🞂 ​When

a patient has sustained enough kidney

damage to require renal replacement therapy on a
permanent basis, the patient has moved into the
fifth or final stage of CKD , also referred to as
chronic renal failure (CRF) or ESRD .
🞂 ​End products of protein metabolism accumulate
in the blood
🞂 ​ Uremia develops and adversely affects every
system in the body
🞂 ​The rate of decline in renal function and
progression of ESRD is related to the underlying
disorder, the urinary excretion of protein, and the
presence of hypertension
STAGE GFR Description
I ≥ 90 ml/min/1.73m² Kidney damage with normal or
increased GFR

2 60 to 89 ml/min/1.73m² Mild decrease in GFR

3 30 to 49 ml/min/1.73m² Moderate decrease in GFR
4 15 to 29 ml/min/1.73m² Severe decrease in GFR
5 < 15ml/min.1.73m² ESRD or Chronic renal failure
Neurolo
🞂 ​ Weakness and fatigue
gic
🞂 ​ Confusion
🞂​ Inability to concentrate
🞂​ Disorientation
🞂 Tremors
🞂 Seizures
🞂 Asterixis
🞂 Restlessness of legs
🞂 Burning of soles of feet
🞂 Behavior changes
Integument
ary
🞂 ​ Gray-bronze skin color
🞂 ​ Dry, flaky skin
🞂 ​ Pruritus
🞂 ​ Ecchymosis
🞂 ​ Purpura
🞂 ​ Thin, brittle nails
🞂 ​ Coarse, thinning hair
Cardiovascu
🞂 ​ Hypertension
lar
🞂 ​ Pitting edema (feet, hands, sacrum)
🞂​ Periorbital edema
🞂​ Pericardial friction rub
🞂​ Engorged neck veins
🞂​ Pericarditis
🞂​ Pericardial effusion
🞂​ Pericardial tamponade
🞂​ Hyperkalemia
🞂​ Hyperlipidemia
Pulmona
🞂 ​ Crackles
ry
🞂 ​ Thick, tenacious sputum
🞂 ​ Depressed cough reflex
🞂 ​ Pleuritic pain
🞂 ​ Shortness of breath
🞂 ​ Tachypnea
🞂 ​ Kussmaul-type respirations
🞂 ​ Uremic pneumonitis
Gastrointesti
nal
🞂 ​ Ammonia odor to breath (“uremic fetor”)

🞂 ​ Metallictaste
🞂 ​ Mouth ulcerations and bleeding

🞂 ​ Anorexia, nausea, and vomiting

🞂 ​ Constipation or diarrhea

🞂 ​ Bleeding from gastrointestinal tract

Hematolo
​ Anemia
gic
🞂
🞂​ Thrombocytopenia

Reproductiv
e
🞂​ Amenorrhea
🞂 ​ Testicular atrophy
🞂 ​ Infertility
🞂 ​ Decreased libido
Musculoskeletal
🞂 ​ Muscle cramps

🞂 ​ Loss of muscle strength

🞂 ​ Renal osteodystrophy

🞂 ​ Bone pain

🞂 ​ Bone fractures

🞂 ​ Foot drop
Glomerular Filtration
Rate
🞂 ​As the GFR decreases the creatinine clearance
decreases, while the serum creatinine and BUN
levels increase
Sodium and Water Retention
🞂 ​Some patients retain sodium and water,
increasing the risk for edema, heart failure, and
hypertension.
🞂 ​Hypertension may also result from activation of
the renin–angiotensin–aldosterone axis and the
concomitant increased aldosterone secretion
🞂 ​ Other patients have a tendency to lose sodium
Acidosis
🞂 ​Metabolic acidosis occurs because the kidneys are
unable to excrete increased loads of acid
🞂 ​Decreased acid secretion results from the inability
of the kidney tubules to excrete ammonia (NH3-)
and to reabsorb sodium bicarbonate(HCO3–)
Anemia
🞂 ​ Anemia develops as a result of inadequate erythropoietin
production, the shortened lifespan of RBCs, nutritional
deficiencies, and the patient’s tendency to bleed.

