Chronic kidney disease (CKD) or Chronic renal failure (CRF) is characterized by a progressive and irreversible loss of kidney function.
Since the kidneys are highly adaptive organs, kidney disease is often not identified right away until there is already a considerable loss of nephrons. Patients with CRF are often asymptomatic and early symptoms may not be recognized.
The following risk factors increase the incidence of CRF:
- Older age
- Cardiovascular disease
- Exposure to nephrotoxic substances
- Family history of kidney disease
CRF is categorized into stages based on the patient’s glomerular filtration rate (GFR):
- Stage 1. Normal or increased GFR (rate greater than or equal to 90)
- Stage 2. Mild decrease in GFR (rate between 60-89)
- Stage 3a. Moderate decrease in GFR (rate between 45-59)
- Stage 3b. Moderate decrease in GFR (rate between 30-44)
- Stage 4. Severe decrease in GFR (rate between 15-29)
- Stage 5. Kidney failure requiring dialysis (GFR less than 15)
The clinical manifestations of CRF often occur due to retained creatinine, urea, phenols, electrolytes, and water and can vary depending on the severity. Symptoms include:
- Loss of appetite
- Shortness of breath
- Changes in urine output
As the kidneys further deteriorate and lose their ability to filter out toxins, other organ systems become affected and irreversible damage may occur. The final stage of CRF is end-stage renal disease (ESRD) which requires dialysis and kidney transplant.
CRF is diagnosed through laboratory studies including BUN, serum creatinine, serum electrolytes, and urinalysis. Since persistent proteinuria is the first sign of kidney failure, screening for this condition typically includes a dipstick evaluation of protein in the urine. Other diagnostic studies conducted to diagnose this condition include renal ultrasound, CT scan, and biopsy.
The Nursing Process
The preservation of existing kidney function, reduction of cardiovascular disease risks, prevention of complications, and promotion of the patient’s comfort are the primary goals of CRF management and treatment.
Nurses are responsible for encouraging health promotion activities that can delay and prevent the onset of CRF. Providing accurate information about the disease process and encouraging the patient to adhere to lifestyle modifications are within the scope of the nurse.
Nursing Care Plan Related to Chronic Renal Failure
Excess Fluid Volume Care Plan
Excess fluid volume is common in patients with CRF because the kidneys are not functioning to remove excess fluids and waste products from the body. When there is excess fluid, complications can arise including swelling, hypertension, and heart problems.
Nursing Diagnosis: Excess Fluid Volume
- Kidney dysfunction
- Decreased urine output
- Sodium retention
- Inappropriate fluid Intake
- Compromised regulatory mechanism
As evidenced by:
- Altered mental status
- Adventitious breath sounds
- Pulmonary congestion
- Altered pulmonary artery pressure
- Altered urine specific gravity
- Imbalanced intake and output
- Jugular vein distension
- The patient will remain free of edema and maintain clear lung sounds without evidence of dyspnea
- The patient will maintain balanced intake and output
Excess Fluid Volume Assessment
1. Assess lung sounds.
Adventitious lung sounds such as rales or crackles and dyspnea signal a complication of fluid retention.
2. Assess and monitor the patient’s intake and output.
The patient’s intake and output should be well documented to help detect imbalances and fluid overload. Damaged kidneys cannot produce as much urine.
3. Assess laboratory values.
BUN and creatinine assess renal function. GFR is determined by the creatinine level and shows how well the kidneys are filtering. Electrolytes are also assessed.
Excess Fluid Volume Interventions
1. Monitor the patient’s weight daily.
It is estimated that 1 kg (2.2 lbs) of weight gained is equivalent to 1 liter of fluid retained. Monitoring the patient’s weight daily must be performed using the same scale during the same time of the day while the patient is wearing the same type of clothing for accurate results.
2. Restrict fluids as indicated.
When restricting fluid intake in patients with CFR, all forms of fluid intake must be considered including oral, intravenous, and enteral sources. Fluid restriction is indicated to prevent and reduce fluid overload.
3. Administer medications as indicated.
Diuretics are often prescribed to patients with CRF to increase urinary elimination of fluids and reduce retention and further complications.
4. Provide care to edematous extremities as needed.
Patients with CRF often exhibit lower extremity edema or anasarca due to excess fluid retention. Reposition the patient every two hours to prevent the development of pressure ulcers and elevate affected extremities to improve blood flow and reduce swelling.
