Nursing Care Plans for Bladder Cancer

Benign or malignant tumors may develop on the bladder. Bladder tumors can develop on the surface of the bladder wall (benign or malignant papillomas) or grow within the bladder wall (usually more virulent) and quickly invade underlying muscles. 

Most bladder tumors are transitional cell carcinomas, arising from the transitional epithelium of mucous membranes. Less common are adenocarcinomas, epidermoid carcinomas, squamous cell carcinomas, sarcomas, tumors in bladder diverticula, and carcinoma in situ. Bladder tumors are most prevalent in men older than age 50 and are more common in densely populated industrial areas, but women are diagnosed at more advanced stages. 

The most common presenting symptom of bladder cancer is hematuria. Gross hematuria obviously warrants a thorough evaluation of the genitourinary system. When gross hematuria is painless and total (present during the entirety of the urinary stream), it especially causes concern for bleeding from the bladder or upper tracts. Irritative urinary symptoms are relatively common at presentation, including frequency, urgency, and dysuria. The combination of these symptoms with hematuria is very suggestive and warrants full urologic evaluation. Depending on the location of their tumors, patients may have symptoms of bladder-outlet obstruction or ureteral obstruction. A small subset, 5% to 10% of patients, have symptoms related to metastatic disease. 

Causes for Bladder cancer 

Environmental carcinogens are known to predispose a person to transitional cell tumors such as 2-naphthylamine, benzidine, tobacco, coffee, and nitrates.Thus, workers in certain industries (rubber workers, weavers, leather finishers, aniline dye workers, hairdressers, petroleum workers, and spray painters) are at high risk for such tumors. The period between exposure to the carcinogen and development of symptoms is about 18 years. Squamous cell carcinoma of the bladder is common in geographic areas where schistosomiasis is endemic, such as Egypt. What is more, it’s also associated with chronic bladder irritation and infection in people with renal calculi, indwelling urinary catheters, chemical cystitis caused by cyclophosphamide, and pelvic irradiation. 

Complications of bladder cancer

If bladder cancer progresses, complications include bone metastases and problems resulting from tumor invasion of contiguous viscera. 

Nursing Assessment 

The patient typically reports gross, painless, intermittent hematuria and often with clots. Patients may complain of suprapubic pain after voiding, and also complain of bladder irritability, urinary frequency, nocturia, and dribbling. If he reports flank pain, he may have an obstructed ureter. 

Patient’s history Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occurs. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia. 

Physical assessment The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures. 

Psychosocial assessment Diagnosis of cancer and treatment of cancer with radical cystectomy and creation of a urinary diversion system can threaten sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido. 

Diagnostic tests for bladder cancer 

To confirm a bladder cancer diagnosis, the patient typically undergoes Cystoscopy should be performed when hematuria first appears. Biopsy (If the test results show cancer cells, further studies will determine the cancer stage and treatment). Excretory urography can identify a large, early-stage tumor or an infiltrating tumor; delineate functional problems in the upper urinary tract; assess hydronephrosis; and detect rigid deformity of the bladder wall. Urinalysis can detect blood and malignant cells in the urine. Retrograde cystography evaluates bladder structure and integrity. Test results also help confirm a bladder cancer diagnosis. A bone scan can detect metastases. A computed tomography scan can define the thickness of the involved bladder wall and disclose enlarged retroperitoneal lymph nodes. Ultrasonography can find metastases in tissues beyond the bladder and can distinguish a bladder cyst from a bladder tumor. Laboratory tests, such as a complete blood count and chemistry profile, may be ordered to evaluate conditions such as anemia that are associated with bladder cancer. 

Nursing diagnosis 

Common nursing diagnosis found in nursing care plans for bladder cancer 

• Acute pain 
• Anxiety 
• Disturbed body image 
• Fear 
• Impaired skin integrity 
• Impaired urinary elimination 
• Ineffective coping 
• Ineffective therapeutic regimen management 
• Risk for infection 
• Sexual dysfunction 

Nursing Interventions 

Acute Pain related to activity of disease process (cancer) 

Nursing Outcomes Evaluation Criteria: Client will 

• verbalize relief or control of pain. 
• Client will appear relaxed and be able to sleep and rest appropriately. 

Nursing Intervention nursing diagnosis Acute Pain related to activity of disease process (cancer): 

1. Assess pain level, location, characteristics, and intensity Rationale Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Pains in Surgical causes usually subside gradually as healing begins. Continued or increasing pain may be a sign of infection. 
2. Listen to the patient’s fears and concerns. Stay with him during periods of severe stress and anxiety, and provide psychological support Rationale Reduction of anxiety and fear can promote relaxation and comfort. 
3. Encourage and maintain bed rest during acute phase, if indicated Rationale Minimizes stimulation and promotes relaxation 
4. Administer analgesics, as indicated Rationale Reduce or control pain and decrease stimulation of the sympathetic nervous system 

Anxiety related to underlying Pathophysiology response, change in health status 

Nursing Outcomes

• verbalize awareness of feelings of anxiety and healthy ways to deal with them. 
• Patients will Report that anxiety is reduced to a manageable level. 
• Patients will express concerns about effect of disease on lifestyle and position within family and society. 
• Patients will demonstrate problem-solving skills and effective coping strategies and Use resources/support systems effectively. 

