2. Recommend client keep a food diary, including estimation of ingested calories, protein, and electrolytes of individual concern—sodium, potassium, chloride, magnesium, and phosphorus Rationale Helps client realize “big picture” and allows opportunity to alter dietary choices to meet individual desires within identified restriction 
  3. Note presence of nausea and anorexia Rationale Symptoms accompany accumulation of endogenous toxins that can alter or reduce intake and require intervention 
  4. Encourage client to participate in menu planning Rationale May enhance oral intake and promote sense of control. 
  5. Recommend small, frequent meals. Schedule meals according to dialysis needs Rationale Smaller portions may enhance intake. Type of dialysis influences meal patterns; for instance, clients receiving Hemodialysis HD might not be fed directly before or during procedure because this can alter fluid removal, and clients undergoing Peritoneal Dialysis PD may be unable to ingest food while abdomen is distended with dialysate. 
  6. Encourage use of herbs and spices such as garlic, onion, pepper, parsley, cilantro, and lemon Rationale Adds zest to food to help reduce boredom with diet, while reducing potential for ingesting too much potassium and sodium 
  7. Suggest socialization during meals Rationale Provides diversion and promotes social aspects of eating. 
  8. Encourage frequent mouth care Rationale Reduces discomfort of oral stomatitis and metallic taste in mouth associated with uremia, which can interfere with food intake 
  9. Refer to nutritionist or dietitian to develop diet appropriate to client’s needs Rationale Necessary to develop complex and highly individual dietary program to meet cultural and lifestyle needs. 
  10. Perform complete nutrition assessment measure muscle mass via triceps skinfold or similar procedure. Determine muscle to fat ratio. Rationale Assesses need and adequacy of nutrient utilization by measuring changes that may suggest presence or absence of tissue catabolism. 
  11. Provide a balanced diet, usually of 2,000 to 2,200 calories/day of complex carbohydrates and ordered amount of high-quality protein and essential amino acids. Rationale Provides sufficient nutrients to improve energy and prevent muscle wasting (catabolism); promotes tissue regeneration and healing and electrolyte balance. 
  12. Restrict sodium and potassium as indicated; for example, avoid bacon, ham, other processed meats and foods, orange juice, and tomato soup Rationale these electrolytes can quickly accumulate, causing fluid retention, weakness, and potentially lethal cardiac Dysrhythmias. 

Sample Nursing Care Plan for patient with Renal Dialysis
Imbalanced Nutrition: Less than Body Requirements May be related to
Gastrointestinal (GI) disturbances (result of uremia or medication side effects)—anorexia, nausea, vomiting, and stomatitis
Sensation of feeling full—abdominal distention during continuous ambulatory peritoneal dialysis (CAPD)
Dietary restrictions—bland, tasteless food; lack of interest in food
Loss of peptides and amino acids (building blocks for proteins) during dialysis

Nutrition Therapy
Monitor food and fluid ingested and calculate daily caloric intake.

Recommend client/significant other (SO) keep a food diary, including estimation of ingested calories, protein, and electrolytes of individual concern—sodium, potassium, chloride, magnesium, and phosphorus.
Note presence of nausea and anorexia.

Encourage client to participate in menu planning.

Recommend small, frequent meals. Schedule meals according to dialysis needs.

Encourage use of herbs and spices such as garlic, onion, pepper, parsley, cilantro, and lemon.

Suggest socialization during meals.
Encourage frequent mouth care.

Refer to nutritionist or dietitian to develop diet appropriate to client’s needs.

Perform complete nutrition assessment—measure muscle mass via triceps skinfold or similar procedure. Determine muscle to fat ratio.
Provide a balanced diet, usually of 2,000 to 2,200 calories/day of complex carbohydrates and ordered amount of high-quality protein and essential amino acids.

Restrict sodium and potassium as indicated; for example, avoid bacon, ham, other processed meats and foods, orange juice, and tomato soup.

Administer multivitamins, including folic acid; vitamins B6, C, and D; and iron supplements, as indicated.
Administer parenteral supplements, as indicated, or IDPN, as necessary.

