I.

INTRODUCTION

DEFINITION OF THE CASE

End-stage Renal Failure also known as End Stage Renal Disease or ESRD are functional
diagnoses characterized by a progressive decrease in GFR or glomerular filtration rate. It
occurs where GFR falls below 5% of its normal function. It is the final stage of chronic kidney
disease. It is defined as irreversible decline in the function of a patient’s kidney. There are many
detrimental effects due to loss of kidney function such as extracellular volume overload also
known as body fluid retention, imbalances in bone and mineral metabolism, protein energy
malnutrition, and dyslipidemia or abnormal amounts of lipids in the blood. In the absence of
dialysis or transplantation, ESRD is severe enough to be fatal leading to death.

STATISTICS (LOCAL AND INTERNATIONAL)

Worldwide, the number of people who are suffering from this disease is staggering. It is
estimated that 2.6 million of the world’s population suffer from ESRD which undergo dialysis or
transplantation and it continues to increase at 5 to 7 percent per year. However due to lack of
access in dialysis or transplantation, 2.3 million suffers premature death. In the United States,
almost 750,000 people are affected per year and it continues to increase at 5% each year.
Mortality rates vary depending on the treatment. Patients that receives transplants have a 3%
mortality rate after 5 years and those on dialysis treatment have a 20 to 25 percent mortality
rate after a year of treatment. In the Philippines, one Filipino develops the disease every hour
often because of poorly controlled hypertension and diabetes according to Philippine Daily
Inquirer dated May 28, 2019. The 2017 Philippine Renal Disease Registry annual report shows
that 21,535 Filipino patients underwent dialysis due to kidney failure in 2016. It is considered as
a staggering increase from 9,716 cases in 2010 – increasing at the rate of 8 – 18 percent per
year.

RISK FACTORS

There is increased risk of developing chronic kidney disease in people with diabetes,
hypertension, heart disease and family history. Diabetes is the leading cause of end-stage renal
disease. Hypertension, on its own, is also a strong factor that causes ESRD. It is a cumulative

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process that can take years to develop but can be limited by managing blood pressure. Drug
and alcohol abuse may also lead to this disease. Family history and other genetic disorders like
polycystic kidney disease, and autoimmune disease called Lupus erythema may also cause
end-stage renal disease. Exposure to toxic drugs including certain antibiotics, chemotherapy,
contrast dyes and excessive use of pain relievers may lead to ESRD over time.

SIGNS AND SYMPTOMS

Symptoms may remain mild or absent until kidney function drops to less than 20% of normal. It
varies from person to person. High levels of urea in the blood, buildup of phosphates and
potassium and failure to remove excess fluids lead to several symptoms experienced by the
patient. Kidneys have begun to fail when there’s itching, muscle cramps, nausea and vomiting,
swelling in the feet and ankles, or too much or not enough urine output, shortness of breath due
to extra fluid in the lungs, anemia, trouble in sleeping and concentrating, poor appetite, weight
loss and anemia.

PREVENTIVE MEASURES

Primary healthcare strategy is critical in preventing further complications caused by ESRD. In

patients with kidney failure, preventive strategies frequently focus on the renal-disease-related
issues of anemia, mineral metabolism, hypertension, and vascular access for dialysis.
Addressing more-general health issues, such as vaccination, cancer screening, control of
diabetes mellitus, and lipid management can be postponed in order to prioritize acute issues
such as infection, bleeding, malnutrition, volume overload, vascular thrombosis and unstable
blood pressure, all of which are common in patients with renal failure. The importance of
ongoing health maintenance in the CKD population cannot be overemphasized. Disadvantaged
by abnormalities of immune function, patients with kidney disease are more susceptible to
infections and malignancies. The traditional cardiovascular risk factors of diabetes and
dyslipidemia plague most patients with renal disease. Preventive goals and treatment strategies
specific to patients with CKD or ESRD can differ from those for the general population.