Nursing Intervention Anxiety 

• Observe behavior indicative of anxiety which can be a clue to the client’s level of anxiety Rationale 
• Explain purpose of tests and procedures in bladder cancer treatment Rationale Reduces anxiety attributable to fear of unknown diagnosis and prognosis. 
• Encourage family and friends to treat client as before. Rationale Reassures client that role in the family and business has not been altered. 
• Administer sedatives and tranquilizers, as indicated. Rationale May be desired to help client relax until physically able to reestablish adequate coping strategies. 
• Review coping skills used in past and Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, lack of problem solving. Rationale These may be useful for the moment, but may eventually interfere with resolution of current situation 

Nursing Diagnosis Impaired urinary elimination 

Nursing Outcomes Evaluation Criteria 

• Patients will Display continuous flow of urine, with output adequate for individual situation 
• Patients will verbalize understanding of condition. 
• Patients will achieve normal elimination pattern. 
• Patients will demonstrate behaviors/techniques to prevent urinary infection. 
• Manage care of urinary catheter, or stoma and appliance following urinary diversion. 

Patient Teaching and Home Health Guidance for Bladder Cancer 

Patient teaching, discharge and home healthcare guidelines for patient with Bladder Cancer. In early stages, bladders Cancer have no symptoms. Commonly, the first sign is gross, painless, intermittent hematuria. Patients with invasive lesions often have suprapubic pain after voiding. Other symptoms include bladder irritability, urinary frequency, nocturia, and dribbling. Provide complete information about disease, disease process and treatment. Provide complete preoperative teaching. Include an explanation of the operation the patient is to undergo. Discuss equipment and procedures that the patient can expect postoperatively. Teach the patient the specific procedure to catheterize the continent coetaneous pouch or reservoir. 

Patient Teaching and Home Health Guidance for Bladder Cancer: 

• Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be anesthetized for cystoscopy. 
• After the test results are known, explain the implications to the patient and his family. 
• Demonstrate essential coughing and deep breathing exercises. 
• In patient with orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding. 

Following creation of an ileal conduit, teach the patient how to care of the stoma and urinary drainage system: 

• If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist. 
• Tell the patient that the ileal conduit stoma should reach its permanent size about 2 to 4 months after surgery. 
• Teach the patient how to care for his urinary stoma. Instruction usually begins 4 to 6 days after surgery. Encourage appropriate relatives or other caregivers to attend the teaching session. Advise them beforehand that a negative reaction to the stoma can impede the patient’s adjustment. 
• If the patient is to wear a urine collection pouch, teach him how to prepare and apply it. First, find out whether he will wear a reusable pouch or a disposable pouch. If he chooses a reusable pouch, he needs at least two to wear alternately. 
• Teach the patient to select the right-sized pouch by measuring the stoma and choosing a pouch with an opening that leaves a (0.3 cm) margin of skin around the stoma. 
• Instruct the patient to remeasure the stoma after he goes home in case the size changes. 
• Tell the patient to empty the pouch every 2 to 3 hours or when it’s one-third full. 
• Advise him to check the pouch frequently to ensure that the skin seal remains intact. 
• Teach the patient to provide stoma care. 
• To ensure a better seal and minimize skin breakdown, teach the patient how to use various products to level uneven abdominal surfaces, such as gullies, scars, and wedges. 
• Postoperatively, tell the patient with a urinary stoma to avoid heavy lifting and contact sports. Encourage him to participate in his usual athletic and physical activities.

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Nursing Procedure Count the Respiratory Rate

The respiratory rate is a count of one full inspiration/expiration cycle for 1 full minute. Assessing respirations includes checking rate, rhythm, and depth. It includes assessing inspiration (taking oxygen into the lungs) and expiration (removing carbon dioxide from the lungs). The normal respiratory rate varies with age. The newborn’s respiratory rate is quite rapid, averaging about 40 breaths per minute. The respiratory rate gradually decreases with age until it reaches the adult rate of 12 to 20 breaths per minute. Respiratory rates that are within normal range are termed eupnea, those above normal range are termed Tachypnea; and those below normal range are called bradypnea. Absent breathing is apnea, and difficult breathing is Dyspnea. Respirations are diaphragmatic on children younger than 7 years of age observe or place hand on abdomen. Respirations are thoracic in children older than 7 years of age observe or place hand on chest. 

Client education Count the respiratory rate: 

• Instruct the client about the reason for assessing respiration. 
• Teach the caregiver to count respiration while the client is not aware. 
• Instruct the caregiver to contact the nurse if there is an alteration in the client’s respiration’s. 
• Clients should be taught to notify their caregiver or nurse when they feel a change in their respiration’s. 
• Clients who have decreased ventilation may benefit from being taught deep-breathing and coughing techniques. 