Monitor laboratory studies, for example:Serum protein, prealbumin or albumin levels Hemoglobin (Hgb), red blood cell (RBC), and iron levels

Administer medications, as appropriate, for example:
Antiemetics, such as prochlorperazine (Compazine)
Histamine blockers, such as famotidine (Pepcid)
Hormones and supplements as indicated, such as erythropoietin (EPO, Epogen) and iron supplement (Niferex)

Insert and maintain nasogastric (NG) or enteral feeding tube, if indicated.

Identifies nutritional deficits and therapy needs, which are extremely variable, depending on client’s age, stage of renal disease, other coexisting conditions, and the type of dialysis being planned.
Helps client realize “big picture” and allows opportunity to alter dietary choices to meet individual desires within identified restriction.
Symptoms accompany accumulation of endogenous toxins that can alter or reduce intake and require intervention.

May enhance oral intake and promote sense of control.
Smaller portions may enhance intake. Type of dialysis influences meal patterns; for instance, clients receiving HD might not be fed directly before or during procedure because this can alter fluid removal, and clients undergoing PD may be unable to ingest food while abdomen is distended with dialysate.
Adds zest to food to help reduce boredom with diet, while reducing potential for ingesting too much potassium and sodium.
Provides diversion and promotes social aspects of eating.
Reduces discomfort of oral stomatitis and metallic taste in mouth associated with uremia, which can interfere with food intake.
Necessary to develop complex and highly individual dietary program to meet cultural and lifestyle needs within specific kilocalorie and protein restrictions while controlling phosphorus, sodium, and potassium.
Assesses need and adequacy of nutrient utilization by measuring changes that may suggest presence or absence of tissue catabolism.
Provides sufficient nutrients to improve energy and prevent muscle wasting (catabolism); promotes tissue regeneration and healing and electrolyte balance. Although client with kidney disease is often advised to limit protein intake, that changes with the start of dialysis. Protein-rich foods, such as fresh meats, poultry, fish and other seafood, eggs and egg whites, and small servings of dairy products are needed for building muscles, repairing tissue, and fighting infection. However, some protein-rich foods may contain a high level of phosphorus, so a dietitian’s input is essential in determining the right amount to eat (Paton, 2007).
These electrolytes can quickly accumulate, causing fluid retention, weakness, and potentially lethal cardiac dysrhythmias. Note: PD is not as effective in lowering elevated Na+ level, necessitating tighter control of Na+ intake.
Replaces vitamin and mineral deficits resulting from malnutrition, anemia, or lost during dialysis.
Hyperalimentation may be needed to enhance renal tubular regeneration and resolution of underlying disease process and to provide nutrients if oral or enteral feeding is contraindicated.
Indicators of protein needs. Note: PD is associated with significant protein loss. Serum albumin levels below 3.4 g/dL suggest need for IDPN infusions.Anemia is the most pervasive complication affecting energy levels in ESRD.
Reduces stimulation of the vomiting center.
Gastric distress is common and may be a neuropathy-induced gastric paresis. Hypersecretion can cause persistent gastric distress and digestive dysfunction.
Although EPO is given to increase numbers of RBCs, it is not effective without iron supplementation. Niferex is preferred because it can be given once daily and has fewer side effects than many iron preparations.
May be necessary when persistent vomiting occurs or when
enteral feeding is desired.

Demonstrate stable weight or gain toward goal with normalization of laboratory values and no signs of malnutrition.
Impaired physical Mobility May be related to
Restrictive therapies—lengthy dialysis procedure
Fear of or real danger of dislodging dialysis lines or catheter
Decreased strength and endurance; musculoskeletal impairment
Perceptual or cognitive impairment
Bed Rest Care
Assess activity limitations, noting presence and degree of restriction or ability.
Encourage frequent change of position when on bedrest or chair rest; support affected body parts and joints with pillows, rolls, sheepskin, and elbow and heel pads, as indicated.
Provide gentle massage. Keep skin clean and dry. Keep linens dry and wrinkle free.
Encourage deep breathing and coughing. Elevate head of bed, as appropriate.
Suggest and provide diversion as appropriate to client’s condition—visitors, radio or TV, and books. Take time to interact with client, showing interest in client’s life.
Instruct in and assist with active and passive range-of-motion (ROM) exercises.

