Chronic renal failure (CRF) is the end result of a gradual, progressive loss of kidney function. Causes include chronic infections (glomerulonephritis, pyelonephritis), vascular diseases (hypertension, nephrosclerosis), obstructive processes (renal calculi), collagen diseases (systemic lupus), nephrotoxic agents (drugs, such as aminoglycosides), and endocrine diseases (diabetes, hyperparathyroidism). This syndrome is generally progressive and produces major changes in all body systems. The final stage of renal dysfunction, end-stage renal disease (ESRD), is demonstrated by a glomeruler filtration rate (GFR) of 15%–20% of normal or less.
CARE SETTING
Primary focus is at the community level, although inpatient acute hospitalization may be required for life-threatening complications.
RELATED CONCERNS
Anemias (iron deficiency, pernicious, aplastic, hemolytic)
Fluid and electrolyte imbalances
Heart failure: chronic
Hypertension: severe
Metabolic acidosis (primary base bicarbonate deficiency)
Psychosocial aspects of care
Upper gastrointestinal/esophageal bleeding
Additional associated nursing diagnoses are found in:
Renal dialysis
Renal failure: acute
Seizure disorders/epilepsy
Patient Assessment Database
ACTIVITY/REST
May report: Extreme fatigue, weakness, malaise
Sleep disturbances (insomnia/restlessness or somnolence)
May exhibit: Muscle weakness, loss of tone, decreased range of motion (ROM)
CIRCULATION
May report: History of prolonged or severe hypertension
Palpitations; chest pain (angina)
May exhibit: Hypertension; JVD, full/bounding pulses; generalized tissue and pitting edema of feet, legs, hands
Cardiac dysrhythmias, distant heart sounds
Weak thready pulses, orthostatic hypotension reflects hypovolemia (rare in end-stage disease)
Pericardial friction rub
Pallor; bronze-gray, yellow skin
Bleeding tendencies
EGO INTEGRITY
May report: Stress factors, e.g., financial, relationship, and so on
Feelings of helplessness, hopelessness, powerlessness
May exhibit: Denial, anxiety, fear, anger, irritability, personality changes
ELIMINATION
May report: Decreased urinary frequency; oliguria, anuria (advanced failure)
Abdominal bloating, diarrhea, or constipation
May exhibit: Change in urine color, e.g., deep yellow, red, brown, cloudy
Oliguria, may become anuric
FOOD/FLUID
May report: Rapid weight gain (edema), weight loss (malnutrition)
Anorexia, heartburn, nausea/vomiting; unpleasant metallic taste in the mouth (ammonia breath)
Use of diuretics
May exhibit: Abdominal distension/ascites, liver enlargement (end-stage)
Changes in skin turgor/moisture
Edema (generalized, dependent)
Gum ulcerations, bleeding of gums/tongue
Muscle wasting, decreased subcutaneous fat, debilitated appearance
HYGIENE
May report: Difficulty performing activities of daily living (ADLs)
NEUROSENSORY
May report: Headache, blurred vision
Muscle cramps/twitching, “restless leg” syndrome; burning numbness of soles of feet
Numbness/tingling and weakness, especially of lower extremities (peripheral neuropathy)
May exhibit: Altered mental state, e.g., decreased attention span, inability to concentrate, loss of memory, confusion, decreasing level of consciousness, stupor, coma
Gait abnormalities
Twitching, muscle fasciculations, seizure activity
Thin, dry, brittle nails and hair
PAIN/DISCOMFORT
May report: Flank pain; headache; muscle cramps/leg pain (worse at night)
May exhibit: Guarding/distraction behaviors, restlessness
RESPIRATION
May report: Shortness of breath; paroxysmal nocturnal dyspnea; cough with/without thick, tenacious sputum
May exhibit: Tachypnea, dyspnea, increased rate/depth (Kussmaul’s respiration)
Cough productive of pink-tinged sputum (pulmonary edema)
SAFETY
May report: Itching skin, frequent scratching
Recent/recurrent infections
May exhibit: Scratch marks, petechiae, ecchymotic areas on skin
Fever (sepsis, dehydration); normothermia may actually represent an elevation in patient who has developed a lower-than-normal body temperature (effect of CRF/ depressed immune response)
Bone fractures; calcium phosphate deposits (metastatic calcifications) in skin, soft tissues, joints; limited joint movement
SEXUALITY
May report: Decreased libido; amenorrhea; infertility
SOCIAL INTERACTION
May report: Difficulties imposed by condition, e.g., unable to work, maintain social contacts or usual role function in family
TEACHING/LEARNING
May report: Family history of polycystic disease, hereditary nephritis, urinary calculus, malignancy History of DM (high risk for renal failure); exposure to toxins, e.g., nephrotoxic drugs, drug overdose, environmental poisons Current/recent use of nephrotoxic antibiotics, angiotensin-converting enzyme (ACE) inhibitors, chemotherapy agents, heavy metals, nonsteroidal anti-inflammatory drugs (NSAIDs), radiocontrast agents
Discharge plan
DRG projected mean length of inpatient stay: 5.9 days
May require alteration/assistance with medications, treatments, supplies; transportation, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Urine:
Volume: Usually less than 400 mL/24 hr (oliguria) or urine is absent (anuria).