Equipment Needed for Count the respiratory rate 

• Stethoscope 
• Watch with a second hand 

General Guidelines for Vital Signs Count the Respiratory Rate 

1. Check record for baseline and factors (age, illness, medications, etc.) influencing vital signs. 
2. Gather equipment, including paper and pen, for recording vital signs. 
3. Wash hands. 
4. Prepare child and family in a quiet and nonthreatening manner. 

Nursing Procedure Count the respiratory rate: 

1. General Guidelines 1-4. 
2. Be sure chest movement is visible. Client may need to remove heavy clothing. 
3. Observe one complete respiratory cycle. If it is easier, place the client’s hand across his abdomen and your hand over the client’s wrist. 
4. Start counting with first inspiration while looking at the second hand of a watch. Infants and children: Count Respiration’s for one full minute for infants and younger children because respiration’s are normally irregular Adults: count for 30 seconds and multiply by 2 to obtain the rate per minute, if an irregular rate or rhythm is present, count for one full minute. 
5. Observe character of respiration’s; Depth of respiration’s by degree of chest wall movement (shallow, normal, or deep) Rhythm of cycle (regular or interrupted) 
6. Observe movement of chest and abdomen; Assess chest movements for symmetry, in infants observe movement of abdomen. Paradoxical abdominal movement, abdomen rises on inspiration as chest retracts (see or saw movement), is abnormal except in premature infants. 
7. Auscultate for normal, abnormal, and diminished and/or absent breath sounds on both back and chest; use a regular pattern; compare breath sounds side-to-side. 
8. Replace client’s gown if needed. 
9. Record rate and character of respiration’s. 
10. Wash hands.

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Nursing Procedure Measuring Blood Pressure

Nursing Procedure Measuring Blood Pressure. Blood pressure (BP) is a measurement of the pressure within the vascular system as the heart contracts (systole) and relaxes (diastole). BP indirectly reflects your patient’s overall cardiovascular functioning. It is equal to CO time’s peripheral vascular resistance (BP CO PVR). Normal BP varies with age. Other factors that can affect BP include stress, genetics, medications, heavy meals, diurnal variations, exercise, and weight. Normal BP for an adult ranges from 100 to less than 120 mmHg (systolic) and from 60 to less than 80 mm Hg (diastolic). Normal BP for children and infants are much lower. A systolic reading 120 to 139 mmHg and a diastolic reading 80 to 89 mmHg is considered prehypertension; a systolic 140 to 159 mm Hg with a diastolic 90 to 99 mmHg, stage 1 hypertension; a systolic 160 mm Hg or higher with a diastolic 100 mm Hg or higher, stage 2 hypertension; and a systolic reading lower than 90 mm Hg and a diastolic reading lower than 60 mm Hg is considered hypotensive. Do not take a blood pressure (BP) on an injured or painful extremity or one where there is an intravenous line (IV). Cuff inflation can temporarily interrupt blood flow and compromise circulation in an extremity already impaired or a vein receiving IV fluids. 

Indirect Blood Pressure Measurement 

• Bladder width should equal 40% and length should be at least 60% of the circumference of the extremity. 
• Auscultatory pressure is the traditional method using a sphygmomanometer cuff. It correlates poorly with directly measured values at the extremes of pressure. 
• Palpatory systolic pressure is defined as the pressure when a pulse is detected in the radial artery as the cuff is deflated. 
• Automated indirect devices measure without manual inflation and deflation. 
• Oscillometric methods correlate well with group average values, but they correlate poorly with intra-arterial pressures in individual patients. 
• Doppler sensing devices are slightly better but still vary quite a bit. 
• Volume clamp devices respond rapidly to changes in blood pressure and may be appropriate for use in critical care in the future. 
• Automated noninvasive monitors have a role in following trends of pressure change but are of little value in situations in which blood pressure fluctuates rapidly. Critical management decisions should not be made based on their results unless use of a direct method is impossible. 

Direct Invasive Blood Pressure Measurement 

Advantages of arterial catheters: 

• measure the end-on pressure propagated by the arterial pulse 
• detect pressures at which Korotkoff sounds are either absent or inaccurate 
• provide beat-to-beat changes in blood pressure 
• eliminate the need for multiple punctures when frequent blood draws needed 

Disadvantages of arterial catheters: 

• Require invasive procedure with complications including arterial injury, ischemia, thrombus formation, infection, and blood loss, among others. 

Equipment Needed Measuring Blood Pressure: 

• Stethoscope 
• Mercury sphygmomanometer with bladder and cuff 
• Alcohol wipe 
• Gloves if required 

Client education needed Measuring Blood Pressure: 

Teach the client to refrain from eating, drinking, or smoking 30 minutes before the procedure. Ask the client to sit or lie down in a warm, quiet room. Ask the client to rest for 5 minutes before taking the measurement. Explain the procedure. Advise the client regarding the correct size blood pressure cuff to use at home for his individual anatomy. Advise the client to take his blood pressure at the same site using the same cuff for consistency. Teach the client that the “top number” in a blood pressure reading is always higher than the “bottom number.” 

