Chronic renal failure is an irreversible condition where nephron loss occurs gradually and usually secondary to another disease.(Cannon, 2004). The condition begins with slowing down of the Glomerular Filtration Rate and the final stages of the disease result in disruption of all body systems, a condition referred to as End Stage Renal Disease (Terrill, 2004). In chronic Renal Failure, the nephron strains to eliminate creatinine, urea and nitrogen leading to complications such as hypertension, acid-base imbalance, pulmonary edema, peripheral neuropathy, osteoporosis, cognitive changes and anemia. Anemia develops as a result of the kidney’s inability to produce adequate amounts of erythropoietin (Sosa-Guerrero and Gamez, 1997)
Renal disease is said to progress from diminished renal reserve to end stage renal disease (Terill, 2004). Diminished renal reserve refers to a sub-clinical condition that often goes undiagnosed unless there are other factors that necessitate a follow-up of renal function (Terrill, 2004). It is often only detected when creatinine clearance is decreased. It is accompanied in changes in biochemistry and hematology of serum. At this point the patient has usually developed uraemic syndrome and will require dialysis (Terrill, 2002). Dialysis aims at removing metabolites of protein metabolism. It is necessary for the maintenance of serum electrolytes within safe levels and for correcting acidosis by restoring the levels o bicarbonate buffers (Black, 1997).
Peritoneal dialysis uses a catheter to fill the peritoneal cavity with dialysis fluid which receives excess water and waste from the blood after it has passed through the peritoneum. The fluid is then drained and discarded (www.kidney.ca/page.asp?intNode/d=22135)
Prior to performing assessment on Mary it is necessary to identify the risk factors that she may have that could exacerbate her condition and also to fine out what forms of treatment she has been on and the medication she is receiving. This will be elicited from her history which shows that she has diabetes, hypertension and has a leg wound on the left leg. This will complicate her management and due to diabetes healing of the wound on her leg will be prolonged.
Assessment
The assessment of Mary will begin with an overview of her general appearance to reveal whether she may be having any skin color changes, respiratory distress or pain. Changes of skin color such as paleness indicate that she likely has anemia which results from decreased erythropoietin production by the kidney. Respiratory distress shown by rapid, deep breaths may result from poor metabolic acidosis as the body tries to correct the acid-base imbalance brought about by impaired kidney function. Decreased hemoglobin levels and low erythrocyte count also contribute to this (Cannon, 2004).
Vital signs measurement will follow. Vital signs are important for indicating infection, her blood pressure values will indicate whether her hypertension is well controlled or not. Respiration rate will also be assessed at this point to determine whether respiratory function has been compromised by CRF. Renal disease results in high levels of hydrogen ions whish combine with bicarbonate ions to form carbonic acid, an unstable compound that dissociates into carbon dioxide and water. The body corrects this by eliminating H+ through rapid, deep respirations to help the kidney conserve bicarbonate ions. This results in a high respiration rate (Doylean, 2000). At this point her weight and height will also be measured to provide values that can calculate her BMI and also to form a base for comparison with other values of weight that will be taken for nutritional evaluation.
Mary will undergo neurological assessment to determine whether any cognitive changes have taken place as a result of the CRF. Her alertness and orientation will be assessed through conversation and asking her questions regarding the time, place and people.
Cardiovascular assessment will provide information on the heart rate and rhythm which are very important because Mary is hypertensive. Angina and palpitations are indications that cardiovascular function is compromised. Assessment will be done by auscultation and palpation of the heart rate and pulse points such as the femoral pulse, dorsalis pedis pulse and radial pulse. Dorsalis pedis is especially important because of the leg wound she has.
Musculoskeletal assessment will provide a chance for observation of the wound that Mary has on her left leg. It will be assessed for infection. She will also be assessed for edema. To determine musculoskeletal function range of motion exercises will be performed following questioning on whether she experience any discomfort when walking and performing other physical activities.
Inspection of the integumentary system for cyanosis, clubbing, bruises and alopecia will likely result in findings of alopecia and ecchymosis related to aging, this however needs to be differentiated from changes due to CRF. Decreased skin turgor may be due to decreased connective tissue that comes with aging, skin bruises could be related to frequent medication through injection (Cannon, 2004).
