End-Stage Renal Disease (ESRD) Nursing Diagnosis & Care Plan

End-stage renal disease (ESRD) or kidney failure happens when the kidneys fail to filter toxic waste and fluid that builds up in the body. 

Kidney damage develops over months or years due to various causes. These conditions include: 

• Diabetes
• Hypertension
• Glomerulonephritis 
• Polycystic kidney disease
• Interstitial nephritis 
• Urinary tract obstruction (such as kidney stones or enlarged prostate)
• Vesicoureteral reflux (a condition when urine flows back to the kidneys)
• Pyelonephritis
• Congenital kidney defects

As ESRD progresses, the patient may present with the following signs and symptoms:

• CNS: headaches, altered mentation, insomnia
• Circulatory: uncontrolled hypertension
• Respiratory: dyspnea, chest pain, fluid in the lungs
• GI: nausea, vomiting, loss of appetite, and metallic taste
• Musculoskeletal: fatigue, muscle weakness, twitches, and cramps
• Genitourinary: Changes in the amount of urine output
• Integumentary: swelling of the feet and ankles, persistent itching

Chronic kidney disease is divided into five stages based on the eGFR (estimated glomerular filtration rate), a blood test that measures the filtering ability of the kidneys.

• Stage 1 presents as an eGFR of 90 ml/min or higher. This is considered a normal eGFR, and the patient will likely be asymptomatic.
• Stage 2 CKD is an eGFR of 60-89 ml/min. This is mild CKD, and the client may not notice symptoms, but protein in the urine or other damage will be observable.
• Stage 3a is an eGFR of 45-59 ml/min. Kidney damage is mild to moderate.
• Stage 3b is an eGFR of 30-44 ml/min. Kidney damage is moderate to severe, and symptoms such as fatigue, edema, muscle cramps, and changes in urination occur.
• Stage 4 CKD is an eGFR of 15-29 ml/min. This is the final stage before kidney failure.
• Stage 5 CKD is end-stage renal disease with an eGFR of less than 15 ml/min. Kidneys may not work at all anymore.

Blood tests, urine tests, imaging tests, and kidney tissue biopsies may be performed to diagnose kidney failure. To track the development of renal failure, the healthcare provider may repeat eGFR and urine tests over time.

Nursing Process

End-stage renal disease is irreversible and has no cure. Preventing the disease’s advancement is crucial for improving long-term prognosis.

Nursing care priorities for patients with end-stage renal disease include:

• Provide support to the patient and family
• Assist in kidney transplantation or dialysis
• Slow the progression of the disease
• Promote physical and psychosocial well-being
• Improve the patient’s overall quality of life
• Instruct on lifestyle modifications

Nursing Care Plans Related to End-stage Renal Disease

Impaired Urinary Elimination

Impaired urinary elimination related to end-stage renal disease can be caused by loss of kidney function to filter and eliminate toxic wastes from the body through urine.

Nursing Diagnosis: Impaired Urinary Elimination

Related to:

• Disease process
• Loss of nephrons 
• Decreasing filtering capability of the kidney (glomerular infiltration rate)
• Urinary tract obstruction
• Inflamed urinary tract
• Kidney infection

As evidenced by:

• Decreased urine output (oliguria)
• Painful urination (dysuria)
• Absence of urine output (anuria)
• Urinary retention
• Difficulty in starting urination (urinary hesitancy)
• Increased urge to urinate (urinary urgency)
• Increased urination at night (nocturia)
• Urinary incontinence

Expected outcomes:

• Patient will manifest improved urine output within the target limit set by the healthcare provider.
• Patient will participate in dialysis treatments as prescribed.

Assessment:

1. Assess the patient’s urinary elimination status.
ESRD often occurs when chronic renal failure has advanced to the point where kidney function is less than 10% of the maximum. The body can no longer generate urine normally or at all.

2. Observe the patient’s urine characteristics.
More frequent urination (urinary urgency) or the presence of blood can happen when the kidneys are not working correctly. Also, frothy or bubbly urine could be an early sign of protein entering the urine due to damaged kidneys.