ACTION: 

General Guidelines for Measuring Blood Pressure 

1. Check record for baseline and factors (age, illness, medications, etc.) influencing vital signs. Provides parameters and helps in device and site selection. 
2. Gather equipment, including paper and pen, for recording vital signs. Promotes organization and efficiency. 
3. Wash hands. Reduces transmission of microorganisms. 
4. Prepare child and family in a quiet and nonthreatening manner. Enhances cooperation and participation; reduces anxiety and fear, which can affect readings. 

Auscultation Method Using Brachial Artery 

1. General Guidelines for Measuring Blood Pressure 1- 4. 
2. Cleanse ear pieces and bell/diaphragm of stethoscope with an alcohol wipe 
3. Determine which extremity is most appropriate for reading. Do not take a pressure reading on an injured or painful extremity or one in which an intravenous line is running. 
4. Select a cuff size that completely encircles upper arm without overlapping 
5. Remove clothing as necessary to expose extremity. Move clothing away from upper aspect of arm. 
6. Position arm at heart level, extend elbow with palm turned upward. 
7. Make sure bladder cuff is fully deflated and pump valve moves freely. 
8. Locate the artery by palpation. Allows for proper placement of stethoscope to hear BP. Locate brachial artery in the antecubital space. 
9. Apply cuff snugly and smoothly over upper arm, 2.5 cm (1 inch) above antecubital space with center of cuff over brachial artery. 
10. Connect bladder tubing to manometer tubing. If using a portable mercury-filled manometer, position vertically at eye level. 
11. Palpate brachial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30 mm Hg above point where palpated pulse disappears, then slowly release valve (deflating cuff ), noting reading when pulse is felt again. 
12. Insert earpieces of stethoscope into ears with a forward tilt, ensuring diaphragm hangs freely. 
13. Relocate brachial pulse with your nondominant hand and place bell or diaphragm chestpiece directly over pulse. Chestpiece should be in direct contact with skin and not touch cuff. Place stethoscope gently over artery. Too firm a pressure will occlude blood vessel. 
14. With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until manometer registers 30 mm Hg above diminished pulse point identified. 
15. Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per second. Listen for five phases of Korotkoff sounds while noting manometer reading. (A faint, clear tapping sound appears and increases in intensity. Swishing sound. Intense sound. Abrupt, distinctive muffled sounds. Sound disappears). 
16. Obtain a blood pressure reading. Systolic pressure: The pressure at which you first hear sounds. . Diastolic pressure: The American Heart Association recommends the onset of muffling as the diastolic pressure in children up to 13 years of age; the pressure when sounds become inaudible is the diastolic pressure in children > 13 years of age. 
17. Deflate cuff rapidly and completely. 
18. Remove cuff or wait 2 minutes before taking a second reading. 
19. Inform client of reading. 
20. Record reading. 
21. If appropriate, lower bed, raise side rails, place call light in easy reach. 
22. Put all equipment in proper place. 
23. Wash hands. 

Measuring Blood Pressure Using Palpation Method on Brachial or Radial Artery 

1. Palpate brachial or radial artery with fingertips of one hand. Inflate cuff to 30 mm Hg above point at which pulse disappears. 
2. Palpation: Continue to slowly release pressure until a pulse is felt. This is the systolic pressure. The diastolic pressure is recorded as P, e.g., 100/P. The systolic pressure obtained by palpation is 5–10 mm Hg lower than that obtained by auscultation. 
3. Deflate cuff slowly as you note on the manometer when the pulse is again palpable. 
4. Deflate cuff rapidly and completely. 
5. Remove cuff or wait 2 minutes before taking a second reading. 
6. Inform client of reading. 
7. Record reading. 
8. Wash hands.

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Nursing Care Plans For Nephrotic Syndrome

Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). These occur as a consequence of excessive leakage of plasma proteins into the urine because of increased permeability of the Glomerular capillary membrane. Nephrotic syndrome essentials of Diagnosis: Edema, Hypertension, Hematuria with or without dysmorphic red cells, red blood cell casts. The Nephrotic syndrome is marked by massive proteinuria greater than 3.5 g/d, low levels of serum albumin, high levels of serum lipids, and pronounced edema. Acute onset of the disorder can occur in instances of circulatory disruption producing systemic shock that decrease the pressure and flow of blood to the kidney. Progression to the Nephrotic syndrome may also occur as a complication of the previously discussed forms of glomerulonephritis. 

Causes of Nephrotic syndrome 

About 75% of Nephrotic syndrome cases result from primary idiopathic glomerulonephritis. Classifications include the following: 

• With minimal change disease (lipid nephrosis or nil disease) in children it’s the main cause of Nephrotic syndrome the glomeruli appear normal by light microscopy. Some tubules may contain increased lipid deposits. 
• Membraneous glomerulonephritis the most common lesion in patients with adult idiopathic Nephrotic syndrome is characterized by uniform thickening of the Glomerular basement membrane containing dense deposits. It can eventually progress to renal failure. 
• Focal glomerulosclerosis can develop spontaneously at any age, follow kidney transplantation, or result from heroin abuse. 
• With membranoproliferative glomerulonephritis, slowly progressive lesions develop in the subendothelial region of the basement membrane. These lesions may follow infection, particularly streptococcal infection. This disease occurs primarily in children and young adults. 