Exercise Promotion
Institute a planned activity or exercise program as appropriate, with client’s input.

Bed Rest Care
Provide foam, water, or air flotation mattress or soft chair cushion.

Influences choice of interventions.

Decreases discomfort, maintains muscle strength and joint mobility, enhances circulation, and prevents skin breakdown.

Stimulates circulation; prevents skin irritation.
Mobilizes secretions, improves lung expansion, and reduces risk of respiratory complications, such as atelectasis or pneumonia.
Decreases boredom; promotes relaxation.

Maintains joint flexibility, prevents contractures, and aids in reducing muscle tension. Note: A high level of phosphorus may cause calcium-phosphorus crystals to build up in the joints, muscles, and other body organs, leading to bone and joint pain. To avoid these risks, client may be prescribed a phosphate binder such as Basalgel or Renagel (Leydig, 2005).
Increases client’s energy and sense of well-being. Studies have shown that regular exercise programs have benefited clients with ESRD, both physically and emotionally. Stable clients have not been shown to have adverse effects (Goodman & Ballou, 2004).
Reduces tissue pressure and may enhance circulation, thereby reducing risk of dermal ischemia and breakdown.
Maintain optimal mobility and function.
Display increased strength and be free of associated complications—contractures and decubitus ulcers.
Self-Care Deficit (specify) May be related to
Intolerance to activity, decreased strength and endurance, pain or discomfort
Perceptual or cognitive impairment (accumulated toxins)

Self-Care Assistance
Determine client’s ability to participate in self-care activities (scale of 0 to 4).

Provide assistance with activities as necessary.

Encourage use of energy-saving techniques: sitting, not standing; using shower chair; and doing tasks in small increments.
Recommend scheduling activities to allow client sufficient time to accomplish tasks to fullest extent of ability.

Underlying condition dictates level of deficit, affecting choice of interventions. Note: Psychological factors, such as depression, motivation, and degree of support, also have a major impact on the client’s abilities.
Meets needs while supporting client participation and
Conserves energy, reduces fatigue, and enhances client’s ability to perform tasks.
Unhurried approach reduces frustration and promotes client participation, enhancing self-esteem.
Participate in ADLs within level of own ability and constraints of the illness.
Risk for Constipation Risk factors may include
Decreased fluid intake, altered dietary pattern
Reduced intestinal motility, compression of bowel (peritoneal dialysate), electrolyte imbalances, decreased mobility

Constipation/Impaction Management
Auscultate bowel sounds. Note consistency and frequency of bowel movements (BMs) and presence of abdominal distention.
Review current medication regimen.

Ascertain usual dietary pattern and food choices.
Suggest adding fresh fruits, vegetables, and fiber to diet within restrictions, when indicated.
Encourage or assist with ambulation, when able.
Provide privacy at bedside commode and bathroom.
Administer stool softeners, such as Colace or bulk-forming laxatives, such as Metamucil, as appropriate.
Keep client nothing by mouth (NPO) status; insert NG tube, as indicated.

Decreased bowel sounds; passage of hard-formed or dry stools suggests constipation and requires ongoing intervention to manage.
Side effects of some drugs, such as iron products and some antacids, may compound problem.
Although restrictions may be present, thoughtful consideration of menu choices can aid in controlling problem.
Provides bulk, which improves stool consistency.
Activity may stimulate peristalsis, promoting return to normal bowel activity.
Promotes psychological comfort needed for elimination.
Produces a softer, more easily evacuated stool.
Decompresses stomach when recurrent episodes of unrelieved vomiting occur. Large gastric output suggests ileus, a common early complication of PD, with accumulation of gas and intestinal fluid that cannot be passed rectally.
Maintain usual or improved bowel function.
Risk for disturbed Thought Processes Risk factors may include
Physiological changes—presence of uremic toxins, electrolyte imbalances, hypervolemia or fluid shifts, hyperglycemia (infusion
of a dialysate with a high glucose concentration)
Delirium Management
Assess for behavioral changes or change in level of consciousness (LOC)—disorientation, lethargy, decreased concentration, memory loss, and altered sleep patterns.
Keep explanations simple and reorient frequently as needed. Provide “normal” day or night lighting patterns, clock, and calendar.\
Provide a safe environment, restrain as indicated, and pad side rails during procedure, as appropriate.