3. Know the patient’s eGFR.
Perform a blood test to establish the glomerular filtration rate. The eGFR calculates the number of milliliters (mL/min) of blood the kidneys can filter each minute. The kidney function decreases as the GFR does. Renal failure is diagnosed when the GFR falls below 15 ml/min.

4. Obtain blood samples for creatinine and BUN.
The kidneys also filter creatinine, a waste product from the muscles. Like BUN, high creatinine levels may indicate that the kidneys cannot filter waste. In ESRD, serum creatinine and blood urea nitrogen (BUN) levels are increased.

5. Palpate the bladder.
A palpable bladder can indicate a dilated urinary collection system or urinary system blockage, which can result in renal failure and kidney damage.

6. Check for costovertebral angle tenderness.
Costovertebral angle (located at the back and bottom of the ribcage) tenderness is associated with a kidney infection (pyelonephritis) and kidney stones. These are possible causative factors of ESRD.

Interventions:

1. Closely monitor the patient’s intake and output.
The patient’s fluid volume is compromised in ESRD. It is vital to monitor the intake and output closely. As kidney failure progresses, renal perfusion and function decline, as does urine production. As ESRD worsens, the patient may be anuric.

2. Explain the importance of dialysis.
Dialysis is a necessary treatment for ESRD to survive. Since the kidneys are no longer functioning, a dialysis machine acts as the kidneys to filter blood and remove fluid.

3. Anticipate a possible kidney transplant.
A kidney transplant surgically implants a donor kidney to help the body regain proper excretion of waste through urine. The healthcare team will discuss options with the patient and prepare them for receiving the organ.

4. Refer to a dietitian.
A dietitian can create a kidney-friendly diet as part of the kidney disease treatment. Proper diet adherence is essential to preserve kidney function.

Excess Fluid Volume

Excess fluid volume related to end-stage renal disease can be caused by kidneys losing their ability to remove excess fluid leading to fluid overload (hypervolemia).

Nursing Diagnosis: Excess Fluid Volume

Related to:

• Sodium retention
• Imbalanced electrolytes
• Uncontrolled hypertension
• Loss of kidney function 
• Decreasing filtering capability of the kidney (glomerular infiltration rate)
• Inappropriate diet
• Nonadherence to fluid restriction
• Comorbidities like heart failure

As evidenced by:

• Edema
• Altered blood pressure
• Altered urine specific gravity
• Intake exceeds output
• Oliguria
• Pulmonary congestion
• Altered mental status
• Hypoalbuminemia
• Electrolyte imbalances

Expected outcomes:

• Patient will achieve an acceptable fluid balance as evidenced by intake and output documentation.
• Patient will remain free from symptoms of excess fluid like edema and dyspnea.
• Patient will display electrolytes within an acceptable range.

Assessment:

1. Weigh the patient daily.
Weigh the patient daily using the same scale at the same time. Sudden weight gain can indicate ESRD complications like fluid retention.

2. Monitor the patient’s intake and output.
The kidneys are in charge of eliminating extra fluid from the body. Fluid can accumulate when the kidneys are not functioning correctly. Accurate intake and output measurements are essential when monitoring patients with ESRD.

3. Check the electrolytes.
Fluid volume is associated with electrolyte balances. Hyperphosphatemia, hyperkalemia, and hypocalcemia are common findings.

4. Obtain urine samples for testing.
The protein albumin in the urine is measured through urine tests. Albumin maintains colloid osmotic pressure, which regulates fluid circulating throughout the body. Hypoalbuminemia is common in ESRD.

5. Monitor for respiratory distress and changes in mentation.
Signs and symptoms of pulmonary congestion and fluid overload must be recognized early to prevent further worsening of the patient’s condition.

Interventions:

1. Administer albumin as indicated.
Patients with ESRD often have low albumin (hypoalbuminemia). Giving albumin raises intravascular oncotic pressure, which moves fluid from the outside into the inside compartment of the cell and releases fluid.