Color: Abnormally cloudy urine may be caused by pus, bacteria, fat, colloidal particles, phosphates, or urates.
Dirty, brown sediment indicates presence of RBCs, hemoglobin, myoglobin, porphyrins.
Specific gravity: Less than 1.015 (fixed at 1.010 reflects severe renal damage).
Osmolality: Less than 350 mOsm/kg is indicative of tubular damage, and urine/serum ratio is often 1:1.
Creatinine clearance: May be significantly decreased (less than 80 mL/min in early failure; less than 10 mL/min in ESRD).
Sodium: More than 40 mEq/L because kidney is not able to reabsorb sodium.
Protein: High-grade proteinuria (3–4+) strongly indicates glomerular damage when RBCs and casts are also present.
Blood:
BUN/Cr: Elevated, usually in proportion. Creatinine level of 12 mg/dL suggests ESRD. A BUN of >25 mg/dL is indicative of renal damage.
CBC: Hb decreased because of anemia, usually less than 7–8 g/dL.
RBCs: Life span decreased because of erythropoietin deficiency, and azotemia.
ABGs: pH decreased. Metabolic acidosis (less than 7.2) occurs because of loss of renal ability to excrete hydrogen and ammonia or end products of protein catabolism. Bicarbonate and PCO2 decreased.
Serum sodium: May be low (if kidney “wastes sodium”) or normal (reflecting dilutional state of hypernatremia).
Potassium: Elevated related to retention and cellular shifts (acidosis) or tissue release (RBC hemolysis). In ESRD, ECG changes may not occur until potassium is 6.5 mEq or higher. Potassium may also be decreased if patient is on potassium-wasting diuretics or when patient is receiving dialysis treatment.
Magnesium, phosphorus: Elevated.
Calcium/phosphorus: Decreased.
Proteins (especially albumin): Decreased serum level may reflect protein loss via urine, fluid shifts, decreased intake, or decreased synthesis because of lack of essential amino acids.
Serum osmolality: Higher than 285 mOsm/kg; often equal to urine.
KUB x-rays: Demonstrates size of kidneys/ureters/bladder and presence of obstruction (stones).
Retrograde pyelogram: Outlines abnormalities of renal pelvis and ureters.
Renal arteriogram: Assesses renal circulation and identifies extravascularities, masses.
Voiding cystourethrogram: Shows bladder size, reflux into ureters, retention.
Renal ultrasound: Determines kidney size and presence of masses, cysts, obstruction in upper urinary tract.
Renal biopsy: May be done endoscopically to examine tissue cells for histological diagnosis.
Renal endoscopy, nephroscopy: Done to examine renal pelvis; flush out calculi, hematuria; and remove selected tumors.
ECG: May be abnormal, reflecting electrolyte and acid-base imbalances.
X-ray of feet, skull, spinal column, and hands: May reveal demineralization/calcifications resulting from electrolyte shifts associated with CRF.