Calcium and Phosphorus Imbalance

🞂 ​ With a decrease in filtration through the glomerulus of the
kidney, there is an increase in the serum phosphate level
and a reciprocal or corresponding decrease in the serum
calcium level.
🞂 ​Hyperkalemia due to decreased excretion,
metabolic acidosis, catabolism, and excessive
intake (diet, medications, fluids)
🞂 ​Pericarditis, pericardial effusion, and pericardial
tamponade due to retention of uremic waste
products and inadequate dialysis
🞂 ​ Hypertension due to sodium and water retention and
malfunction of the renin–angiotensin–aldosterone system
🞂 ​ Anemia due to decreased erythropoietin production,
decreased RBC lifespan, bleeding in the GI tract from
irritating toxins and ulcer formation, and blood loss during
hemodialysis
🞂 ​ Bone disease and metastatic and vascular calcifications due
to retention of phosphorus, low serum calcium levels,
abnormal vitamin D metabolism, and elevated aluminum
level
🞂 ​Goal:
to maintain kidney function and
homeostasis for as long as possible
Pharmacologic
​ Calcium and Phosphorus Binders
Therapy
🞂
◦ calcium carbonate or calcium acetate
◦ sevelamer hydrochloride (Renage)
◦ Magnesium-based antacids are avoided to prevent magnesium toxicity
🞂​ Antihypertensive and Cardiovascular Agents
◦ Antihypertensive agents
◦ digoxin (Lanoxin) or dobutamine (Dobutrex)
🞂​ Antiseizure Agents
◦ IV diazepam (Valium) or phenytoin (Dilantin)
🞂​ Erythropoietin
◦ Recombinant human erythropoietin (Epogen)
🞄 administered intravenously or subcutaneously
◦ Iron supplements
Nutritional
​ Protein is restricted because urea, uric acid, and organic
Therapy
🞂
acids accumulate rapidly in the blood
◦ allowed protein must be of high biologic value (dairy products,
eggs, meats)
🞂 ​ Usually, the fluid allowance per day is 500 mL to 600 mL
more than the previous day’s 24-hour urine output
🞂 ​ Calories are supplied by carbohydrates and fat to
prevent wasting.
🞂 ​ Vitamin Supplementation
Dialysis
🞂 ​usually initiated when the patient cannot maintain
a reasonable lifestyle with conservative treatment.
NURSING DIAGNOSIS: Excess fluid volume related to decreased urine
output,
dietary excesses,
Nursing and retention of sodium and water
Interventions
🞂 ​ Assess fluid status:
◦ Daily weight
◦ Intake and output balance
◦ Skin turgor and presence of edema
◦ Distention of neck veins
◦ Blood pressure, pulse rate, and rhythm
◦ Respiratory rate and effort
🞂​ Limit fluid intake to prescribed volume.
🞂​ Identify potential sources of fluid:
◦ Medications and fluids used to take or administer medications: oral and intravenous
◦ Foods
🞂​ Explain to patient and family rationale for fluid restriction.
🞂​ Assist patient to cope with the discomforts resulting from fluid restriction.
🞂​ Provide or encourage frequent oral hygiene.
NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements
related to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous
membranes
Nursing Interventions
🞂 ​ Assess nutritional status:
◦ Weight changes
◦ Laboratory values (serum electrolyte, BUN, creatinine, protein, transferrin, and iron levels)
🞂​ Assess patient’s nutritional dietary patterns:
◦ Diet history
◦ Food preferences
◦ Calorie counts
🞂​ Assess for factors contributing to altered nutritional intake:
◦ Anorexia, nausea, or vomiting
◦ Diet unpalatable to patient
◦ Depression
◦ Lack of understanding of dietary restrictions
◦ Stomatitis
🞂​ Provide patient’s food preferences within dietary restrictions.
🞂 ​ Promote intake of high-biologic-value protein foods: eggs, dairy products, meats.
🞂 ​ Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between
meals.
🞂 ​ Alter schedule of medications so that they are not given immediately before meals.
🞂 ​ Explain rationale for dietary restrictions and relationship to kidney disease and
increased
urea and creatinine levels.
🞂 ​ Provide written lists of foods allowed and suggestions for improving their taste without
use of sodium or potassium.
🞂 ​ Provide pleasant surroundings at meal-times.
🞂 ​ Weigh patient daily.
🞂 ​ Assess for evidence of inadequate protein intake:
◦ Edema formation
◦ Delayed wound healing
◦ Decreased serum albumin levels
NURSING DIAGNOSIS: Deficient knowledge regarding condition and
treatment
Nursing
🞂 ​ Assess Interventions
understanding of cause of renal failure, consequences of renal failure, and its treatment:
◦ Cause of patient’s renal failure