Other causes of Nephrotic syndrome include All of diseases that increase glomerular protein permeability, which leads to increased urinary excretion of protein, especially albumin, and subsequent hypoalbuminemia. Include metabolic diseases such as diabetes mellitus; collagen-vascular disorders, such as systemic lupus erythematosus and periarteritis nodosa; circulatory diseases, such as heart failure, sickle cell anemia, and renal vein thrombosis; nephrotoxins, such as mercury, gold, and bismuth; infections, such as tuberculosis and enteritis; allergic reactions; pregnancy; hereditary nephritis; and certain neoplastic diseases such as multiple myeloma. 

Pathophysiology of Nephrotic syndrome 

Increased permeability of the Glomerular membrane is attributed to damage to the membrane and changes in the electrical charges in the basal lamina and podocytes, producing a less tightly connected barrier. This facilitates the passage of high-molecular-weight proteins and lipids into the urine. Albumin is the primary protein depleted from the circulation. The ensuing hypoalbuminemia appears to stimulate the increased production of lipids by the liver. The lower oncotic pressure in the capillaries resulting from the depletion of plasma albumin increases the loss of fluid into the interstitial spaces, which, accompanied by sodium retention, produces the edema. Depletion of immunoglobulin’s and coagulation factors places patients at an increased risk of infection and coagulation disorders. Tubular damage, in addition to Glomerular damage, occurs, and the Nephrotic syndrome may progress to chronic renal failure. 

Clinical Manifestations of Nephrotic syndrome 

The dominant Clinical Manifestations of Nephrotic syndrome is mild to severe dependent edema of the ankles or sacrum, or periorbital edema, especially in children. Such edema may lead to ascites, pleural effusion, weight gain, and high blood pressure. Insidious onset of pitting dependent edema, periorbital edema, and ascites, weight gain Fatigue, headache, malaise, irritability Marked proteinuria leading to depletion of body proteins Hyperlipidemia may lead to accelerated atherosclerosis 

Complications of Nephrotic syndrome 

Major complications include malnutrition, infection, coagulation disorders, and accelerated atherosclerosis. Thromboembolic complications renal vein thrombosis, venous and arterial thrombosis in extremities, pulmonary embolism, coronary artery thrombosis, cerebral artery thrombosis (especially in the lungs and legs). Hypovolemia. Hypochromic anemia can develop from excessive urinary excretion of transferrin. Opportunistic infections, hypertension, pleural effusion, and pericardial effusion may occur. Acute renal failure may occur. Altered drug metabolism due to decrease in plasma proteins. Progression to end stage renal failure 

Nephrotic Syndrome Treatment 

Nephrotic Syndrome Treatment. Correction of the underlying cause if possible is requires for effective treatment of Nephrotic syndrome. If it is caused by another disease, that underlying disease is treated. Supportive treatment consists of a nutritious, with restricted sodium intake, diuretics for edema, and antibiotics for infection. All nephrotoxins should be avoided. Some patients respond to an 8-week course of a corticosteroid such as prednisone followed by maintenance therapy. Others respond better to a combination of prednisone and azathioprine or cyclophosphamide. Treatment for hyperlipidemia frequently is unsuccessful. Immunosuppressant, antihypertensive, and diuretics can also help control symptoms. Angiotension converting enzyme inhibitors can decrease protein loss in urine. Some patients respond to a course of corticosteroid therapy, followed by a maintenance dose. Patients with chronic Nephrotic syndrome that’s unresponsive to therapy may require vitamin D replacement 

Management of Nephrotic syndrome 

Treatment of causative Glomerular disease Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria Corticosteroids or immunosuppressant agents to decrease proteinuria General management of edema: Sodium and fluid restriction, Infusion of salt-poor albumin, Dietary protein supplements Low-saturated-fat diet If the kidneys lose their ability to function, dialysis may be necessary. 

Special considerations in Nephrotic syndrome Treatment 

Frequently check urine protein levels. Measure blood pressure while the patient is in a supine position and also while he’s standing, be alert for a drop in blood pressure that exceeds 20 mm Hg. If the patient has had a kidney biopsy, watch for bleeding and shock. Monitor intake and output, and check weight at the same time each morning after the patient voids and before he eats and while he’s wearing the same kind of clothing. Ask the dietitian to plan a high protein, low sodium diet. Provide good skin care because the patient with Nephrotic syndrome usually has edema, if needed provide antiembolism stockings To avoid thrombophlebitis, encourage activity and exercise Offer the patient and family reassurance and support, especially during the acute phase, when edema is severe and the patient’s body image changes. 

Nursing Assessment of Nephrotic syndrome 

Patient’s history, Patients may report no illness before the onset of symptoms some patient have a history of systemic multisystem disease, such as lupus erythematosus, diabetes mellitus, amyloidosis, or multiple myeloma or have a history of an insect sting or venomous animal bite.The patient may complain of lethargy and depression. Your assessment may reveal two common problems: periorbital edema, which occurs primarily in the morning and is more common in children, and mild to severe dependent edema of the ankles or sacrum. Nurses should note orthostatic hypotension, ascites, and swollen external genitalia, signs of pleural effusion, anorexia, and pallor. Obtain history of onset of symptoms including changes in characteristics of urine and onset of edema. 