NURSING PRIORITIES
1. Maintain homeostasis.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment needs.
4. Support adjustment to lifestyle changes.
DISCHARGE GOALS
1. Fluid/electrolyte balance stabilized.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Dealing realistically with situation; initiating necessary lifestyle changes.
5. Plan in place to meet needs after discharge.
CARE SETTING
Primary focus is at the community level, although inpatient acute hospitalization may be required for life-threatening complications.
RELATED CONCERNS
Anemias (iron deficiency, pernicious, aplastic, hemolytic)
Fluid and electrolyte imbalances
Heart failure: chronic
Hypertension: severe
Metabolic acidosis (primary base bicarbonate deficiency)
Psychosocial aspects of care
Upper gastrointestinal/esophageal bleeding
Additional associated nursing diagnoses are found in:
Renal dialysis
Renal failure: acute
Seizure disorders/epilepsy
Patient Assessment Database
ACTIVITY/REST
May report: Extreme fatigue, weakness, malaise
Sleep disturbances (insomnia/restlessness or somnolence)
May exhibit: Muscle weakness, loss of tone, decreased range of motion (ROM)
CIRCULATION
May report: History of prolonged or severe hypertension
Palpitations; chest pain (angina)
May exhibit: Hypertension; JVD, full/bounding pulses; generalized tissue and pitting edema of feet, legs, hands
Cardiac dysrhythmias, distant heart sounds
Weak thready pulses, orthostatic hypotension reflects hypovolemia (rare in end-stage disease)
Pericardial friction rub
Pallor; bronze-gray, yellow skin
Bleeding tendencies
EGO INTEGRITY
May report: Stress factors, e.g., financial, relationship, and so on
Feelings of helplessness, hopelessness, powerlessness
May exhibit: Denial, anxiety, fear, anger, irritability, personality changes
ELIMINATION
May report: Decreased urinary frequency; oliguria, anuria (advanced failure)
Abdominal bloating, diarrhea, or constipation
May exhibit: Change in urine color, e.g., deep yellow, red, brown, cloudy
Oliguria, may become anuric
FOOD/FLUID
May report: Rapid weight gain (edema), weight loss (malnutrition)
Anorexia, heartburn, nausea/vomiting; unpleasant metallic taste in the mouth (ammonia breath)
Use of diuretics
May exhibit: Abdominal distension/ascites, liver enlargement (end-stage)
Changes in skin turgor/moisture
Edema (generalized, dependent)
Gum ulcerations, bleeding of gums/tongue
Muscle wasting, decreased subcutaneous fat, debilitated appearance
HYGIENE
May report: Difficulty performing activities of daily living (ADLs)
NEUROSENSORY
May report: Headache, blurred vision
Muscle cramps/twitching, “restless leg” syndrome; burning numbness of soles of feet
Numbness/tingling and weakness, especially of lower extremities (peripheral neuropathy)
May exhibit: Altered mental state, e.g., decreased attention span, inability to concentrate, loss of memory, confusion, decreasing level of consciousness, stupor, coma
Gait abnormalities
Twitching, muscle fasciculations, seizure activity
Thin, dry, brittle nails and hair
PAIN/DISCOMFORT
May report: Flank pain; headache; muscle cramps/leg pain (worse at night)
May exhibit: Guarding/distraction behaviors, restlessness
RESPIRATION
May report: Shortness of breath; paroxysmal nocturnal dyspnea; cough with/without thick, tenacious sputum
May exhibit: Tachypnea, dyspnea, increased rate/depth (Kussmaul’s respiration)
Cough productive of pink-tinged sputum (pulmonary edema)
SAFETY
May report: Itching skin, frequent scratching
Recent/recurrent infections
May exhibit: Scratch marks, petechiae, ecchymotic areas on skin
Fever (sepsis, dehydration); normothermia may actually represent an elevation in patient who has developed a lower-than-normal body temperature (effect of CRF/ depressed immune response)
Bone fractures; calcium phosphate deposits (metastatic calcifications) in skin, soft tissues, joints; limited joint movement
SEXUALITY
May report: Decreased libido; amenorrhea; infertility
SOCIAL INTERACTION
May report: Difficulties imposed by condition, e.g., unable to work, maintain social contacts or usual role function in family
TEACHING/LEARNING
May report: Family history of polycystic disease, hereditary nephritis, urinary calculus, malignancy History of DM (high risk for renal failure); exposure to toxins, e.g., nephrotoxic drugs, drug overdose, environmental poisons Current/recent use of nephrotoxic antibiotics, angiotensin-converting enzyme (ACE) inhibitors, chemotherapy agents, heavy metals, nonsteroidal anti-inflammatory drugs (NSAIDs), radiocontrast agents
Discharge plan
DRG projected mean length of inpatient stay: 5.9 days
May require alteration/assistance with medications, treatments, supplies; transportation, homemaker/maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Urine:
Volume: Usually less than 400 mL/24 hr (oliguria) or urine is absent (anuria).