◦ Meaning of renal failure
◦ Understanding of renal function
◦ Relationship of fluid and dietary restrictions to renal failure
◦ Rationale for treatment (hemodialysis, peritoneal dialysis, transplantation)
🞂​ Provide explanation of renal function and consequences of renal failure at patient’s level of
understanding and guided by patient’s readiness to learn.
🞂 ​ Assist patient to identify ways to incorporate changes related to illness and its treatment
into lifestyle.
🞂 ​ Provide oral and written information as appropriate about:
◦ Renal function and failure
◦ Fluid and dietary restrictions
◦ Medications
◦ Reportable problems, signs, and symptoms
◦ Follow-up schedule
◦ Community resources
◦ Treatment options
NURSING DIAGNOSIS: Activity intolerance related to fatigue,
anemia, retention of waste products, and dialysis procedure
Nursing Interventions
🞂 ​ Assess factors contributing to activity intolerance:
◦ Fatigue
◦ Anemia
◦ Fluid and electrolyte imbalances
◦ Retention of waste products
◦ Depression
🞂​ Promote independence in self-care activities as tolerated; assist if
fatigued.
🞂​ Encourage alternating activity with rest.
🞂​ Encourage patient to rest after dialysis treatments.
NURSING DIAGNOSIS: Risk for situational low self-esteem related to
dependency, role changes, change in body image, and change in sexual function
Nursing Interventions
🞂 ​ Assess patient’s and family’s responses and reactions to illness and treatment.
🞂 ​ Assess relationship of patient and significant family members.
🞂 ​ Assess usual coping patterns of patient and family members.
🞂 ​ Encourage open discussion of concerns about changes produced by disease and
treatment:
◦ Role changes
◦ Changes in lifestyle
◦ Changes in occupation
◦ Sexual changes
◦ Dependence on health care team
🞂​ Explore alternate ways of sexual expression other than sexual intercourse.
🞂​ Discuss role of giving and receiving love, warmth, and affection.
Hyperkalemia
🞂 ​Monitor serum potassium levels. Notify physician
if level greater than 5.5 mEq/L, and prepare to
treat hyperkalemia.
🞂 ​Assess patient for muscle weakness, diarrhea,
E C G changes (tall tented T waves and widened
QRS)
Pericarditis, Pericardial Effusion, and Pericardial
​ Assess patient for fever, chest pain, and a pericardial friction rub (signs
Tamponade
🞂
of pericarditis) and, if present, notify physician.
🞂 ​ If patient has pericarditis, assess for the following every 4 hours:
◦ Paradoxical pulse _10 mm Hg
◦ Extreme hypotension
◦ Weak or absent peripheral pulses
◦ Altered level of consciousness
◦ Bulging neck veins
🞂​ Prepare patient for cardiac ultrasound to aid in diagnosis of pericardial
effusion and cardiac tamponade.
🞂​ If cardiac tamponade develops, prepare patient for emergency
pericardiocentesis.
Hypertension
🞂 ​ Monitor and record blood pressure as indicated.
🞂 ​Administer antihypertensive medications as
prescribed.
🞂 ​Encourage compliance with dietary and fluid
restriction therapy.
🞂 ​Teach patient to report signs of fluid overload,
vision changes, headaches, edema, or seizures.
Anemia
🞂 ​ Monitor RBC count, hemoglobin, and hematocrit levels as
indicated.
🞂 ​ Administer medications as prescribed, including iron and
folic acid supplements, Epogen, and multivitamins.
🞂 ​ Avoid drawing unnecessary blood specimens.
🞂 ​ Teach patient to prevent bleeding: avoid vigorous nose
blowing and contact sports, and use a soft toothbrush.
🞂 ​ Administer blood component therapy as indicated
Bone Disease and Metastatic
Calcifications
🞂 ​Administer the following medications as
prescribed: phosphate binders, calcium
supplements, vitamin D supplements.
🞂 ​Monitor serum lab values as indicated (calcium,
phosphorus, aluminum levels) and report
abnormal findings to physician.
🞂 ​ Assist patient with an exercise program
Types:
🞂​
Hemodialysis
🞂 ​CRRT
🞂 ​PD
Acute dialysis is indicated when
there is
🞂 ​ High level of serum 🞂 ​ may also be used to remove
potassium medications or toxins from
🞂 ​ fluid overload, or the blood
impending pulmonary 🞂 ​ edema that does not
edema respond to other treatment
🞂 ​ increasing acidosis 🞂 ​ hepatic coma
🞂 ​ Pericarditis 🞂 ​ Hyperkalemia
🞂 ​ severe confusion 🞂 ​ Hypercalcemia
🞂 ​ Hypertension
🞂 ​ uremia
Chronic or maintenance dialysis is indicated in
advanced C K D and ESRD in the following instances:
🞂 ​ presence of uremic signs and symptoms affecting all body
systems
🞂 ​ Hyperkalemia