MEDICAL, SURGICAL PHARMACOLOGICAL AND NURSING MANAGEMENT

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There are two types of dialysis, Hemodialysis and Peritoneal dialysis. They both remove waste
products and extra fluid from the blood. It basically replaces the function of the kidneys in the
body. Hemodialysis works through a dialysis machine and a special filter called an artificial
kidney or also known as dialyzer. Peritoneal dialysis therapy is a type of dialysis that uses the
lining of the patient’s abdomen or also known as peritoneum where fluids and blood are
exchanged. Both therapies are used to remove toxins, excess fluid and correct electrolyte
problems. The surgical management of ESRD is kidney transplant procedure which removes
the non-functioning kidneys and replaces it with healthy kidney from a living or deceased donor.
Taking immunosuppressant medication to prevent rejection is necessary. The patient's age and
health condition before transplantation affect the risk of complications. Maintaining an active
lifestyle and specific nutritional diet is essential to prevent further complications. Nursing
management includes checking the vital signs, talking with the patients to assess the condition,
health teaching about the illness and the treatment, monitoring the therapy from start to finish,
making sure medications given are accurate, evaluating patient’s reaction to the therapy and
more.

COMPLICATIONS

There are a lot of possible complications of ESRD. It includes increased risk for infections, pain
in muscle, bone and joint, weak bones, skin infections from dry skin, and nerve damage. There
are also less common but more serious complication such as failure of the liver, problems in
heart and blood vessels, fluid buildup in the lungs, hyperkalemia, anemia, and damage to the
central nervous system. ESRD affects almost any areas of the body.

II. PATHOPHYSIOLOGY

RISK FACTORS

There are a lot of risk factors that contribute to the disease. There are predisposing and
precipitating factors. The precipitating factors such as uncontrolled diabetes and hypertension
can eventually lead to ESRD. An uncontrolled diabetic and/or hypertensive patient can easily
and quickly progress to an end-stage kidney disease patient. The disease can result from both
type 1 or type 2 diabetes. With either type, the poor management of blood sugar contributes to
the risk of having ESRD. Uncontrolled high blood pressure can cause arteries around the

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kidneys to narrow, weaken or harden. These damaged arteries are not able to deliver enough
blood to the kidney tissue. Experiencing acute kidney injury, a history of cardiovascular disease,
hyperlipidemia, metabolic syndrome, hepatitis C virus, HIV infection, and malignancy are further
risk factors. Other diseases such as Glomerulonephritis ( an inflammation of the kidney's
filtering units or glomeruli), interstitial nephritis (an inflammation of the kidney's tubules and
surrounding structures), Polycystic kidney disease, prolonged obstruction of the urinary tract
(from conditions such as enlarged prostate, kidney stones and some cancers),
Vesicoureteralreflux (a condition that causes urine to back up into your kidneys) and recurrent
kidney infection, also called Pyelonephritis. Predisposing factors includes individual's genetic
and phenotypic make-up also puts an individual at risk for kidney disease. Factors such as race,
gender, age, and family history are also highly considered. Exposure to heavy metals,
excessive alcohol consumption, smoking, and the use of analgesic medications also constitute
risks.

SIGNS AND SYMPTOMS

Signs and symptoms are often nonspecific meaning they may also be caused by other illnesses.
These signs and symptoms may not appear due to the high ability of the kidneys to adapt and
compensate for loss of function so it becomes visible when irreversible damage has happened.
The symptoms, which is apparent to the patient only, includes nausea, itching, muscle cramps,
trouble sleeping, fatigue, chest pain (if fluid builds up around the lining of the heart and loss of
appetite. The signs of ESRD includes significant change in urine output, edema in the feet or
ankles due to excess fluid, and high blood pressure that is difficult to control.

PREVENTIVE MEASURES

In order to reduce the risk of developing end-stage renal disease, there are several steps that
can be taken. If a patient has a diabetes, blood sugar must be managed. High blood pressure
must be closely monitored and treated aggressively as it can further damage the kidneys in
patients with kidney disease. Avoiding over the counter arthritis medicines and non-steroidal
anti-inflammatory drugs is also helpful. Reduced intake of protein or a low-protein diet may also
reduce the development of existing kidney disease. In terms of lifestyle, losing weight, having an
active lifestyle, eating a balanced diet of nutritious, low-sodium foods, controlling blood

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pressure, taking medications as prescribed, controlling sugar levels and having regular check
up can help reduce the risk of developing ESRD.

