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
- 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.
- 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
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
Disabled family coping
Excess fluid volume
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Impaired oral mucous membrane
Impaired urinary elimination
Ineffective sexuality patterns
Ineffective tissue perfusion: Renal
Interrupted family processes
Risk for infection
Risk for injury
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.
- 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.