What is the nursing management for renal failure?

09 February, 2015

Chronic kidney disease is irreversible, but management and treatment options are available to help patients self-manage the condition and maintain their quality of life Abstract Chronic kidney disease is a long-term condition that commonly exists with other conditions such as diabetes, hypertension and heart failure. The majority of people with CKD are managed in the community by a GP and community nursing team rather than a nephrologist. This article provides an overview of its stages, management and treatment. Citation: Dring B, Hipkiss V (2015) Managing and treating chronic kidney disease. Nursing Times; 111: 7, 16-19. Authors: Belinda Dring is nurse specialist at Nottingham University Hospitals Trust; Vicki Hipkiss is renal nurse specialist at Bradford Teaching Hospitals Foundation Trust. This article has been double-blind peer reviewed Scroll down to read the article or download a print-friendly PDF here

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Acute kidney injury (AKI), also known as Acute Renal Failure (ARF) occurs when the kidneys lose their filtering ability resulting in the build-up of waste products in the blood. This condition develops rapidly, in hours or days, and is common in critically ill patients. 

This condition affects other organs in the body if not treated promptly and can be life-threatening. Common signs and symptoms include oliguria, fluid retention, edema, dyspnea, confusion, fatigue, nausea, weakness, and seizures and coma in severe cases. 

Advanced age, already being hospitalized, and chronic conditions like diabetes, hypertension, heart failure, and liver disease increase the risk of AKI. The causes of AKI are categorized into 3 sections.

1. Impaired blood flow from:

2. Direct kidney damage due to:

• Blood clots
• Glomerulonephritis
• Lupus
• Medications like chemotherapy drugs or IV contrast
• Alcohol or drug use
• Rhabdomyolysis

3. Urinary blockage from:

• Cancer of the bladder, cervix, colon, and prostate
• Kidney stones
• Nerve damage

The diagnosis of AKI can be confirmed through blood work, urinalysis, ultrasounds or CT scans, and biopsy. 

The Nursing Process 

Assessment and monitoring play an essential role in the nursing care for patients with AKI, as subtle changes can signal progression of the disease or the development of complications. Nurses are involved in treatment by administering medications like diuretics, potassium-lowering drugs, and calcium supplements. In severe cases, dialysis is indicated to help remove toxins from the blood. Nurses may care for patients before, during, and after dialysis treatments. 

Patient education is also important to address the patient’s and the family member’s knowledge deficits related to the causes and prevention of AKI.

Nursing Care Plans Related to Acute Kidney Injury

Excess Fluid Volume Care Plan 

Excess fluid volume is common in patients with AKI due to the kidneys inability to filter and get rid of excess fluid in the body. Its management will include volume status determination, fluid resuscitation, fluid overload management, nephrotoxicity prevention, and adjustment of medications based on the patient’s renal function.

Nursing Diagnosis: Excess Fluid Volume

Related to:

• Compromised regulatory mechanism (kidney/renal failure)
• Excess fluid intake
• Excess sodium intake

As evidenced by:

• Fluid intake is greater than output; oliguria
• Jugular vein distention
•  Blood pressure changes 
• Generalized edema
• Weight gain
• Restlessness
• Changes in mental status 
• Adventitious lung sounds
• Dyspnea

Expected Outcomes:

• The patient will display balanced fluid volume as evidenced by balanced I&O without weight gain.
• The patient will exhibit stable vital signs with the absence of edema.

Excess Fluid Volume Assessment

1. Assess and monitor intake and output accurately.
Normal urine output is at least 30mL/hour. Accurate monitoring of intake and output is necessary to preserve renal function, replace fluids as needed, and reduce the risk of fluid overload.

2. Assess and observe for edema of the hands, feet, and lumbosacral area.
Edema occurs primarily in dependent tissues throughout the body like the lumbosacral area, feet, and hands. The patient can gain about 10 lbs or 4.5kg before pitting edema occurs.

3. Assess and monitor the patient’s level of consciousness.
Changes in the level of consciousness may indicate fluid shifts, accumulation of toxins, developing hypoxia, and electrolyte imbalance.

4. Monitor and review laboratory tests.
Rises in serum creatinine levels and blood urea nitrogen (BUN) can identify AKI. Proteinuria can also indicate kidney damage.

Excess Fluid Volume Interventions

1. Monitor weight daily.
Daily weights will help monitor fluid status. Sudden weight gain of more than 0.5kg/day can indicate fluid retention.

2. Auscultate lung and heart sounds.
Fluid overload can lead to heart failure and pulmonary edema as evidenced by the development of extra heart sounds and adventitious breath sounds.

3. Administer or restrict fluids as indicated.
Fluid management is essential in the treatment of AKI. Excess fluid volume requires a calculated administration of fluids and also the restriction of fluids orally.

