Nursing Diagnosis

Last week we took a look at the ways nurses care for patients with CKD throughout the various stages.  This week we will look at some nursing diagnoses related to CKD and ESRF.  Below I have listed five that I think particularly relate to the information presented in this blog.  In the table I have highlighted Decreased Cardiac Output.  I have chosen this nursing diagnosis to look at in depth because I want to emphasize the connection of heart disease and kidney failure.  Kidney damage can lead to cardiac damage, which can lead to more kidney damage, and so on.  As nurses, it is of upmost importance that we are always thinking about the whole patient, and promoting the bio-psychosocial well being of our patients.

5 Nursing Diagnoses to Consider when working with CKD patients

1. Decreased Cardiac Output r/t congestive heart failure, elevated potassium levels interfering with conduction system
2. At risk for injury (osteoporosis, neuropathy, muscle weakness)
3. Risk for electrolyte imbalance (Renal dysfunction)
4. Activity intolerance (Risk factor: anemia, decreased CO)
5. Risk for Powerlessness (Risk factor: Chronic illness 

Nursing Diagnosis with Care Plan

	Decreased Cardiac Output (CO)
Actual or Potential	Actual
Related to	Elevated potassium levels Altered heart rate Altered heart rhythm Altered stroke volume Altered afterload
Plan/Outcome	Patient will achieve adequate cardiac output as evidence by blood pressure, pulse rate and rhythm within define limits; strong peripheral pulses; brisk capillary refill; no chest pain or shortness of breath; adequate urinary output; ability to tolerate activity Patient will not have side effects from cardiac medications Patient will understand how to remain free of cardiac disease
Nursing Intervention	Listen to heart and lungs Assess for hypertension Patient education about ACE-I and ARBs, and other cardiac medications including the importance of taking them regularly Assess for chest pain Assess activity level Patient education on eating a heart healthy diet Refer patient to rehabilitation services if needed Patient education on the importance of being active, interspersed with times of rest Encourage patient to perform self-care, and to take control of their medical condition whenever possible Patient education on daily weights, and monitoring blood pressure at home Help patient quit smoking Help the patient identify stress reduction techniques that will work for them, and teach new ones they might be able to use Discuss advanced directive and end-of-life care options before the patient’s health declines

For more examples of nursing diagnosis and plans of care check out the following websites Nursing Care Blog and Nurse Labs.  

 

References

Ackley BJ, Ladwig GB.  Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. 10^th ed. Maryland Heights, MO: Mosby Elsevier; 2012. 

Nursing Care

This week we will look at the nursing care of individuals with CKD.  The American Nephrology Nurses Association (ANNA) has created a wonderful set of modules about CKD care.  I have summarized the modules here, however I encourage you to go to their site yourself and have a more in-depth look.

The role of the nurse varies according to the stage of the disease that the patient has progressed to:

Stage 5

Transplant

Care Setting hospital

•    Patient education on immunosuppressive medication - these medications must be taken for life.   Tell patients they will have an increased risk of infection, and what they can do to stay healthy   

•    The nurse must also watch for complications from surgery such as leakage or bleeding from the surgical site, signs of infection, or a sudden change in blood pressure could mean the patient's body is rejecting the new kidney

RRT (Renal Replacement Therapy)

Care Settings include home health, rehabilitation hospital, extended care facility, long-term care facility, dialysis clinic; some hospitals have dialysis services

•    Check weight before and after dialysis

•    Maintaining good vascular access, meaning the site where the needles are inserted are free of infection and blood is flowing to and from them

•    Medication management and education - since dialysis basically is clearing the system, it is important that medication (especially blood pressure medication) be given after dialysis treatment has finished 

•    Weekly/Monthly lab draws (never draw from arm that has the fistula)

•    Connect patient with resources for transportation to and from dialysis appointments

No Therapy 

•    Patient and family will be counseled on end-of-life care

•    Plan should be in place for when the patient decides to stop using dialysis

Stages 3 & 4 Moderate to Severe

Care Settings general and family practice, for stage 4 nephrologist, many of these patients are older, and quite ill with other diseases in addition to CKD

•    Help patient manage co-morbid illnesses, including high blood pressure and diabetes

•    Promote self-management (i.e. lifestyle modifications, medication adherence, smoking cessation) 

•    Slow progression

•    Patient education on how to avoid complications, and when to call for help

•    Prepare patient RRT – go over dialysis options, transportation, vein mapping, access referral

Stages 1 & 2

Care Settings general and family practice

•    Heart disease risk reduction (lifestyle modification, medications)

•    Patient education on how to monitor BG and BP at home, and on the importance of getting kidney function labs drawn annually

•    Education on drugs to avoid (antifungals, NSAIDS)

•    Emphasis on self-management.  The patient is ultimately in control of their health!!  Progression is slow so there are many opportunities to maintain health at this stage. 

•    Monitor response to therapy

CKD in Children

•    Nurses would perform all the same care for children as they do for adults.  However, children with CKD are also at a high risk for slowed growth, both physically and cognitively.

•    Nurses working with children may need to be more creative in their approach to building a relationship with the patient, they may find themselves using play as a tool with which to provide care

That should give you a pretty good idea of what the nurse does at the various stages of CKD.  Before you go check out this message from one of my favorite CKD patients, Ms. Sheila Shaw!