Disease Process
Renal failure (RF) is a prevalent chronic disease that inflicts an enormous burden on the healthcare system not only in the United States but also in other developed and developing countries across the world (Matavinovic, 2009, p. 1). RF is a condition in which “the kidneys fail to remove metabolic end-products from the bloodstream and regulate the fluid, electrolyte, and pH balance of the extracellular fluids” (Huether & McCance, 2012, p. 433). The underlying cause of RF, according to these authors, is closely related to renal illness, systematic illness, or urologic faults that have no renal bearing. The stages of progression of RF include diminished renal reserve, renal insufficiency, renal failure, and end-stage renal disease. RF can occur as an acute or a chronic disorder, with available nursing scholarship demonstrating that acute RF is abrupt in onset and often is reversible if identified early and managed appropriately, while chronic RF is the end result of irreparable damage to the kidneys which develops slowly over the course of a number of years (Hinkle & Cheever, 2013, p. 1275-1278; Huether & McCance, 2012, p. 433). RF with dialysis qualifies as a chronic RF.
The clinical manifestations of RF include “alterations in water, electrolyte, and acid-base balance; mineral and skeletal disorders; anemia and coagulation disorders; hypertension and alterations in cardiovascular function; gastrointestinal disorders; neurologic complications; disorders of skin integrity; and immunologic disorders” (Huether & McCance, 2012, p. 438). The pathophysiology of RF can be explained in four stages, namely (1) rate of renal blood flow to the tissue becomes higher than that of other well perfused vascular beds such as heart, liver and brain, (2) glomerular capillaries become vulnerable to hemodynamic injury due to the high intra- and transglomerular pressure, (3) glomerular filtration becomes exposed to negatively charged molecules which serve as a barrier in retarding anionic macromolecules, and (4) the sequential organization of nephron’s microvasculature and the downstream position of the tubuli with respect to glomeruli, not only maintains the glomerulo-tubular balance but also promotes the dispersion of glomerular injury to tubulointerstitial compartment in disease, exposing tubular epithelial cells to uncharacteristic ultrafiltrate.
Diagnosis of RF should include “assessment measures to identify persons at risk for the development of acute renal failure, including those with pre-existing renal insufficiency and diabetes” (Huether & McCance, 2012, p. 436). Additional diagnosis for RF should include inability to concentrate urine as well as “evidence of proteinuria, hemoglobinuria, and casts or crystals in the urine” (Huether & McCance, 2012, p. 436). Treatment for RF may include kidney transplantation, adequate caloric intake, dialysis, and continuous renal replacement therapy (Patzer, Sayed, Kutner, McClellan, & Amaral, 2013, p. 1769).
Human Response
The outcome of people with RF with dialysis is to a large extent dependent on the underlying cause as well as presence or absence of other medical conditions. Individuals with RF with dialysis may exhibit high levels of stress and anxiety than those with acute RF since dialysis is associated with high levels of morbidity and mortality (Patzer et al., 2013, p. 1769). Dialysis is also associated with end-stage RF, thus individuals who undertake the procedure are bound to exhibit high levels of psychological and financial distress.
The characteristic nursing diagnosis for a patient with end-stage RF include (1) surplus fluid volume associated with incapacity of the kidneys to deal with surplus body fluid, (2) imbalanced nutritional values: less than body requirements associated with the effects of uremia, (3) damaged skin integrity of lower extremities associated with dehydrated skin and burning sensation, and (4) danger of contagious infections associated with insidious catheters and damaged immune function (Murphy & Byrne, 2010, p. 146). Nursing interventions may include ensuring the patient adheres to the prescribed fluid intake on a daily basis. Nursing professionals must also ensure that the patient “demonstrate reduced extracellular fluid volume by weight loss, decreased peripheral edema, clear lung sounds, and normal heart sounds” (Shuvy et al., 2015, p. 2). Additionally, nursing professionals must ensure that RF patients remain free of contagious infections and are able to take and retain 100% of set diet intake, including light meals. Lastly, nurses should not only initiate procedures intended to heal the lower extremity skin lesions but also demonstrate appropriate peritoneal catheter care as well as CAPD.
