End – Stage Renal

Disease
 Description

* Chronic renal failure, or end-stage renal disease
(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.
 Signs and Symptoms

* Cardiovascular: hypertension, pitting edema (feet,
hands, sacrum), periorbital edema, pericardial
friction rub, engorged neck veins, pericarditis,
pericardial effusion, pericardial tamponade,
hyperkalemia, hyperlipidemia.


* Integumentary: gray-bronze skin color, dry flaky
skin, pruritus, ecchymosis, purpura , thin brittle
nails, coarse thinning hair.

* Pulmonary: crackles; thick, tenacious sputum;
depressed cough reflex,: pleuritic pain; shortness of
breath; tachypnea; Kussmaul-type respirations;
uremic pneumonitis (“uremic lung”)



* Gastrointestinal: ammonia odor to breath (fetor
uremicus), metallic taste, mouth ulcerations and
bleeding, anorexia, nausea and vomiting, hiccups,
constipation or diarrhea, bleeding from
gastrointestinal tract.
* Neurologic: weakness and fatigue, confusion,
inability to concentrate, disorientation, tremors,
seizures, asterixis, restlessness of legs, burning of
soles of feet, behavior changes.


* Musculoskeletal: muscle cramps, loss of muscle
strength, renal osteodystrophy, bone pain,
fractures, foot drop.



* Reproductive: amenorrhea, testicular atrophy,
infertility, decrease libido.



* Hematologic: anemia, thrombocytopenia.
 Diagnostic Procedures



* Blood tests ( to determine blood cell counts,
electrolytes levels, and kidney function.



* Urine tests



* Chest x-ray – a diagnostic test that uses
invisible electromagnetic energy beams to produce
images of internal tissues, bones, and organs onto
film.


* Bone scan- a nuclear imaging method to
evaluate any degenerative and/ or arthritic
changes in joints; to detect bone diseases and
tumors; to determine the cause of bone pain or
inflammation.



* Renal ultrasound- a non-invasive test in which a
transducer is passed over the kidney producing
sound waves which bounce off the kidney,
transmitting a picture of the organ on a video
screen. The test is use to determine the size and
shape of the kidney, and to detect a mass, kidney
stone, cyst or other obstruction or abnormalities.
* Electrocardiogram (ECG or EKG- a test that
records the electrical activity of the heart, shows
abnormal rhythms (arrhythmias or dysrhythmias),
and detects heart muscle damage.

*Kidney biopsy- a procedure in which tissue samples



are removed ( with a needle or during surgery) from

the body for examination under a microscope; to
determine if cancer or other abnormal cells are
present.
 Nursing Management

Assessment:

*Assess fluid status and help patient limit
fluid intake to prescribed limit.



*Assess nutritional status and address
factors contributing to nutritional imbalance.



* Assess patient’s understanding about the
condition and it treatment, explain renal function,
and assist patient to identify ways to incorporate
lifestyle changes related to illness and treatment.
 * Assess factors contributing to fatigue.


* Assess patient’s and family’s responses and
reaction o illness and treatment. Encourage open
discussion of concerns about changes produced by
diasease and treatment.



* Assess for and monitor collaborative
problems (eg, hyperkalemia, pericarditis,
pericardial effusion and pericardial tamponade,
hypertension, anemia ,bone disease, and metastatic
calcifications.
 Medical Management

* Complication can be prevented or delayed by
administering prescribed antihypertensive,
cardiovascular agents, anticonvulsants,
erythropoietin, iron supplements, phosphate-
binding agents, and calcium supplements.



* Dietary interventions needed with careful
regulation of protein intake, fluid intake to balance
fluid losses and sodium intake and with some
restriction of potassium.
 * Adequate intake of calories and vitamins is
ensured. Calories are supplied with carbohydrates
and fats to prevent wasting.


* Protein is restricted; protein must be of high
biologic value (dairy products, eggs, meats.



* Vitamin supplementation.



* Fluid allowance is 500 to 600 mL of fluid or more
than 24- hour urine output.

 Pharmacologic Management

*Hyperphosphatemia and hypocalcemia are treated
with aluminum-based antacids or calcium
carbonate; both must be given with food.



*Hypertension is managed by intravascular volume
control and antihypertensive medication.



* Heart failure and pulmonary edema are treated
with fluid restriction, low-sodium diet, diuretics,
inotropic agents, and dialysis.
* Metabolic acidosis is treated, if necessary, with
sodium bicarbonate supplements or dialysis.

*Hyperkalemia is treated with dialysis; medications are



monitored for potassium content; patient is placed on

potassium-restricted diet; Kayexelate is
administered as needed.



*Patient is observed for early evidence of neurologic
abnormalities.



*The onset of seizures,type,duration,and general
effect on patient are recorded; physician is notified
immediately and patient is protected from injury
 * Intravenous diazepam or phenytoin is administered to
control seizure.

*

Anemia is treated with recombinant human
erythropoietin; hematocrit is monitored frequently.


* Heparin is adjusted as necessary to prevent clotting of



dialysis lines during treatments.



* Serum iron and transferrin levels are monitored to



assess iron states.



* Blood pressure and serum potassium levels are



monitored.
*Patient is referred to a dialysis and transplantation
center early in the course of progressive renal
disease. Dialysis is initiated when patient cannot
maintain a reasonable lifestyle with conservative
treatment.
 Other Nursing Interventions

Managing Excess Fluid Volume



*Assess fluid status and identify potential
sources of imbalanced.



*Monitor patient’s progress and complication with
treatment regimen.



 Promoting Balance Nutrition



* Implement a dietary program to ensure
proper nutritional intake within the limits of the
treatment regimen.



* Provide a referral for a nutritional
consultation.
 Educating the patient and Family

Teaching Patient’s Self-Care



* Provide ongoin g explanations and information to
patient and family concerning ESRD, treatment
options, and potential complications.



*Teach patient and family what problems to
report: signs of worsening renal failure,
hyperkalemia, assess problems.

 * Provide medication teaching and show patient
undergoing hemodialysis how to assess vascular
access for patency and precaution to take.
 Continuing Care

*Provide assistance and emotional support to
patient and family in dealing with dialysis and it’s
long term implications.



*Stress the importance of follow-up
examinations and treatment.



*Refer patient to home care nurse for
continued monitoring and support.

 NURSING CARE
PLAN
 Nursing diagnosis


Ineffective tissue perfusion

related to decreased cardiac
output as evidenced by
BP=80/40 mmhg,
nausea,vomoting, diaphoresis
and pr=120bpm.
“grabe lingin ulo ku day” as
verbalized by the client.

GoaL
Within 1 hour of nursing
interventions, client will be
able to maintain adequate
tissue perfusion.
 Interventions
Independent:
 
Monitor vital signs Provide baseline for
especially BP. comparison to follow
 and evaluate
 response to
interventions.
Elevate head of bed
To promote circulation
and maintain
head/neck in midline and to increase
or neutral position. gravitational blood
flow.

Encourage quiet, Conserves energy and
restful atmosphere. lower tissue oxygen
 demand.
Emphasize necessity Smoking promote
for smoking vasoconstriction of
cessation. blood vessels and
may further
compromise
perfusion.
Encourage use of To decrease tension
relaxation activities. level.
Dependent: 
Administer 
medication as 
prescribed by the Osmotic diuretic that
doctor. increases BP.
*mannitol

Evaluation
After 1 hour of nursing intervention,
goal fully met as evidenced by
BP=110/80mmhg,
PR=80bpm,absence of nausea,
vomiting, and diaphoresis.
“la nah galingin ulo ko.” as verbalized

by the client.