Drain peritoneal dialysate promptly at end of specified equilibration period.
Investigate reports of headache, associated with onset of dizziness, nausea and vomiting, confusion or agitation, hypotension, tremors, or seizure activity.

Monitor changes in speech pattern, development of dementia, and myoclonus activity during HD.

May indicate level of uremic toxicity, response to or developing complication of dialysis such as “dialysis dementia,” and need for further assessment and intervention.
Improves reality orientation.

Prevents client trauma and inadvertent removal of dialysis lines or catheter.

Prompt outflow will decrease risk of hyperglycemia or hyperosmolar fluid shifts affecting cerebral function.
May reflect development of disequilibrium syndrome, which can occur near completion of or following HD and is thought to be caused by ultrafiltration or by the too-rapid removal of urea from the bloodstream not accompanied by equivalent removal from brain tissue. The hypertonic cerebrospinal fluid (CSF) causes a fluid shift into the brain, resulting in cerebral edema and increased intracranial pressure.
Occasionally, accumulation of aluminum may cause dialysis dementia, progressing to death if untreated.
Regain usual or improved level of mentation.
Recognize changes in thinking and behavior and demonstrate behaviors to prevent or minimize changes.
Anxiety [specify level]/Fear May be related to
Situational crisis, threat to self-concept, change in health status, role functioning, socioeconomic status
Threat of death, unknown consequences or outcome

Anxiety Reduction
Assess level of fear of both client and SO. Note signs of denial, depression, or narrowed focus of attention.
Explain procedures and care as delivered. Repeat explanations frequently, as needed. Provide information in multiple formats, including pamphlets and films.

Acknowledge normalcy of feelings in this situation.

Provide opportunities for client and SO to ask questions and verbalize concerns.
Encourage SO to participate in care, as able and desired.

Acknowledge concerns of client and SO.

Point out positive indicators of treatment—improvement in laboratory values, stable BP, and lessened fatigue.

Arrange for visit to dialysis center and meeting with another dialysis client, as appropriate.

Address financial considerations. Refer to appropriate resources.

Helps determine the kind of interventions required.
Fear of unknown is lessened by information and knowledge and may enhance acceptance of permanence of ESRD and necessity for dialysis. Alteration in thought processes and high levels of anxiety or fear may reduce comprehension, requiring repetition of important information. Note: Uremia can impair short-term memory, requiring repetition or reinforcement of information provided.
Knowing feelings are normal can allay fear that client is losing control.
Creates feeling of openness and cooperation and provides information that will assist in problem identification and solving.
Involvement promotes sense of sharing, strengthens feelings of usefulness, provides opportunity to acknowledge individual capabilities, and may lessen fear of the unknown.
Prognosis and possibility of need for long-term dialysis and resultant lifestyle changes are major concerns for this client and those who may be involved in future care.
Promotes sense of progress in an otherwise chronic process that seems endless while client still is experiencing physical deterioration and depression.
Interaction with others who have encountered similar problems may assist client and SO to work toward acceptance of chronic condition and focus on problem-solving activities.
Treatment for kidney failure is expensive, although Medicare and other health insurance programs pay much of the cost.
Verbalize awareness of feelings and reduction of anxiety or fear to a manageable level.
Demonstrate problem-solving skills and effective use of resources.
Appear relaxed and able to rest and sleep appropriately.
Disturbed Body Image/situational low Self-Esteem May be related to
Situational crisis, chronic illness with changes in usual roles and body image

Body Image [or] Self-Esteem Enhancement
Assess level of client’s knowledge about condition and treatment and anxiety related to current situation.
Discuss meaning of loss and change to client.

Note withdrawn behavior, ineffective use of denial, or behaviors indicative of overconcern with body and its functions.

