INTRODUCTION

When the 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.Chronic renal failure (CRF) is the end result of a gradual,
progressive loss of kidney function.Causes include chronic infections
(glomerulonephritis, pyelonephritis), vascular diseases (hypertension, nephrosclerosis),
obstructive processes (renal calculi), collagen diseases (systemic lupus), nephrotoxic agents
(drugs, such as aminoglycosides), and endocrine diseases (diabetes, hyperparathyroidism).This
syndrome is generally progressive and produces major changes in all body systems.The final
stage of renal dysfunction, end-stage renal disease (ESRD), is demonstrated by a glomerular
filtration rate (GFR) of 15%–20% of normal or less.Renal failure results when the kidneys
cannot remove the body’s metabolic wastes or perform their regulatory functions.The
substances normally eliminated in the urine accumulate in the body fluids as a result of impaired
renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and
acid-base disturbances.Renal failure is a systemic disease and is a final common pathway of
many different kidney and urinary tract diseases.Accumulation. As renal function declines, the
end products of protein metabolism (normally excreted in urine) accumulate in
the blood.Adverse effects. Uremia develops and adversely affects every system in the
body.Progression. The disease tends to progress more rapidly in patients who excrete
significant amounts of protein or have elevated blood pressure than those without these
conditions.

10% of the population worldwide is affected by chronic kidney disease (CKD), and
millions die each year because they do not have access to affordable treatment.According the
2010 Global Burden of Disease study, chronic kidney disease was ranked 27th in the list of
causes of total number of deaths worldwide in 1990, but rose to 18th in 2010. This degree of
movement up the list was second only to that for HIV and AIDs. Over 2 million people worldwide
currently receive treatment with dialysis or a kidney transplant to stay alive, yet this number may
only represent 10% of people who actually need treatment to live.Of the 2 million people who
receive treatment for kidney failure, the majority are treated in only five countries – the United
States, Japan, Germany, Brazil, and Italy. These five countries represent only 12% of the world
population. Only 20% are treated in about 100 developing countries that make up over 50% of
the world population.More than 80% of all patients who receive treatment for kidney failure are
in affluent countries with universal access to health care and large elderly populations.It is

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estimated that number of cases of kidney failure will increase disproportionately in developing
countries, such as China and India, where the number of elderly people are increasing. In the
Philippines, the Department of Health reports that one person dies every hour from kidney
failure. More than 7,000 cases of kidney failure in the country are recorded every year. This puts
kidney failure as the ninth-leading cause of death among Filipinos today, according to the
National Kidney and Transplant Institute. Dr. Aileen Riego-Javier, NKTI executive director, said
that, for every 1 million Filipinos, 120 of them are most likely to develop kidney failure. Each
year approximately 10,000 people need to replace their kidney function.

The following are the risk factors. Diabetes, which is the most common risk factor for
chronic kidney failure in the United States. Those aged 60 or older. Kidney disease present at
birth (congenital) or family history of kidney disease. Autoimmune Disorder (Lupus
erythematosus)Bladder outlet obstruction (BPH and Prostatitis)Race (Sickle cell
disease.Precipitating factors include: occupational hazard like overexposure to toxins and to
some medication. Sedentary Lifestyle (hypertension, atherosclerosis). Diet (High residue diet).

Because virtually every body system is affected in ESRD, patients exhibit a number of
signs and symptoms.Peripheral neuropathy, a disorder of the peripheral nervous system, is
present in some patients.Severe pain. Patients complain of severe pain and discomfort.Restless
leg syndrome and burning feet can occur in the early stage of uremic peripheral neuropathy.

Preventive measures for end stage renal disease If you have kidney disease, you may
be able to slow its progress by making healthy lifestyle choices:Lose weight if you need to. Be
active most days. Eat a balanced diet of nutritious, low-sodium foods. Control your blood
pressure. Take your medications as prescribed. Have your cholesterol levels checked every
year. Control your blood sugar level. Don't smoke or use tobacco products. Get regular
checkups.

The goal of management is to maintain kidney function and homeostasis for as long as
possible.Pharmacologic therapy: Calcium and phosphorus binders treat hyperphosphatemia
and hypocalcemia;Antihypertensive and cardiovascular agents(digoxin and dobutamine)
manage hypertension;Anti-seizure agents (IV diazepam or phenytoin) are used for seizures,
and;Erythropoietin (Epogen) is used to treat anemia associated ESRD.Nutritional
therapy. Dietary intervention includes careful regulation of protein intake, fluid intake to balance

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fluid losses, sodium intake to balance sodium losses, and some restriction of potassium.Dialysis
is usually initiated if the patient cannot maintain a reasonable lifestyle with conservative
treatment. The patient with ESRD requires astute nursing care to avoid the complications of
reduced renal function and the stresses and anxieties of dealing with a life-threatening illness. A
kidney transplant is a surgical procedure to place a healthy kidney from a live or deceased
donor into a person whose kidneys no longer function properly. A kidney transplant is often the
treatment of choice for end-stage renal disease, compared with a lifetime on dialysis.