Physical examination, Perform physical examination looking for evidence of edema and hypovolemic. Assess vital signs, daily weights, intake and output, and laboratory values. In later stages, inspect the patient for massive generalized edema of the scrotum, labia, and abdomen. Pitting edema is usually present in dependent areas. The patient’s skin appears extremely pale and fragile. You may note areas of skin erosion and breakdown. Often, urine output is decreased from normal and may appear characteristically dark, frothy, or opalescent. Some patients have hematuria as well. 

Diagnostic Evaluation of Nephrotic syndrome 

Urinalysis marked proteinuria, microscopic hematuria, urinary casts, appears foamy 24-hour urine for protein (increased) and creatinine clearance (decreased) Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria Needle biopsy of kidney for histological examination of renal tissue to confirm diagnosis Serum chemistry decreased total protein and albumin, normal or increased creatinine, increased triglycerides, and altered lipid profile 

Nursing Diagnosis of Nephrotic syndrome 

Common nursing diagnosis found in nursing care plans for patients with Nephrotic syndrome 

• Imbalanced nutrition: Less than body requirements 
• Disturbed body image 
• Excess fluid volume 
• Ineffective tissue perfusion: Renal 
• Risk for injury 
• Risk for Deficient Fluid Volume related to disease process 
• Risk for Infection related to treatment with immunosuppressant 

Nursing Interventions 

Risk for Deficient Fluid Volume related to disease process 

Desired Outcomes/Evaluation Criteria Client Will: 

Hydration, Maintain adequate fluid balance as evidenced by vital signs and weight within client’s normal range, palpable peripheral pulses, moist mucous membranes, and good skin turgor. 

Risk for Deficient Fluid Volume related to disease process: 

Nursing Goal Increasing Circulating Volume and Decreasing Edema 

• Monitor daily weight, intake and output, and urine specific gravity. Rationale: Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment. 
• Monitor CVP (if indicated), vital signs, orthostatic blood pressure, and heart rate to detect hypovolemic. Rationale: Indicators of hydration and circulating volume and need for intervention. 
• Monitor serum BUN and creatinine to assess renal function. Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction. 
• Administer diuretics or immunosuppressant as prescribed, and evaluate patient’s response. Rationale: May be used short-term to reduce tissue edema to facilitate movement of stone. 
• Infuse I.V. albumin as ordered. Rationale: NS is associated with significant protein loss. Serum albumin levels below 3.4 g/dL suggest need for IDPN infusions. 
• Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of Thromboembolic complications. Rationale: Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. 
• Enforce mild to moderate sodium and fluid restriction if edema is severe; provide a high-protein diet. Rationale: As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia. 

Risk for Infection related to treatment with immunosuppressant 

Desired Outcomes Evaluation Criteria Client Will: 

Immune Status, Experience no signs or symptoms of infection. 

Nursing Intervention : 

Nursing Goal Preventing Infection 

• Monitor for signs and symptoms of infection. Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response. 
• Monitor temperature routinely; check laboratory values for neutropenia. Rationale: A shifting of the differential to the left is indicative of infection. 
• Use aseptic technique for all invasive procedures and strict hand washing by patient and all contacts; prevent contact by patient with persons who may transmit infection. Rationale: Reduces risk of cross-contamination. 
• Monitor effectiveness of antimicrobial therapy. Rationale: within 24 to 48 hours Signs of improvement in condition should occur. 

Patient Teaching Discharge and Home Healthcare Guidelines 

Patient Teaching Discharge and Home Healthcare Guidelines for patient with Nephrotic syndrome. The most common sign of Nephrotic syndrome is mild to severe edema of the ankles or sacrum, and periorbital edema, especially in children. Edema may lead to ascites, pleural effusion, weight gain, and high blood pressure. Accompanying signs and symptoms include orthostatic hypotension, lethargy, anorexia, depression, and pallor. Major complications are malnutrition, infection, coagulation disorders, Thromboembolic vascular occlusion, and accelerated atherosclerosis. 