Investigate reports of feelings of depersonalization or the bestowing of humanlike qualities on machinery.
Assess for use of addictive substances, primarily alcohol, other drugs, and self-destructive or suicidal behavior.

Determine stage of grieving. Note signs of severe or prolonged depression.
Acknowledge normalcy of feelings.

Encourage verbalization of personal and work conflicts that may arise. Active-listen concerns.
Determine client’s role in family constellation and client’s perception of expectation of self and others.
Recommend SO treat client normally and not as an invalid.

Assist client to incorporate disease management into lifestyle.
Identify strengths, past successes, and previous methods client has used to deal with life stressors.

Help client identify areas over which he or she has some measure of control. Provide opportunity to participate in decision-making process.
Recommend participation in local support group.

Refer to healthcare and community resources, such as social service, vocational counselor, and psychiatric clinical nursespecialist.

Identifies extent of problem or concern and necessary interventions.
Many clients and their families have difficulty dealing with changes in life and role performance as well as the client’s loss of ability to control own body.
Indicators of developing difficulty handling stress of what is happening. Note: Client may feel tied to and controlled by the technology central to his or her survival, even to the point of extending body boundary to incorporate dialysis
May reflect dysfunctional coping and attempt to handle problems in an ineffective manner.
Identification of grief stage client is experiencing provides guide to recognizing and dealing appropriately with behavior as client and SO work to come to terms with loss and limitations associated with condition. Prolonged depression may indicate need for further intervention.
Recognition that feelings are to be expected helps client accept and deal with them more effectively.
Helps client identify problems and problem-solve solutions. Note: Home dialysis may provide more flexibility and enhance sense of control for clients who are appropriate candidates for this form of therapy.
Long-term and permanent illness or disability alter client’s ability to fulfill usual role(s) in family and work setting.
Unrealistic expectations can undermine self-esteem and affect outcome of illness.
Conveys expectation that client is able to manage situation and helps maintain sense of self-worth and purpose in life.
Necessities of treatment assume a more normal aspect when they are a part of the daily routine.
Focusing on these reminders of own ability to deal with problems can help client deal with current situation.
Provides sense of control over seemingly uncontrollable situation, fostering independence.

Reduces sense of isolation as client learns that others have been where client is now. Provides role models for dealing with situation, problem-solving, and “getting on with life.” Reinforces that therapeutic regimen can be beneficial.
Provides additional assistance for long-term management of chronic illness and change in lifestyle.
Identify feelings and methods for coping with negative perception of self.
Verbalize acceptance of self in situation.
Demonstrate adaptation to changes and events that have occurred, as evidenced by setting realistic goals and active participation in care and life in general.
Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs May be related to
Lack of exposure or recall
Unfamiliarity with information resources
Cognitive limitations

Teaching: Disease Process
Note level of anxiety or fear and alteration of thought processes.Time teaching appropriately.

Review particular disease process, prognosis, and potential complications in clear concise terms, periodically repeating and updating information, as necessary.

Encourage and provide opportunity for questions.

Acknowledge that certain feelings and patterns of response are normal during course of therapy.

Emphasize necessity of reading all product labels—food, beverage, and over-the-counter (OTC) drugs—and not taking medications or herbal supplements without checking with healthcare provider.

Stress importance of establishing and adhering to medication schedule reflecting the specific form of renal disease, timing of dialysis, and properties of the individual medications.
Discuss significance of maintaining nutritious eating habits, preventing wide fluctuation of fluid and electrolyte balance, and avoidance of crowds or people with infectious processes.
Instruct client about epoetin (Epogen) or darbepoetin (Aransep), when indicated. Have client or SO demonstrate ability to administer and state adverse side effects and healthcare practices associated with this therapy.

Identify healthcare and community resources, such as dialysis support group, social services, and mental health clinic.

