{ "name": "Chronic Kidney Disease", "slug": "chronic-kidney-disease", "url": "https://nursingplex.com/care-plans/chronic-kidney-disease", "category": "Urinary & Renal", "summary": "Progressive renal failure; dietary restriction, anemia care and dialysis preparation.", "nursing_diagnoses": [ "Excess fluid volume", "Imbalanced nutrition", "Fatigue", "Risk for infection" ], "overview": [ "Chronic kidney disease is a progressive, irreversible loss of nephron function present for three months or more. Diabetes and hypertension cause most cases; glomerulonephritis, polycystic kidney disease, repeated acute kidney injury, obstruction and nephrotoxic drugs account for the rest. Surviving nephrons hyperfilter to compensate, which works for years and then accelerates the damage, so patients are usually asymptomatic until a large share of function is gone.", "Staging follows the glomerular filtration rate: stage 1 is 90 mL/min or higher with evidence of damage, stage 2 is 60–89, stage 3 is 30–59, stage 4 is 15–29, and stage 5 — end-stage renal disease — is below 15 mL/min or requiring dialysis. Symptoms usually begin in stage 3 and dominate by stage 4.", "As filtration falls the kidney fails at four jobs at once. It cannot excrete nitrogenous waste, so urea and creatinine rise and uremia produces nausea, pruritus, metallic taste, confusion and eventually pericarditis. It cannot balance electrolytes and acid, so potassium and phosphate climb, calcium falls and metabolic acidosis develops. It cannot regulate volume, so fluid overload, hypertension and heart failure follow. And it cannot make erythropoietin or activate vitamin D, producing anemia and renal bone disease. Hyperkalemia and cardiovascular disease are the leading causes of death." ], "key_facts": [ { "label": "Most immediately lethal complication", "text": "Hyperkalemia. Peaked T waves, a widening QRS and bradycardia demand immediate treatment with calcium gluconate for membrane stabilization, then insulin with dextrose, and dialysis for definitive removal." }, { "label": "Mineral balance", "text": "Phosphate rises and calcium falls, driving secondary hyperparathyroidism and renal osteodystrophy. Phosphate binders must be taken with meals to work." }, { "label": "Anemia", "text": "Caused by loss of erythropoietin; treated with erythropoiesis-stimulating agents plus iron, targeting a moderate hemoglobin rather than a normal one." }, { "label": "Diet pattern", "text": "Restrict sodium, potassium, phosphorus and fluid; moderate high-quality protein, liberalized somewhat once dialysis begins because dialysis removes protein." }, { "label": "Fistula care", "text": "No blood pressure, IV or venipuncture in the access arm. Check for a palpable thrill and audible bruit every shift." } ], "nursing_priorities": [ "Slow progression by controlling blood pressure and blood glucose.", "Maintain fluid, electrolyte and acid-base balance, above all potassium.", "Prevent and treat anemia and renal bone disease.", "Adjust or avoid nephrotoxic and renally cleared medications.", "Manage uremic symptoms — pruritus, nausea, fatigue, neuropathy.", "Prepare the patient for renal replacement therapy and protect the access.", "Support coping with a lifelong, life-altering illness." ], "assessment": { "subjective": [ "Fatigue, weakness and inability to concentrate", "Anorexia, nausea, metallic taste and early morning vomiting", "Intense generalized itching", "Muscle cramps, restless legs and numbness or tingling of the feet", "Shortness of breath on exertion or when lying flat", "Decreasing urine output, or nocturia earlier in the disease", "Depression, anxiety and loss of role and independence" ], "objective": [ "Rising BUN and creatinine with a falling estimated GFR", "Hyperkalemia, hyperphosphatemia, hypocalcemia and metabolic acidosis", "Hypertension, weight gain, peripheral and periorbital edema, crackles, jugular venous distention", "Normocytic anemia with pallor, plus bruising from platelet dysfunction", "Uremic frost, dry sallow skin, excoriations from scratching", "Uremic fetor, stomatitis and gastrointestinal bleeding", "Kussmaul respirations from acidosis; pericardial friction rub in advanced uremia", "ECG changes of hyperkalemia: peaked T waves, flattened P waves, widened QRS", "Asterixis, confusion, seizures or coma in severe uremia" ], "related_factors": [ "Progressive nephron loss with reduced glomerular filtration", "Inability to excrete nitrogenous waste, potassium, phosphate and hydrogen ions", "Sodium and water retention with activation of the renin-angiotensin system", "Deficient erythropoietin and impaired vitamin D activation", "Dietary and fluid restrictions with complex multi-drug regimens", "Uremic pruritus, neuropathy and altered taste" ] }, "goals": [ "Serum potassium stays within the ordered range with no ECG evidence of hyperkalemia.", "Weight, blood pressure and edema remain within the