• Patient Teaching Discharge and Home Health-care Guidelines for patient with Nephrotic syndrome: 
• Teach the patient and family about the disease process, prognosis, and treatment plan for Nephrotic Syndrome. Teach the patient and family the purpose, dosage, route, desired effects, and side effects for all prescribed medications 
• Explain that they need to monitor the urine daily for protein and keep a diary with the results of the tests. 
• Have the patient or family demonstrate the testing techniques before discharge to demonstrate their ability to perform these monitoring tasks. 
• Instruct the patient and family to avoid exposure to communicable diseases and to engage in scrupulous infection control measures (e.g. frequent hand washing). 
• Encourage patients with hypercoagulability to maintain hydration and mobility and to follow the medication regimen. Inform patients on anticoagulant therapy of the need for laboratory monitoring of activated partial thromboplastin time or prothrombin time. 
• Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as GI bleeding, stunted growth (children), bone fractures, and immunosuppressant. 
• If the patient is taking immunosuppressant, teach him and family members to report even mild signs of infection. If he’s undergoing long-term corticosteroid therapy, teach him and family members to report muscle weakness and mental changes, Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as Gastrointestinal GI bleeding, stunted growth (children), bone fractures, and immunosuppressant. 
• Suggest to the patient that he take steroids with an antacid or with cimetidine or ranitidine, to prevent Gastrointestinal GI complications, explain that the adverse effects of steroids subside when therapy stops, but warn the patient not to discontinue the drug abruptly or without a physician’s consent. 
• Show the patient how to safely apply and remove anti-embolism stockings, If the physician prescribes anti-embolism stockings for home use. 
• Stress the importance of adhering to the special diet or Ask the dietitian to plan a high-protein, low-sodium diet 
• Encourage patients to resume normal activities as soon as possible.

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Nursing Procedure Taking Temperatures

What is Body temperature? Body temperature is the difference between heat produced and heat lost. The hypothalamus acts as the body’s thermostat to maintain a constant body temperature. The balance is maintained between the body’s heat producing functions (metabolism, shivering, muscle contraction, exercise, and thyroid activity) and the heat-losing functions (radiation, convection, conduction, and evaporation). When one temperature becomes greater than the other, temperature changes are seen greater heat-producing functions result in temperature elevations (fever/hyperthermia), and greater heat losing functions result in temperature decreases (hypothermia). 

Sites of measurement of Body temperature: 

• Core temperature true body temperature. Rectal, bladder, and tympanic temperatures are in general the most reliable sites for maesuring body temperature. 
• Sublingual convenient site to measuring body temperature. Tachypnea and consumption of hot or cold substances affect result. Best for intermittent measurement. 
• Axillary temperatures average 1.5° to 1.9°C lower than tympanic. The accuracy of axillary temperatures is affected by inability to maintain probe position. 
• Tympanic measured with specifically designed thermometer. In theory, correlates well with core temperature. In practice, correlates poorly because of difficulty performing the technique and technical malfunctions, with a high degree of user dissatisfaction. 
• Skin poor correlation with core temperature. 

ROUTE	ADVANTAGES	DISADVANTAGES
·         Oral (Normal: 98.6_F; 37_C)       ·         Rectal (Normal: 99.5_F; 37.5_C)       ·         Tympanic (Normal: 99.5_F; 37.5_C)       ·         Axillary (Normal: 97.6_F; 36.5_C)       ·         Forehead (Normal: 94_F; 34.4_C)       ·         Temporal arterial (Normal: Close to rectal temperature, 1_F or 0.5_C higher than an oral temperature, and 2_F or 1_C higher than an axillary temperature)	Easy, fast, accurate More reflective of core Temperature Fast More reflective of core temperature Safe, good for children Safe, good for children and newborns Safe and easy	Cannot be used for clients who are unconscious, confused, prone to seizures, recovering from oral surgery, or under age 6. Need to wait 15–20 minutes after eating. Cannot be used for clients who have rectal bleeding, hemorrhoids, or diarrhea or who are recovering from rectal surgery. Contraindicated for cardiac clients because it may stimulate the vagus nerve and decrease heart rate. Not recommended for newborns because of risk of perforating anus. Reports of accuracy are conflicting. Measures skin surface, which can be variable. Measures skin surface temperature. Least accurate method.

Equipment Needed: 

• Thermometer: Glass, oral, or rectal, at client’s bedside. Or Electronic thermometer with disposable protective 
• Sheath Tympanic membrane thermometer with probe 
• Cover Disposable, single-use chemical strip thermometer 
• Lubricant for rectal and glass thermometer 
• Two pairs of nonsterile gloves 
• Tissues 

Purpose of Nursing Procedure Taking Temperatures: 

The thermometer measures body temperature. Measurements may be oral, rectal, temporal artery, tympanic, axillary, or skin. A rectal measurement is most reflective of core temperature, whereas skin or surface measurements are the least reflective. Thermometers measure temperature in either degrees Fahrenheit (F) or centigrade/Celsius (C). 

Types of thermometers include: 

• Glass mercury thermometer: Used for oral, rectal, or axillary temperature measurements. 
• Electronic digital thermometer: Used for oral, rectal, or axillary temperature measurements. 
• Tympanic thermometer: Uses infrared sensors to sense temperature measurements of the tympanic membrane. 
• Temporal artery thermometer: Measures arterial temperature through infrared scanning of the temporal artery. 
• Disposable paper strips with temperature sensitive dots: Used for oral or skin/surface temperature measurements. 

Client education needed when measuring Body temperature: 

Explain to client why an accurate body temperature is needed. Describe the equipment to the client and explain what to expect during the procedure. Answer any questions regarding the procedure and fears the client may have. 