Potential complications of chronic renal failure that concern the nurse and necessitate a
collaborative approach to care include the following: Hyperkalemia. Hyperkalemia due to
decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications,
fluids).Pericarditis. Pericarditis due to retention of uremic waste products and inadequate
dialysis.Hypertension. Hypertension due to sodium and water retention and the malfunction of
the renin-angiotensin-aldosterone system.Anemia. 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. Bone disease and
metastatic and vascular calcifications due to retention of phosphorus, low serum calcium levels,
abnormal vitamin D metabolism, and elevated aluminum levels.
PATHOPHYSIOLOGY

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 NURSING CAREPLANS

Assessment Diagnosis Goal Intervention Evaluation

Objective Excess fluid  Patient will  Monitor and record vital signs  Patient
 Decreased volume relat demonstrate  Assess possible risk factors demonstrated
mental agility ed to behaviors to  Monitor and record vital signs. behaviors to
 Swelling of decreased monitor fluid  Assess patient’s appetite monitor fluid
feet and urine output, status and  Note amount/rate of fluid intake from all status and
ankles dietary reduce sources reduce
 Weight gain excesses, recurrence of  Compare current weight gain with recurrence of
 Poorly and fluid excess admission or previous stated weight fluid excess
retention of  Patient will  Patient
controlled  Auscultate breath sounds
sodium and manifest stabilize manifested
hypertension  Record occurrence of dyspnea
 Elevated water fluid volume AEB stabilize fluid
 Note presence of edema.
serum balance I&O, volume AEB
 Measure abdominal girth for changes. balance I&O,
creatinine normal VS, stable
 Evaluate mentation for confusion and normal VS,
Subjective weight, and free
personality changes. stable weight,
 Shortness of from signs of
 Observe skin mucous membrane.
breath edema. and free from
 Change position of client timely. signs of edema.
 Difficulty of  Review lab data like BUN, Creatinine,  Demonstrated
breathing Serum electrolyte. techniques/beh
 Restrict sodium and fluid intake if aviors that
indicated enable
 Record I&O accurately and calculate fluid resumption of
volume balance activities.
 Weigh client
 Encourage quiet, restful atmosphere.
 Promote overall health measure.

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 Assessment Diagnosis Goal Intervention Evaluation
Objective Impaired Urinary  Patient will  Establish rapport.  Patient
 Increase in Lab Elimination R/T verbalize  Monitor and record vital signs. verbalized
results (BUN, failing glomerular understanding  Assess pt’s general condition understanding of
Creatinine, Uric filtration AEB of condition.  Review for laboratory test for changes condition.
Acid Level) Impaired  Patient will in renal function  Patient
 Oliguria excretion of participate in  Establish realistic activity goal with participated in
 Anuria nitrogenous measures to client. measures to
products correct/compen  Determine clients pattern of elimination correct/compens
Subjective secondary sate for defects.  Palpate bladder to assess retention ate for defects.
 Hesitancy to Renal Failure
 Investigate pain, noting location
 Urinary Retention
 Determine client’s usual daily fluid
intake
 Note condition of skin and mucous
membranes, color of urine.
 Observe for signs of infection.
 Emphasize the need to adhere with
prescribe diet.
 Emphasize importance of having good
hygiene.
 Emphasize importance of adhering to
treatment regimen.

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 Assessment Diagnosis Goal Intervention Evaluation
Objective Acute pain  Patient will  Establish rapport  Patient
 Diaphoresis demonstrate  Monitor and record vital signs. demonstrated
 RR & BP use  Assess pt’s general condition use
changes of relaxations  Accept patient’s description of pain. of relaxations
 Facial Grimaces kills to relieve  Perform a comprehensive assessment of pain kills to relieve
 Guarding pain. (location, onset, characteristics, and frequency) pain.
behaviors  Patient will  Determine possible pathophysiology and causes  Patient
 Facial Mask report of pain reported
 Narrowed relief/control of  Assess patient’s perception along with relief/control of
Focus pain. behavioral and physiological responses. pain.
Subjective  Perform pain assessment each time pain occurs,
 Costovertebral note and investigate changes from previous
pain/ Flank pain report.
 Limited ROM  Assess patient’s description of pain.
 Body weakness  Observe nonverbal cues including how client
 Sleep walks, holds body, sits, facial expressions, cool
Disturbance fingertips/ toes, which can mean constricted
vessels
 Assess for referral pain as appropriate
 Review patient’s previous experiences with pain
and methods found either helpful or unhelpful for
pain control in the past.
 Explore method for alleviation/ control of pain.
 Encourage verbalization of feelings about the
pain.
 Provide quite environment, calm activities and
adequate rest reinforce
 Provide comfort measures such as back rub,
change position, use of heat/ cold.
 Instruct/encourage use of relaxation exercise
such as focused breathing.
 Encourage diversional activities such as TV and
socialization with others.
 Assist with self-care activities.

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 Assist in treatment of underlying disease
process causing pain.
 Evaluate effectiveness of therapies.
 Provide for individualized physical therapy/
exercise program that can be continued by the
client discharge refer to physical therapist.
 Administer analgesics as ordered.

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 REFERENCES

Belleza, M. (2016, November 11). Chronic Renal Failure Nursing Care and Management: Study
Guide. Retrieved from https://www.google.com/amp/s/nurseslabs.com/chronic-renal-
failure/?amp
End-stage renal disease. (2019, August 17). Retrieved from
https://www.mayoclinic.org/diseases-conditions/end-stage-renal-disease/diagnosis-
treatment/drc-20354538
Global Facts: About Kidney Disease. (2015, March 11). Retrieved from
https://www.kidney.org/kidneydisease/global-facts-about-kidney-disease
Tacio, H. D. (2018, April 5). Kidney problems on the rise. Retrieved from
https://businessmirror.com.ph/2018/04/05/kidney-problems-on-the-rise/
END STAGE RENAL DISEASE CASE STUDY

Candace F. Balbin, RN
Makati Medical Center
NRPP-BATCH 58
November 4, 2019