5. Prepare the patient for dialysis as indicated.
Patients with stage 5 renal failure will require dialysis. Dialysis nurses are trained to provide hemodialysis or peritoneal dialysis.
Impaired Urinary Elimination Care Plan
Impaired urinary elimination is common in patients with CRF as the kidneys lose their ability to filter waste products through urine production.
Oliguria or low urine output is characterized by urine excretion of less than 20 ml per hour or less than 400 ml per day. This is considered one of the earliest signs of impaired renal function.
Nursing Diagnosis: Impaired Urinary Elimination
- Chronic kidney disease
As evidenced by:
- Urinary retention
- Urinary incontinence
- The patient will produce at least 400 mL of urine per 24 hours
- The patient will not experience complications from oliguria
Impaired Urinary Elimination Assessment
1. Assess the patient’s urinary elimination patterns and problems.
Understanding the patient’s normal urinary elimination patterns can help formulate the best approach to promoting healthy elimination patterns.
2. Assess urine characteristics.
Assess the amount, color, clarity, and odor of urine for additional complications such as infection.
Impaired Urinary Elimination Interventions
1. Administer diuretics as indicated.
Diuretics promote urinary elimination and prevent fluid overload in patients with CRF.
2. Administer fluids with caution.
Fluid therapy can help with promoting urinary elimination but can cause worsening fluid retention and electrolyte imbalances. Monitor closely.
3. Educate on expectations.
With CRF, urine production may increase and decrease. Educate the patient that as the disease progresses urine production will slow and may stop completely.
4. Prevent infections.
Patients who are receiving dialysis due to severe CFR are at risk for infections from dialysis catheters and fistulas. Monitor for fever and abdominal pain.
Risk for Electrolyte Imbalance Care Plan
Patients with CRF are at risk of developing electrolyte imbalance due to impaired kidney function. This condition is often complicated by decreased sodium and calcium and increased potassium, magnesium, and phosphate.
Nursing Diagnosis: Risk for Electrolyte Imbalance
- Renal failure
- Kidney dysfunction
As evidenced by:
A risk diagnosis is not evidenced by any signs and symptoms, as the problem has not occurred yet and nursing interventions will be directed at the prevention of symptoms.
- The patient will maintain normal serum potassium, sodium, calcium, magnesium, and phosphorus levels
Risk for Electrolyte Imbalance Assessment
1. Assess laboratory data.
Abnormal electrolyte panels indicate the progression of CRF.
2. Assess and monitor vital signs.
Imbalances in electrolytes can often lead to complications like respiratory failure and dysrhythmias observed through vital signs and EKGs.
Risk for Electrolyte Imbalance Interventions
1. Administer lactulose.
Hyperkalemia is the most common electrolyte imbalance in CRF and has the potential to cause serious cardiac arrhythmias. Lactulose promotes the fecal excretion of electrolytes as well as ammonia, urea, and creatinine.
2. Administer loop diuretics.
Loop diuretics are potassium-wasting and will rid the body of potassium. Loop diuretics are most beneficial when used with thiazide.
3. Provide or restrict nutrition based on lab work.
Electrolytes are found in many foods and fluids. Restrict intake when levels are high or provide additional sources if deficient.
4. Educate the patient about signs of high potassium and other risks.
Patients with CRF are susceptible to hyperkalemia and hyponatremia. Hyperkalemia can cause muscle weakness, restlessness, cramping, and a slow heart rate. Hyponatremia can cause muscle cramps, nausea, disorientation, and alterations in mental status.
References and Sources
- Chronic Kidney Disease, Fluid Overload, and Diuretics: A Complicated Triangle. Khan, Y. H., Sarriff, A., Adnan, A. S., Khan, A. H., & Mallhi, T. H. (2016). PloS one, 11(7), e0159335. https://doi.org/10.1371/journal.pone.0159335
- Chronic Kidney Disease (CKD). National Kidney Foundation. 2022. https://www.kidney.org/atoz/content/about-chronic-kidney-disease
- Chronic Kidney Disease. NHS. August 29, 2019. https://www.nhs.uk/conditions/kidney-disease/
- Chronic Kidney Disease. Mayo Clinic. September 3, 2021. https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.