individualized target range.", "The patient stays within the prescribed daily fluid allowance.", "The patient lists high-potassium and high-phosphorus foods to avoid and takes binders with meals.", "Hemoglobin and phosphate move toward target values on follow-up labs.", "The vascular access remains patent with a palpable thrill and no signs of infection.", "The patient verbalizes understanding of renal replacement options and participates in the decision." ], "interventions": [ { "title": "Manage fluid balance", "points": [ "Weigh the patient daily at the same time, on the same scale, in similar clothing — weight change is the most reliable fluid indicator.", "Record strict intake and output, counting ice chips, IV flushes and medication fluids.", "Enforce the prescribed fluid restriction and spread the allowance across the day; offer ice chips, hard candy, frequent mouth care and chilled fluids for thirst.", "Assess daily for edema, crackles, jugular distention, orthopnea and rising blood pressure." ] }, { "title": "Protect against electrolyte emergencies", "points": [ "Review potassium with every lab draw and report values above the ordered threshold immediately.", "Teach avoidance of high-potassium foods: bananas, oranges, potatoes, tomatoes, avocado, dried fruit, nuts, chocolate and especially salt substitutes containing potassium chloride.", "Recognize hyperkalemia clinically — muscle weakness, cramps, paresthesias, bradycardia and ECG change — and keep the patient on a monitor when values are high.", "Give phosphate binders with meals and explain that taking them between meals makes them useless.", "Administer sodium bicarbonate for acidosis as ordered and watch for tetany when acidosis is corrected in a hypocalcemic patient." ] }, { "title": "Support nutrition", "points": [ "Coordinate with a renal dietitian for an individualized plan of controlled protein, sodium, potassium and phosphorus.", "Offer small frequent meals, treat nausea before eating, and provide oral care to reduce metallic taste.", "Teach that dialysis increases protein needs; pre-dialysis restriction and post-dialysis liberalization confuse many patients.", "Track albumin, prealbumin and weight trends for protein-energy wasting.", "Advise against most over-the-counter supplements and phosphorus-laden processed foods, colas and dairy." ] }, { "title": "Treat anemia, bone disease and pruritus", "points": [ "Administer erythropoiesis-stimulating agents and iron as ordered, monitoring hemoglobin and blood pressure — these agents can raise pressure and increase clot risk.", "Encourage energy conservation and pace activity for fatigue.", "Give active vitamin D and calcium as ordered and teach fall precautions for weakened bones.", "Manage itching with cool baths, emollients, short nails, cotton clothing and prescribed antipruritics rather than scratching, which invites infection." ] }, { "title": "Protect the kidneys and the access", "points": [ "Review every medication for nephrotoxicity or renal dosing: NSAIDs, aminoglycosides, contrast dye and many antivirals.", "Hold metformin and coordinate hydration protocols around contrast studies as ordered.", "Keep tight glycemic and blood pressure control; ACE inhibitors or ARBs are usually renoprotective but require potassium and creatinine monitoring.", "Post signs at the bedside: no blood pressure, venipuncture or IV in the fistula or graft arm.", "Assess the access every shift for thrill, bruit, warmth, redness or drainage and teach the patient to check it daily." ] }, { "title": "Prepare for renal replacement and support coping", "points": [ "Explain hemodialysis, peritoneal dialysis and transplant clearly, including schedule, access and lifestyle impact.", "Anticipate dialysis disequilibrium — headache, nausea and confusion after early rapid treatments — and report it.", "Hold dialyzable medications until after treatment when ordered.", "Acknowledge grief, loss of independence and depression, and refer to counseling, peer support and social work for transport and financial help." ] } ], "patient_teaching": [ "Weigh yourself every morning and report a gain of 2 to 3 pounds in a day or 5 pounds in a week.", "Stay within your fluid limit and use ice chips, hard candy or frequent mouth rinses for thirst.", "Avoid salt substitutes and high-potassium foods; ask before trying any new food or supplement.", "Take phosphate binders with your first bite of food, not between meals.", "Never take NSAIDs such as ibuprofen or naproxen — use only pain medicines your provider approves.", "Protect your access arm: no blood pressure cuffs, no blood draws, no tight sleeves or heavy lifting, and check for the buzzing thrill daily.", "Keep every dialysis appointment; skipping treatments allows potassium and fluid to build to dangerous levels.", "Report muscle weakness, palpitations, severe shortness of breath, chest pain, or confusion right away." ] }