4. Administer prescribed medications as indicated.
Diuretics are prescribed to promote urine output and reduce edema.

Decreased Cardiac Output Care Plan

Decreased cardiac output in patients with acute kidney injury may be caused by heart failure, acute myocardial infarction, or pulmonary embolus. This results in decreased pumping of the heart and reduced blood flow to the rest of the body.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Fluid overload 
• Fluid shifts, fluid deficits
• Electrolyte imbalance

As evidenced by:

• Dysrhythmias, EKG changes
• Jugular vein distention
• Decreased central venous pressure
• Dyspnea
• Prolonged capillary refill
• Color changes (pallor, cyanosis)
• Decreased peripheral pulses
• Crackles in lungs
• Cough

Expected Outcomes:

• The patient will maintain normal cardiac output as evidenced by stable heart rate and blood pressure along with renal perfusion observed by urine output
• The Patient will demonstrate activity tolerance as evidenced by performing ADLs without dyspnea

Decreased Cardiac Output Assessment

1. Assess and monitor heart rate and blood pressure.
Excess fluid volume and hypertension can increase cardiac workload which may lead to cardiac failure.

2. Monitor heart sounds and EKG.
The new onset of gallop (S3, S4) rhythm, fine crackles in the lungs, and tachycardia can indicate the onset of heart failure. In pulmonary edema, the patient will exhibit coarse crackles during inspiration and severe dyspnea. The development of dysrhythmias can signal cardiac dysfunction.

Decreased Cardiac Output Interventions

1. Administer oxygen.
High-flow oxygen or a ventilator may be necessary to increase oxygenation for cardiac function and tissue perfusion.

2. Encourage bed rest.
Frequent rest is required to prevent overexertion and stress on the heart. Group activities and assessments to reduce interruptions and maximize sleep.

3. Monitor electrolytes.
Increased and decreased levels of potassium can affect the heart muscle and cause arrhythmias. Calcium has cardiac effects and decreased levels can enhance the toxic effects of potassium.

4. Administer medications as indicated.
Inotropic agents may be prescribed to improve cardiac output though care must be taken to preserve renal function. Antidysrhythmics, vasopressors, and blood products may be required. Monitor administration closely to prevent fluid overload.

Imbalanced Nutrition: Less Than Body Requirements Care Plan

AKI is associated with the imbalance of protein breakdown and production, resulting in muscle wasting, protein wasting, and weight loss. As kidney function continues to deteriorate, protein-energy wasting accelerates, appetite decreases, and malnutrition will start to develop.

Nursing Diagnosis: Imbalanced Nutrition

Related to:

• Dietary restrictions to reduce nitrogenous waste products
• Increased metabolic needs
• Anorexia

As evidenced by:

• Joint and muscle pain
• Fatigue
• Lack of appetite
• Decreased albumin

Expected Outcomes:

• The patient will remain free of malnutrition as evidenced by nutritional markers and electrolytes within normal limits

Imbalanced Nutrition: Less Than Body Requirements Care Plan Assessment

1. Assess and monitor weight.
Monitoring the patient’s weight will help determine a loss of weight or weight gain which can signal malnutrition or fluid overload.

2. Assess and document dietary intake.
Monitoring dietary intake will help in identifying the patient’s dietary deficiencies and needs. The patient’s general physical condition and lack of appetite may be affecting intake.

3. Monitor laboratory studies.
Assess albumin, transferrin, iron, glucose, BUN, and amino acid levels to identify gaps in nutrition.

Imbalanced Nutrition: Less Than Body Requirements Care Plan Interventions

1. Educate the patient about appropriate dietary regimens and restrictions.
This will provide the patient with a certain measure of control within his or her dietary restrictions. Recent dietary guidelines recommend controlled and moderate protein intake for patients with AKI.

2. Encourage mouth care before meals.
Mucous membranes may be cracked or dry and can develop mouth sores. Clean oral hygiene makes eating more pleasant and may help with increasing appetite.

3. Consult with a dietitian for support.
Dietitians can help determine individual calorie and nutrient needs within the patient’s dietary restrictions. They can help formulate the most effective routes and regimens for the patient’s nutritional needs.

4. Encourage and provide small but frequent meals.
Small frequent meals promote appetite, provide nutrients, and reduce nausea and vomiting which are common in patients with AKI.

References and Sources

1. Acute Kidney Injury (AKI). Medscape. Updated: Jun 10, 2022. https://emedicine.medscape.com/article/243492-overview
2. Acute Kidney Injury. NHS. 2019. From https://www.nhs.uk/conditions/acute-kidney-injury/
3. Acute Kidney Injury (AKI). National Kidney Foundation. 2022. From https://www.kidney.org/atoz/content/AcuteKidneyInjury
4. Goyal A, Daneshpajouhnejad P, Hashmi MF, et al. Acute Kidney Injury. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441896/
5. Mayo Clinic. (2020, July 23). Acute kidney failure – Symptoms and causes. Mayo Clinic. From https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes/syc-20369048
6. Ostermann, M., Straaten, H.M.Ov. & Forni, L.G. Fluid overload and acute kidney injury: cause or consequence?. Crit Care 19, 443 (2015). https://doi.org/10.1186/s13054-015-1163-7