🞂 ​ fluid overload

🞂 ​ not responsive to diuretics and fluid restriction

🞂 ​ general lack of well-being

🞂 ​Used for patients who are acutely ill and require
short-term dialysis (days to weeks) and for
patients with advanced C K D and ESRD who
require long-term or permanent renal replacement
therapy.
🞂 ​Does not compensate for the loss of endocrine or
metabolic activities of the kidneys.
🞂​ Objectives:
◦ to extract toxic nitrogenous substances from the blood
◦ to remove excess water
🞂​ Dialyzer serves as a synthetic semipermeable
membrane, replacing the renal glomeruli and
tubules as the filter for the impaired kidneys
🞂 ​ Principles on which hemodialysis is based:
◦ Diffusion
◦ Osmosis
◦ Ultrafiltration
🞂 ​The body’s buffer system is maintained using a
dialysate bath made up of bicarbonate (most
common) or acetate, which is metabolized to form
bicarbonate.
🞂 ​The anticoagulant heparin is administered to keep
blood from clotting in the dialysis circuit.
Vascular Access
Devices
🞂 ​ Immediate access to the patient’s circulation for acute
hemodialysis is achieved by inserting a double-lumen,
noncuffed, large-bore catheter into the
◦ Subclavian
◦ Internal
◦ Jugular
◦ femoral vein
Arteriovenous Fistula (AVF)
🞂 ​ preferred method of permanent access
🞂 ​ created surgically (usually in the forearm) by
anastomosing an artery to a vein, either side to side or
end to side
🞂 ​ 2 to 3 months to “mature” before it can be used
🞂 ​ Patient is encouraged to perform hand exercises to
increase the size of the vessels (ie, squeezing a rubber
ball for forearm fistulas) to accommodate the large-
bore needles.
Arteriovenous
​ can be created by subcutaneously interposing a
Graft
🞂
biologic, semibiologic, or synthetic graft material
between an artery and vein
🞂 ​ a graft is created when the patient’s vessels are not
suitable for creation of an AV fistula
🞂 ​ Common complications:
◦ Stenosis
◦ Infection
◦ thrombosis
🞂​ Cardiovascular complications. 🞂​ Other complications of dialysis
◦ Heart failure, coronary heart treatment may include:
disease, angina, stroke, and ◦ Episodes of shortness of breath
peripheral vascular insufficiency ◦ Hypotension
🞂​ Anemia ◦ Nausea and vomiting, diaphoresis,
🞂​ Gastric ulcers tachycardia, and dizziness
◦ Painful muscle cramping
🞂​ Bone pain and fracture
◦ Exsanguination
🞂​ Sleep problems ◦ Dysrhythmias
◦ Air embolism (rare)
◦ Chest pain
◦ Dialysis disequilibrium - results
from cerebral fluid shifts.
Promoting Pharmacologic Therapy
🞂 ​Monitor patients with ongoing medications to
ensure that blood and tissue levels of these
medications are maintained without toxic
accumulation.
🞂 ​Educate patient as to when and when not to take
their meds (especially antihypertensives)
Promoting Nutritional and Fluid Therapy
🞂 ​ Restrict dietary protein (1.2 to 1.3 g/kg ideal body
weight per day)
🞂 ​ Restrict fluids (amount equal to the daily urine output
plus 500 mL/day)
🞂 ​ Restrict sodium ( 2 to 3 g/day)