MEDICAL, SURGICAL PHARMACOLOGICAL AND NURSING MANAGEMENT

Managing ESRD involves three different renal replacement therapies such as Hemodialysis,
Peritoneal Dialysis and Kidney transplantation. The objective of the hemodialysis treatment is to
purify the patient’s blood by removing toxic wastes such as urea, creatinine and excess fluids. It
acts as the body’s kidneys. There are three settings upon which the procedure can be done,
inpatient, outpatient and at home. Because it provides rapid and excellent removal of solutes, it
is the choice of therapy for individuals that needs acute dialysis and maintenance therapy.
Hemodialysis involves getting the patient’s blood to the dialyzer, therefore, an access or
entrance to the blood vessels is necessary. It is done with minor surgery, usually located in the
arms of the patient. The dialysis machine pumps the blood through the filter and returns it to the
body. This mechanism starts with the blood entering at one end of the filter and then forced into
many, very thin, hollow fibers. Dialysis solution passes in the opposite direction on the outside
of the fibers as it passes through the hollow fibers. Waste products from the blood move into the
dialysis solution. The filtered blood remains in the hollow fibers and returns to the patient’s body.
Hemodialysis procedure can be done in three locations, at the hospital, in a dialysis center or at
home and the frequency of the treatment is being decided by the Nephrologist. Peritoneal
dialysis has the same objective as with the Hemodialysis but it differs in terms of process.
Within the patient’s abdomen, the peritoneum is the membrane used for the exchange of the
patient’s blood and the fluid called dialysate fluid. A catheter is inserted surgically in the
abdomen through which 2 to 3 liters of the dialysate is introduced in 10 to 15 minutes.
Medication may be added to the fluid before infusion. Waste products diffuse across the
peritoneum as the dwell remains in the patient’s abdomen. Usually after 4 to 6 hours, the fluid is
removed and replaced with fresh fluid. There are two types of peritoneal dialysis, CAPD or
continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. The difference is in
the schedule and the usage, one is via machine and the other is by hand. Both can be done in a
clean, private and while travelling. The medical management of predialysis and dialysis patients
involves complex and highly variable pharmacotherapy, including frequent monitoring and
evaluation to make sure of the best pharmacotherapy, observance to medication, and control of
other risk factors. The most commonly used anticoagulant in hemodialysis (because it is well
tolerated and can be quickly alternate with protamine sulfate) is Heparin. A high number of

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prescribed medications, poor medication adherence, and frequent dosage changes may
contribute to drug-related illness and related problems.

COMPLICATIONS

PART III. NURSING CARE PLAN

A. ASSESSMENT
OBJECTIVE – BP 140/70 mmHg; temp 37.5 C; normal WBC count
SUBJECTIVE - Restlessness

B. DIAGNOSIS
Risk for systemic infection related to

C. GOAL
SHORT TERM – Within the shift, the patient should not develop signs and symptoms
of infection temperature remains normal
LONG TERM – Within a month, the patient must not have infection throughout
hemodialysis therapy sessions

D. INTERVENTION
PREVENTIVE – Promoted good hand hygiene to client and staff
Use aseptic technique when manipulating IV/invasive lines
CURATIVE
REHABILITATIVE

E. EVALUATION
__________________________________________________________________________
A. ASSESSMENT
OBJECTIVE –
SUBJECTIVE -

B. DIAGNOSIS -
a. Anxiety related to Chronic Illness with changes in body image

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 C. GOAL
SHORT TERM – After an hour of nursing intervention, the patient will verbalize
awareness of feelings of anxiety
LONG TERM – After 2 weeks, the patient will verbalize gradual acceptance of
his/her condition

D. INTERVENTION
PREVENTIVE
CURATIVE
REHABILITATIVE

E. EVALUATION

__________________________________________________________________________
A. ASSESSMENT
OBJECTIVE
SUBJECTIVE

B. DIAGNOSIS -

C. GOAL
SHORT TERM
LONG TERM

D. INTERVENTION
PREVENTIVE
CURATIVE
REHABILITATIVE

E. EVALUATION