Color: Abnormally cloudy urine may be caused by pus, bacteria, fat, colloidal particles, phosphates, or urates.
Dirty, brown sediment indicates presence of RBCs, hemoglobin, myoglobin, porphyrins.
Specific gravity: Less than 1.015 (fixed at 1.010 reflects severe renal damage).
Osmolality: Less than 350 mOsm/kg is indicative of tubular damage, and urine/serum ratio is often 1:1.
Creatinine clearance: May be significantly decreased (less than 80 mL/min in early failure; less than 10 mL/min in ESRD).
Sodium: More than 40 mEq/L because kidney is not able to reabsorb sodium.
Protein: High-grade proteinuria (3–4+) strongly indicates glomerular damage when RBCs and casts are also present.
Blood:
BUN/Cr: Elevated, usually in proportion. Creatinine level of 12 mg/dL suggests ESRD. A BUN of >25 mg/dL is indicative of renal damage.
CBC: Hb decreased because of anemia, usually less than 7–8 g/dL.
RBCs: Life span decreased because of erythropoietin deficiency, and azotemia.
ABGs: pH decreased. Metabolic acidosis (less than 7.2) occurs because of loss of renal ability to excrete hydrogen and ammonia or end products of protein catabolism. Bicarbonate and PCO2 decreased.
Serum sodium: May be low (if kidney “wastes sodium”) or normal (reflecting dilutional state of hypernatremia).
Potassium: Elevated related to retention and cellular shifts (acidosis) or tissue release (RBC hemolysis). In ESRD, ECG changes may not occur until potassium is 6.5 mEq or higher. Potassium may also be decreased if patient is on potassium-wasting diuretics or when patient is receiving dialysis treatment.
Magnesium, phosphorus: Elevated.
Calcium/phosphorus: Decreased.
Proteins (especially albumin): Decreased serum level may reflect protein loss via urine, fluid shifts, decreased intake, or decreased synthesis because of lack of essential amino acids.
Serum osmolality: Higher than 285 mOsm/kg; often equal to urine.
KUB x-rays: Demonstrates size of kidneys/ureters/bladder and presence of obstruction (stones).
Retrograde pyelogram: Outlines abnormalities of renal pelvis and ureters.
Renal arteriogram: Assesses renal circulation and identifies extravascularities, masses.
Voiding cystourethrogram: Shows bladder size, reflux into ureters, retention.
Renal ultrasound: Determines kidney size and presence of masses, cysts, obstruction in upper urinary tract.
Renal biopsy: May be done endoscopically to examine tissue cells for histological diagnosis.
Renal endoscopy, nephroscopy: Done to examine renal pelvis; flush out calculi, hematuria; and remove selected tumors.
ECG: May be abnormal, reflecting electrolyte and acid-base imbalances.
X-ray of feet, skull, spinal column, and hands: May reveal demineralization/calcifications resulting from electrolyte shifts associated with CRF.
NURSING PRIORITIES
1. Maintain homeostasis.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment needs.
4. Support adjustment to lifestyle changes.
DISCHARGE GOALS
1. Fluid/electrolyte balance stabilized.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Dealing realistically with situation; initiating necessary lifestyle changes.
5. Plan in place to meet needs after discharge.
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