🞂 ​ Potassium restriction (depends on the amount of

residual renal function and the frequency of dialysis)
Meeting Psychosocial Needs
🞂 ​ Give the patient and family the opportunity to express
feelings of anger and concern about the limitations that the
disease and treatment impose, possible financial problems,
and job insecurity
🞂 ​ Counseling and psychotherapy
🞂 ​ Administer antidepressants as indicated
🞂 ​ Refer patient to a mental health provider
🞂 ​ Patients and their families should be encouraged to discuss
end-of-life options and have developed advanced
directives or living wills.
🞂 ​ may be indicated for patients with acute or chronic renal
failure who are too clinically unstable for traditional
hemodialysis,
◦ for patients with fluid overload secondary to oliguric renal
failure
◦ for patients whose kidneys cannot handle their acutely high
metabolic or nutritional needs.
🞂 ​ does not require dialysis machines or dialysis personnel to
carry out the procedures, and can be initiated quickly
🞂 ​ A hemofilter (an extremely porous blood filter
containing a semipermeable membrane) is used in all
types.
🞂​ Goals of PD:
◦ to remove toxic substances and metabolic wastes
◦ To reestablish normal fluid and electrolyte balance
🞂​ may be the treatment of choice for patients with renal failure
who are unable or unwilling to undergo hemodialysis or renal
transplantation.
🞂 ​ Peritoneal membrane that covers the abdominal organs and lines
the abdominal wall serves as the semipermeable membrane
🞂 ​ Sterile dialysate fluid is introduced into the peritoneal cavity
through an abdominal catheter at intervals
🞂​ Usually takes 36 to 48 hours to achieve what
hemodialysis accomplishes in 6 to 8 hours.
🞂 ​ Assess the vascular access for patency
🞂 ​ Take precaution to ensure that the extremity with the
vascular access is not used for measuring blood
pressure or for obtaining blood specimens
🞂 ​ Assess for bruit over the venous access site every 8
hours
🞂 ​ Observe for signs and symptoms of infection in the
access site
🞂 ​ Assess the integrity of the dressing and change it as
needed
🞂 ​ Regulate IV fluids (usually slow)
🞂 ​ Monitor Intake and Output
🞂 ​Monitor
patients whose metabolic rate accelerates
accumulate waste products more quickly
🞂 ​ Assess for signs of pulmonary edema
🞂 ​ Assess for signs of pericarditis
🞂 ​ Check serum electrolyte levels
🞂 ​ Monitor dietary intake
🞂 ​Administer antihistamine and analgesics as
ordered
🞂 ​ Keep pt’s skin clean and well moisturized