The gastrointestinal system will b inspected and palpated to check for masses and any abnormalities in shape noted. Auscultation to check for bowel sounds will also be done. The urinary system will be assessed for any burning, hesitancy or frequency that Mary might be experiencing. Frequency can be assessed by observing how many times she voids, while burning and hesitancy can be assessed by asking her to report whenever she experiences (Doylean, 2000)
To provide holistic care, assessment of Mary’s roles and relationships is necessary as this will determine how well she copes with her health situation. This can be done by observing Mary’s interactions with family members, friends and other patients. Conversation with Mary will also provide insight on her values, beliefs and fears and her knowledge and understanding of her disease condition and treatment process (White, 2000 Results from diagnostic tests will also provide valuable information in addition to the results from physical assessment. Evaluation of results from laboratory tests and diagnostic tests such as chest X-rays, pulmonary function tests and echocardiograms among others will determine the nursing interventions for many. Lab values for creatinine, pH, bicarbonate ions, hemoglobin and thyroid hormones will help in determining whether Mary’s chronic renal failure is responding to management and also whether her diabetes is well-managed.
Nursing Diagnoses
1. Imbalanced nutrition, less than body requirements related to anorexia, diabetes (Carpenito-Moyet, 2005)
2. Fatigue related to peritoneal dialysis, hypertension, anemia, evidenced by decreased energy and decreased erythrocyte count and low hemoglobin levels
3. Risks for infection related to invasive procedures (peritoneal dialysis), diabetes, and venous wound on leg.
4. Risk for impaired skin integrity related to anemia, renal failure, diabetes and presence of leg wound.
5. Risk for ineffective therapeutic regimen management related to insufficient knowledge of condition, dietary restriction, signs and symptoms (Carpenito-Moyet, 2005).
Interventions
Improving nutrition
Outcome: Mary will maintain a stable weight within normal limits and adhere to the recommended dietary program.
Interventions
At a height of 160 cm and with a weight of 67kg, Mary’s BMI shows she is overweight which is a risk factor that would complicate her diabetes and hypertension making her condition of chronic renal failure worse. Altering her eating habits to a diet that is low on sodium, potassium and phosphorous will reduce the load on her kidneys as these are the three substances regulated by the kidney (Cannon, 2004). Most foods high in sodium levels are high salt foods and high in fat which contribute to increase in weight, reducing this would make Mary lose weight. Mary will be taught which foods to eat that are part of a good diet so as to slow and lower hyperlipidemia, diabetes and hypertension. Mary’s dietary program will be planned in consultation with a nutritionist and will include low protein intake so as to avoid and alleviate uremia (Cannon, 2004). To ensure that the diet program is beneficial to Mary her electrolyte levels will be monitored so that any shifts can be noted and corrected as soon as possible.
Glycemic control also needs to be maintained. Ensuring that Mary’s glucose levels are within normal limits by providing highly nutritive meals timely and in an attractive manner so that Mary is encouraged to cat to prevent hypoglycemic episode. Deranged glucose metabolism and hyperinsulinaemia lead to atherosclerotic complications in patients with CFR (Cannon, 2004)
Managing fatigue
Outcome: Mary will be able to perform physical activity and obtain adequate rest
Mary will be given an opportunity to rate her fatigue so that it can be determined when she feels most exhausted. This will help to plan care and activities for the periods she has a lot of energy. Mary will also be encouraged to be as independent as possible. To avoid weakness and fatigue becoming a safety issue, Mary’s room will be kept free of clutter and whenever necessary she will be assisted with ambulation (Doenges, 2000). Hypertension contributes to the weakness and fatigue that Mary will feel-consequently; hypertension will be managed by ensuring she gets all the prescribed medication. The first line drugs for hypertension in CRF are ACE inhibitors because they delay progression of CRF, reduce proteinuria and microalbuminuria and improve function of the left ventricle (Doylean, 2000). However if Mary will be on this medication she will be monitored closely for hyperkalemia and deterioration because the drugs have an effect of reducing GFR.
Optimizing Mary’s dietary intake through consultation with a nutritionist will also help to address her problem of fatigue. Administering other medications as prescribed such as oxygen, oxygen and vitamins will help to manage fatigue that Mary may experience (Doenge, 2000).
Managing risk for infection.
Outcome: Mary will remain free of infection.
Interventions
Mary’s wound on the left leg will be cleared regularly to ensure that infection does not occur and that fast healing is promoted. Prescribed antibiotics will be given as ordered for purposes of prophylaxis. Regular assessment for infection such as checking temperature increases, inspecting for redness and palpating the dorsalis pedis pulse are important ways of monitoring that infection has not occurred on Mary’s leg wound. Mary’s site for peritoneal dialysis will also be monitored for cleanliness so that it does not become a site of entry for microbes which cause Mary to develop peritonitis (www.kidney.calpagge.asp?intNodeid=22135)
Managing risk for impaired skin integrity
Outcome: Mary’s skin will remain healthy and intact
Interventions
To ensure that Mary’s skin is kept safe from skin breakdown, her skin will be inspected during every shift. The skin will be observed for breakdown, redness and purpura. Any report of itching will investigate to ensure the skin remains intact.