Nursing Process
NANDA – Priority Nursing Diagnosis Statement
Nursing professionals may experience a knowledge deficit on some risk factors for RF with dialysis, such as exposure to (1) heavy metals including lead, cadmium, arsenic, mercury and uranium, (2) agrochemicals, (3) nephrotoxic substances including aristilochic acid and herbal remedies, (4) nonsteroidal anti-inflammatory drugs, and (5) infectious diseases including leptospirosis, Hantavirus, leprosy and malaria (Orantes et al., 2011, p. 14). Nurses also need to develop awareness on how to identify and modify risk factors arising from a multifactorial process which is to a large extent mediated by genetic influences, external factors, drug therapy, metabolic disturbances, dietary intake, and other factors (Levin, 2001, p. 58).
Goal Statement
The primary goal should be to improve patient care by not only helping nursing professionals to know and better understand the evidence that determines current practice, but also by coming up with evidence-based recommendations to manage the symptoms of RF while demonstrating to patients and their family members about the best ways to manage the condition.
Identification of Learning Needs
There is need to educate patients and their families about how to manage the symptoms associated with RF. There is also the need to educate patients about some of the common diseases that may be associated with RF and how to manage them without necessarily having to look for medical intervention. Additionally, patients and their families need to be educated on the appropriate renal diet with the view to derailing the progression of the disease while keeping symptoms at a manageable level. Awareness also needs to be created on when to seek help for dialysis and other medical procedures. Last and perhaps most important, patients need to be educated on how to live positively with the disease in order to avoid other conditions that may aggravate the situation. Such conditions include stress and depression. Patients need to be provided with emotional support by nurses, family members, and members of the multidisciplinary team to overcome these challenges (Murphy & Byrne, 2010, p. 151).
Nursing Interventions
- The nursing care of RF with dialysis is not only challenging but also multifaceted as the patient can be in real danger of morbidity or mortality (Murphy & Byrne, 2010, p. 146)
- It is important that nursing professionals comprehend what RF with dialysis is, and the management of it so as to develop the capacity to deliver holistic care to the patient concerned (Murphy & Byrne, 2010, p. 146).
- Nurses must be able to assess how the disease affects the patient holistically, including obtaining an accurate and comprehensive history of the patient, checking for any discrepancies in the urinary pattern, checking for any episodes of alterations in blood pressure, and checking for drug therapies previously used by the patient (Murphy & Byrne, 2010, p. 146-147).
- Nursing management of the condition should include fluid management, metabolic acidosis management, electrolyte management, immune system management, nutritional management, personal care management, as well as patient education management (Murphy & Byrne, 2010, p. 149-151).
References
Hinkle, J.L., & Cheever, K.H. (2013). Brunner & Suddarth’s textbook of medical-surgical nursing (13th ed.). New York, NY: LWW.
Huether, S.E., & McCance, K.L. (2012). Understanding pathophysiology (5th ed.). Maryland Heights, Missouri: Mosby.
Levin, A. (2001). Identification of patients and risk factors in chronic kidney disease – evaluating risk factors and therapeutic strategies. Nephrology Dialysis Transplantation, 16(7), 57-60.
Matavinovic, M.S. (2009). Pathophysiology and classification of kidney diseases. Journal of the International Federation of Clinical Chemistry and Laboratory Medicine, 1-10. Web.
Murphy, F., & Byrne, G. (2010). The role of the nurse in the management of acute kidney injury. British Journal of Nursing, 19(3), 146-152.
Orantes, C.M., Herrera, R., Almaguer, M., Brizuela, E.G., Hernandez, C.E., Bayarre, H…Castro, B.E. (2011). Chronic kidney disease and associated risk factors in the Bajo Lempa region of El Salvador: Nefrolempa study, 2009. MEDICC Review, 13(4), 14-22.
Patzer, R.E., Sayed, B.A., Kutner, N., McClellan, W.M., & Amaral, S. (2013). Racial and ethnic differences in pediatric access to preemptive kidney transplantation in the United States. American Journal of Transplantation, 13(7), 1769-1781.
Shuvy, M., Abedat, S., Mustafa, M., Duvdevan, N., Meir, K., Beeri, R…Lotam, C. (2015). Cellular changes during renal failure-induced inflammatory aortic valve disease. PLoS ONE, 10(6), 1-10.