🞂 ​Teach the patient to keep the nails trimmed to

avoid scratching and excoriation
🞂 ​ Monitor BP
🞂 ​ Teach patient about antihypertensive meds

🞂 ​Antihypertensive agents must be withheld before

dialysis to avoid hypotension
🞂 ​ Prevent infection
🞂 ​ Instruct pt on proper care of catheter site
🞂 ​ Monitor all drugs taken by pt during dialysis
🞂​ Provide opportunities for patients to express
their feelings and reactions and to
🞂 ​explore options; refer to psychologists, counselors,
spiritual advisors as needed.
🞂 ​referto stones (calculi) in the urinary tract and
kidney
🞂 ​occurrence of urinary stones occurs
predominantly in the third to fifth decades of life
and affects men more than women
🞂 ​About half of patients with a single renal stone
have another episode within 5 years
🞂 ​ Stones are formed in the urinary tract when urinary
concentrations of substances such as calcium oxalate, calcium
phosphate, and uric acid increase
🞂 ​ Stone formation is not clearly understood, and there are a
number of theories about their causes:
◦ there is a deficiency of substances that normally prevent
crystallization in the urine, such as citrate, magnesium, nephrocalcin
◦ fluid volume status of the patient
◦ Certain factors favor the formation of stones:
🞄 Infection
🞄 urinary stasis
🞄 periods of immobility
🞂 ​ Calcium stones (75%)- Increased calcium concentrations in
the blood and urine
🞂 ​ Uric acid stones (5% to10% of all stones) may be seen in
patients with gout or myeloproliferative disorders
🞂 ​ Struvite stones account for 15% of urinary calculi and form
in persistently alkaline, ammonia rich urine caused by the
presence of urease-splitting bacteria such as Proteus,
Pseudomonas, Klebsiella, Staphylococcus, or
Mycoplasma species. Predisposing factors for struvite
stones include neurogenic bladder, foreign bodies, and
recurrent UTIs.
🞂​ Cystine stones (1% to 2% of all stones) occur exclusively in patients
with a rare inherited defect in renal absorption of cysteine
🞂 ​ Several conditions as well as certain metabolic risk factors
◦ Anatomic derangements
◦ inflammatory bowel disease and in those with an ileostomy or
bowel
resection because these patients absorb more oxalate.
🞂​ Medications known to cause stones:
◦ Antacids
◦ Acetazolamide (Diamox)
◦ vitamin D
◦ laxatives
◦ high doses of aspirin
🞂 ​ Mild to severe flank pain
🞂 ​ Nausea
🞂 ​ Vomiting
🞂 ​ Fever and Chills
🞂 ​ Hematuria
🞂 ​ Abdominal distension
🞂 ​ Urinary frequency
🞂 ​ Urinary hesitancy
🞂 ​ Dysuria
🞂 ​ Anuria
🞂 ​ X-ray of KUB
🞂 ​ UTZ of KUB
🞂 ​ IV urography
🞂 ​ Retrograde pyelography
🞂 ​ 24-hour urine test for measurement of calcium, uric
acid, creatinine, sodium, pH, and total volume
🞂 ​ Dietary and medication histories
🞂 ​ family history of renal stones
🞂 ​ Stone analysis
🞂​ Fluids
🞂​ Antimicrobial agents
🞂​ Opioid analgesics
🞂​ Diuretics
🞂​ Low-calcium diet
🞂​ Oxalate-binding cholestyramine (Questran)
🞂​ Parathyroidectomy
🞂​ Allopurinol (Zyloprim)
🞂​ Daily small doses of ascorbic acid
🞂​ Percutaneous Ultrasonic lithotripsy
🞂​ Extracorporeal shockwave lithotripsy (ESWL)
🞂 ​ Monitor intake and output
🞂 ​ Monitor pattern of voiding

🞂 ​ Relieve pain

🞂 ​ Monitor and manage potential complication

🞂 ​ Increase fluid intake of approximately 3 to 4 L