Teaching: Procedure/Treatment
Discuss procedures and purpose of dialysis in terms understandable to client. Repeat explanations as required.
Instruct client and SO in home dialysis, as indicated:

Operation and maintenance of equipment (including vascular shunt), sources of supplies

Aseptic or clean technique
Self-monitoring of effectiveness of procedure
Management of potential complications

Contact persons

Sources for supplies when away from home

These factors directly affect ability to access and use knowledge. In addition, during the dialysis procedure, client’s cognitive function may be impaired, and clients themselves state that they feel “fuzzy.” Therefore, learning may not be optimal during this time.
Providing information at the level of the client’s and SO’s understanding will reduce anxiety and misconceptions about what client is experiencing. Note: Research suggests nocturnal home HD is associated with improved left ventricular function, decreased BP and pulse pressure, and reduced used of antihypertensive medications.
Enhances learning process, promotes informed decision making, and reduces anxiety associated with the unknown.
Client and SO may initially be hopeful and positive about the future, but as treatment continues and progress is less dramatic, they can become discouraged and depressed, and conflicts of dependence versus independence may develop.
It is difficult to maintain electrolyte balance when exogenous intake is not factored into dietary restriction; for example, hypercalcemia can result from routine supplement use in combination with increased dietary intake of calcium-fortified foods and medicines.
This is necessary to ensure that therapeutic levels of the drugs are reached and that toxic levels are avoided.

Depressed immune system, presence of anemia, invasive procedures, and malnutrition potentiate risk of infection.
Epogen is used for the management of the anemia associated with chronic renal failure (CRF) and ESRD. The drug is given to increase and maintain RBC production, which allows client to feel better and stronger. Darbepoetin is a non-natural recombinant protein that can stimulate RBC production, but the half-life is about three times longer than erythropoietin, resulting in less frequent dosing.
Knowledge and use of these resources assist client and SO to manage care more effectively. Interaction with others in similar situation provides opportunity for discussion of options and making informed choices, including stopping dialysis or renal transplantation.
A clear understanding of the purpose, process, and what is expected of client and SO facilitates their cooperation with regimen and may enhance outcomes.
Home dialysis is associated with better outcomes in general and better survival rates as dialysis is usually performed 5 to 7 days/week and is more intensive. This decreases fluctuations in fluid, solute, and electrolyte balance, more closely mimicking renal function. However, specific criteria for client and SO participation and training, home resources, and professional oversight must be met in order to consider this option.
Information diminishes anxiety of the unknown and provides opportunity for client to be knowledgeable about own care.
Prevents contamination and reduces risk of infection.
Provides information necessary to evaluate effects of therapy and need for change.
Reduces concerns regarding personal well-being; supports efforts at self-care.
Readily available support person can answer questions, troubleshoot problems, and facilitate timely medical intervention, when indicated, reducing risk and severity of complications.Note: Home dialysis clients usually are monitored by conventional dialysis center or interdisciplinary team.
Home dialysis clients are often capable of travel, even overseas, with proper preplanning and support.
Verbalize understanding of condition and relationship of signs and symptoms of the disease process and potential complications.
Verbalize understanding of therapeutic needs.
Correctly perform necessary procedures and explain reasons for actions.

Patient Teaching Home Health Guidance for Patient with Renal Dialysis
Patient teaching discharge and home healthcare guidelines for Patient with Renal Dialysis. May require assistance with treatment regimen, transportation, activities of daily living (ADLs), homemaker and maintenance tasks, end-of life decisions, palliative care Explain to patient and be sure the patient understands All medications, including the dosage, route, action, and adverse effects. Encourage client to participate in menu planning. Recommend small, frequent meals. Schedule meals according to dialysis needs. Encourage use of energy-saving techniques: sitting, not standing; using shower chair; and doing tasks in small increments. Recommend scheduling activities to allow client sufficient time to accomplish tasks to fullest extent of ability. 

Lifestyle Management for Renal Dialysis 
Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake. Ongoing health care monitoring includes careful adjustment of medications that are normally excreted by the kidney or are dialyzable. Surveillance for complications. Arteriosclerotic cardiovascular disease, heart failure, disturbance of lipid metabolism (hypertriglyceridemia), coronary heart disease, stroke Intercurrent infection Anemia and fatigue Gastric ulcers and other problems Bone problems (renal osteodystrophy, aseptic necrosis of hip) from disturbed calcium metabolism Hypertension Psychosocial problems: depression, suicide, sexual dysfunction