Chronic Kidney Failure

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WHAT YOU SHOULD KNOW:

 Chronic kidney failure is also called chronic renal failure or CRF. It is a long-term kidney
disease. The kidneys are two bean-shaped organs that remove unwanted chemicals and
waste from the blood. Your kidneys slowly stop working in chronic kidney failure. This
usually occurs when you have high blood pressure or high blood sugar levels (diabetes).
You may have decreased urine output, edema (swelling) of arms, feet, and face, or
increased blood pressure.

 Blood and urine tests can check if your kidneys are working well. Tests that take pictures
of kidneys, such as ultrasound, x-rays, and computerized tomography (CT) scans can also
be used. Chronic kidney failure can only be controlled with proper and timely treatment.
It can get worse and become end-stage renal disease if left untreated.

AFTER YOU LEAVE:

Medicines:

 Keep a written list of the medicines you take, the amounts, and when and why you take
them. Bring the list of your medicines or the pill bottles when you see your caregivers.
Learn why you take each medicine. Ask your caregiver for information about your
medicine. Do not use any medicines, over-the-counter drugs, vitamins, herbs, or food
supplements without first talking to caregivers.

 Always take your medicine as directed by caregivers. Call your caregiver if you think
your medicines are not helping or if you feel you are having side effects. Do not quit
taking your medicines until you discuss it with your caregiver. If you are taking medicine
that makes you drowsy, do not drive or use heavy equipment.

 Avoid medicines that may cause more damage to your kidneys. These include aspirin,
certain antibiotics, and some herbal supplements. Ask your caregiver which medicines
you should not use.

 It is very important that you take your high blood pressure and diabetes medicine as
directed by your caregiver.

Ask your caregiver when to return for a follow-up visit. Keep all appointments. Write down
any questions you may have. This way you will remember to ask these questions during your
next visit.
Diet: Changing what you eat and drink may be hard at first. You may need to make these
changes part of your daily routine. A caregiver called a dietitian or nutritionist may work with
you to find the right diet for you.

 You may need to eat a high-calorie, low-protein diet. You may also need to eat low
sodium (salt) and potassium foods, such as cereals, grains, blueberries, or lettuce.

 Keep a list of items in your kitchen that you can eat on your diet. You may use special
cookbooks to help find new recipes.

 Follow your caregiver’s advice about drinking liquids. Write down how much liquid you
drink and how much you urinate.

 Sucking on hard candy or chewing gum may keep your mouth moist without having to
drink liquids. Lemon wedges may also help keep your mouth moist.

Daily weight: Your caregiver will help you learn what your ideal weight should be. Weigh
yourself every morning about the same time and write it down. If your kidneys are not working
right, you may have extra fluid in your body. Call your caregiver if you have gained or lose more
weight than what your caregiver suggests in one day.

Wellness hints:

 Avoid alcohol-containing drinks: These include beer, wine, liquor, such as whiskey or
gin, or other adult drinks.

 Exercise: Talk to your caregiver before you start exercising. Together you can plan the
best exercise program for you. It is best to start slowly and do more as you get stronger.
Exercising makes the heart stronger, lowers blood pressure, and keeps you healthy.

 Quit smoking: It is never too late to quit smoking. Smoking harms the heart, lungs, and
the blood. You are more likely to have a heart attack, lung disease, and cancer if you
smoke. You will help yourself and those around you by not smoking. Ask your caregiver
for more information about how to stop smoking if you are having trouble quitting.

 Stress: Stress may slow healing and cause illness later. Since it is hard to avoid stress,
learn to control it. Learn new ways to relax, such as deep breathing, meditation, relaxing
muscles, music, or biofeedback. Talk to someone about things that upset you.

Diet

Diet is an important consideration for those with impaired kidney function. Consultation with a
dietician may be helpful to understand what foods may or may not be appropriate.

Since the kidneys cannot easily remove excess water, salt, or potassium, they may need to be
consumed in limited quantities. Foods high in potassium include bananas, apricots, and salt
substitutes.
Phosphorus is a forgotten chemical that is associated with calcium metabolism and may be
elevated in kidney failure. Too much phosphorus can leech calcium from the bones and cause
osteoporosis and fractures. Foods with high phosphorus content include milk, cheese, nuts, and
cola drinks.

Medications

Medications may be used to help control some of the issues associated with kidney failure.

 Phosphorus-lowering medications [calcium carbonate (Caltrate), calcitriol (Rocaltrol), sevelamer

(Renagel)]

 Red blood cell production stimulation [erythropoietin, darbepoetin (Aranesp)]

 Red blood cell production (iron supplements)

 Blood pressure medications

 Vitamins

Once the kidneys fail completely, the treatment options are limited to dialysis or kidney
replacement by transplantation.

NCP Renal Failure : Chronic

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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.