Hydration status will also be monitored by keeping a record of his input and output, weighing her daily so that any changes in weight can be noted and acted upon. Inspection of mucus membranes is also part of checking the hydration status. Dry mucus membranes increase the likelihood for skin breakdown (Doenges et al, 2000)
To further ensure that skin breakdown is prevented Mary will be monitored for edema be checking for any swelling on her extremities and at pressure points. Edematous areas are more prone to skin breakdown. Mary will also be encouraged to change her position frequently to prevent applying pressure in on one area. In addition, she will be provided with a foam cushion to ensure that prolonged pressure is reduced. (Doenges, 2000)
To eliminate edema, Mary’s legs will be elevated so that venous return is promoted.
Managing risk for ineffective regimen management.
Outcome: Mary will demonstrate understanding of her condition manifested by the ability to explain in her own words the, nature of her own illness and general management principles of diabetes and hypertension and adherence to the management regimen.
Interventions
Mary will be educated on the effect that diabetes has on her CRF. She will be involved in planning of her dietary program so that she can get a chance to learn how to make healthy food choices and also learn why it is necessary. Including her will help her to see that her likes and dislikes have been considered increasing the chances that she will adhere to the dietary regimen (Doenges, 2000).
Mary will also be educated on the effects off her medication and their indications so that she is aware of their functions and also to prepare her for the side effects that accompany them. She will be given an opportunity to ask questions concerning her condition to reduce her fears and anxieties. Mary will also be expected to explain in her own words her treatment process to evaluate that she has understood her role in management of her condition. This enhances compliance on her part (White, 2000). The discharge plan Mary will involve checking that she has adequate understanding of CRF, diabetes and hypertension and he role in the management of the illness,. She will be educated on each aspect of her illness with highlights on dietary restriction, home safety and her physical limitations with caution for her not exert herself unnecessarily. She will also be told about the risks that she faces such as the risk of skin breakdown and the risk of infection. Emphasis will be placed on the importance of hand washing as a means of ensuring that spread of germs is kept to a minimum. She will also be taught about signs of infections such as discharge, swelling, redness and general malaise.
Mary will also be referred to the local office of the National Foundation for Kidney Diseases so the she can get more information whenever necessary. Part of the discharge plan will also involve providing emotional support for Mary by answering any questions she may have and providing her with an opportunity to ventilate her feelings.
Teaching her family members ways in which they can participate in Mary’s care. Evaluation of her socioeconomic needs, cultural background and how accessible medical care is for her will be included in the discharge plan to ensure that the client’s anxiety and fears are allayed and that her post-discharge care is as holistic as possible (White, 2000).
Care for the chronic renal failure patient can be demanding and it is necessary that health care staffs are knowledgeable on new trends and developments that related to management of the patients. The age of the patient limits her chances of being placed on a kidney transplant list and even if many were to be place on a list, it does not guarantee that she will get the kidney in good time. As such management of the condition buy preventing complications and further degradation of her kidney is the best way to ensure that she remains healthy.
REFERENCES
Black JM & Matassarin-Jacobs E1997 Medical Surgical Nursing: Clinical Management for Continuity of Care (5th Ed.). Pennsylvania: Saunders.
Cannon JD 2004 Recognizing Chronic Renal Failure….the Sooner the Better retrieved from http://findarticles.com/p/articles/mi_qa36889/is_20040/ai_n9396279/p
Doenges, ME, Moorhouse, MF, & Geissler, AC (2000). Nursing Care Plans: Guidelines For Individualizing Patient Care (5th Ed.). Pennsylvania: Davis
Doylean S 2000 Understanding Chronic Renal Failure, Nursing retrieved fro http://findarticles.com/articles/mi_qa3689/is_200004/ai-n8903118
Lynda Juall Carpenito2005, Handbook of Nursing Diagnosis Lippincott Williams& Wilkins ISBN 0781761301
Peritoneal dialysis, The Kidney Foundation retrieved from www.kidney.ca/page.asp?intNodeId=22135
Sosa-Guerrero S and Gomez N.J. 1997 Dealing with end-stage renal disease. AJN, American Journal of Nursing [Online], Available: http://www.nursingcenter.com/ce/test/article.cfm?id=CDFE00E0%2D11D3%2D
[2001February 23]
Terrill B, 2002 Renal Nursing: A Practical Approach Ausmed Publications ISBN 0957798881
White L 2000, Foundations of Nursing: Caring for the Whole Person Thomson Delmar
ISBN 0766808262