2. Promote diuresis.
Loop diuretics (such as furosemide) are the drug of choice for ESRD to excrete the extra fluid out of the body to relieve edema and pulmonary congestion.

3. Limit sodium intake.
Because the kidneys cannot effectively remove extra sodium and fluid from the body, sodium and fluid build up in the tissues and circulation. Sodium will be restricted in the diet.

4. Elevate edematous extremities.
Elevating edematous extremities promotes venous return and reduces edema.

5. Restrict fluids as ordered.
Maintaining proper fluid balance is crucial since regular hydration can lead to harmful fluid buildup in ESRD. Ensure adherence to daily fluid restrictions.

6. Regulate the blood pressure.
Too much fluid in the blood arteries can elevate the blood pressure and further damage the kidneys. Renal artery stenosis is when the kidneys’ blood vessels constrict and cause high blood pressure.

Deficient Knowledge

Deficient knowledge related to end-stage renal disease can be caused by misinformation, leading to further complications and poor outcomes.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Misinformation about ESRD and its management
• Inadequate access to resources
• Inadequate commitment to learning 
• Inadequate information about ESRD
• Inadequate interest in learning 
• Inadequate participation in care planning
• Misconceptions about ESRD treatment

As evidenced by:

• Inquiries about ESRD
• Inaccurate follow-through of instructions 
• Expressed myths about ESRD
• Nonparticipation in care
• Nonadherence to treatment
• Development of complications

Expected outcomes:

• Patient will verbalize understanding of ESRD, its symptoms, and its management.
• Patient will adhere to the treatment plan as evidenced by lab values within the expected ranges.
• Patient will not develop complications from ESRD.

Assessment:

1. Assess the patient’s current knowledge about ESRD.
Ask the patient what they know about ESRD. From there, the nurse can tailor the patient’s health teaching plan.

2. Determine the patient’s willingness and motivation to learn.
Patients with ESRD may feel powerless over this progressive disease, affecting their motivation to learn and adhere to the treatment regimen.

3. Check the patient’s health literacy.
Health literacy can affect health outcomes and treatment compliance. ESRD requires a commitment to a complicated treatment regimen. Myths and misinformation can affect the receipt of accurate information about ESRD and its management.

Interventions:

1. Instruct the patient on lifestyle modifications.
Arm the patient with information so they can make informed decisions. Instruct patients that simple changes such as exercise, quitting smoking, and adhering to their medication regimen can preserve kidney function.

2. Allow inquiries about dialysis and kidney transplant.
Remain approachable, so the patient feels at ease asking questions. Dialysis and kidney transplants require life-long maintenance, and support from nurses can enhance adherence.

3. Instruct on appropriate diets.
Adhering to a kidney-friendly diet can be difficult. The patient may need to limit salt, potassium, and fluids. Provide easy-to-understand written instructions on foods the patient should limit.

4. Have the patient verbalize symptoms of concern.
Teach the patient about the signs of developing complications from ESRD. Dyspnea, confusion, changes in urination, weight gain, high blood pressure, and muscle cramps require immediate assessment.

5. Educate on fistula care.
A fistula is created to allow for vascular access with dialysis. Complications such as infection or bleeding can occur as it heals. Instruct on proper care and when to alert the healthcare provider if concerns arise.

References

1. Burns, S. (2014). AACN essentials of critical care nursing (3rd ed.). McGraw-Hill Education / Medical.
2. Cleveland Clinic. (2020, November 13). End-stage renal (Kidney) disease: What is it, causes, dialysis & more. Retrieved February 2023, from https://my.clevelandclinic.org/health/diseases/16243-end-stage-renal-kidney-disease
3. Mayo Clinic. (2021, October 12). End-stage renal disease – Symptoms and causes. Retrieved February 2023, from https://www.mayoclinic.org/diseases-conditions/end-stage-renal-disease/symptoms-causes/syc-20354532
4. National Center for Biotechnology Information. (2021, September 16). End-stage renal disease – StatPearls – NCBI bookshelf. Retrieved February 2023, from https://www.ncbi.nlm.nih.gov/books/NBK499861/