General Guidelines for Nursing Procedure Taking Temperatures: 

• Review medical record for baseline data and factors that influence vital signs. 
• Explain to the client that vital signs will be assessed. 
• Encourage client to remain still and refrain from drinking, eating, and smoking. 
• Assess client’s toileting needs and proceed as appropriate. 
• Gather equipment. 
• Provide for privacy. 
• Wash hands and apply gloves. 
• Adjust Position the client in a sitting or lying position with the head of the bed elevated 45° to 60° for measurement of all vital signs except those designated otherwise. 
• Remove gloves and wash hands. 

Oral Temperature: Glass Thermometer 

1. Select correct color tip of thermometer from client’s bedside container 
2. Remove thermometer from storage container and cleanse under cool water. 
3. Use a tissue to dry thermometer from bulb’s end toward fingertips. 
4. Read thermometer by locating mercury level. It should read 35.5°C (96°F). 
5. If thermometer is not below normal body temperature reading, grasp thermometer with thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal. 
6. Place thermometer in client’s mouth under the tongue and along the gum line to the posterior sublingual pocket. Instruct client to hold lips closed. 
7. Leave in place as specified by agency policy, usually 3–5 minutes. 
8. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end. 
9. Read at eye level and rotate slowly until mercury level is visualized. 
10. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. 
11. Remove and dispose of gloves in receptacle. 
12. Wash hands. 
13. Record reading and indicate site as “OT.” 
14. Wash hands. 

Oral Temperature Electronic Thermometer 

1. Repeat Procedure 1–8 of General Guidelines 
2. Place disposable protective sheath over probe 
3. Grasp top of the probe’s stem. Avoid placing pressure on the ejection button. 
4. Place tip of thermometer under the client’s tongue and along the gumline to the posterior sublingual pocket lateral to center of lower jaw. 
5. Instruct client to keep mouth closed around thermometer. 
6. Thermometer will signal (beep) when a constant temperature registers. 
7. Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well. 
8. Inform client of temperature reading. 
9. Remove gloves and wash hands. 
10. Record reading and indicate site “OT.” 
11. Return electronic thermometer unit to charging base. 
12. Wash hands. 

Rectal Temperature 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area. 
3. Place tissues in easy reach. Apply gloves. 
4. Prepare the thermometer. 
5. Lubricate tip of rectal thermometer or probe (usually a rectal thermometer has a red cap). 
6. With dominant hand, grasp thermometer. With other hand, separate buttocks to expose anus. 
7. After Instruct client to take a deep breath. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 inches); adult, 3.5 cm (1.5 inches). If resistance is felt, do not force insertion. 
8. Hold thermometer in place for about 2 minutes. 
9. Wipe secretions off glass thermometer with a tissue. Dispose of tissue in a receptacle. 
10. Read measurement and inform client of temperature reading. 
11. While holding glass thermometer in one hand, use other hand to wipe anal area with tissue to remove lubricant or feces. Dispose of soiled tissue. Cover client. 
12. Cleanse thermometer. 
13. Remove and dispose of gloves in receptacle. Wash hands. 
14. Record reading and indicate site Rectal Temperature RT 

Axillary Temperature 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest. 
3. Make sure axillaries skin is dry; if necessary, pat dry. 
4. Prepare thermometer. 
5. Place thermometer or probe into center of axilla. Fold client’s upper arm straight down and place arm across client’s chest. 
6. Leave glass thermometer in place as specified by agency policy (usually 6–8 minutes). Leave an electronic thermometer in place until signal is heard. 
7. Remove and read thermometer. 
8. Inform client of temperature reading. 
9. Cleanse glass thermometer. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. 
10. Assist client with replacing gown. 
11. Record reading and indicate site Axillary Temperature 
12. Wash hands. 

Disposable (Chemical Strip) Thermometer 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Apply tape to appropriate skin area, usually forehead. 
3. Observe tape for color changes. 
4. Record reading and indicate method. 
5. Wash hands. 

Tympanic Temperature: Infrared Thermometer 

1. Repeat Procedure 1–8 of General Guidelines. 
2. Position client in Sims’ position. 
3. Remove probe from container and attach probe cover to tympanic thermometer unit. 
4. Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and back. Gently insert probe with firm pressure into ear canal. 
5. Remove probe after the reading is displayed on digital unit (usually 2 seconds). 
6. Remove probe cover and replace in storage container. 
7. Return tympanic thermometer to storage unit. 
8. Record reading and indicate site 
9. Wash hands.

Continue

Nursing Care Plans Chronic Renal Failure CRF

Chronic renal failure CRF or end-stage renal disease, ESRD is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or kidney transplantation is performed. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous wastes in the blood). Few symptoms develop until after more than 75% of Glomerular filtration is lost. Then, the remaining normal parenchyma deteriorates progressively and symptoms worsen as renal function decreases. 

Pathophysiology of Chronic renal failure 

End result of the gradual, progressive destruction of nephrons and decrease in Glomerular Filtration Rate (GFR), resulting in loss of kidney function that produces major changes in all body systems. Chronic kidney disease (CKD), although ultimately irreversible, may be slowed by improved standardized blood tests and availability of new drugs to control blood pressure 

Stages of renal failure

Chronic kidney disease CKD stages correspond to the degree of nephron loss:

• Decreased renal reserve, Glomerular Filtration Rate GFR may be normal; slightly higher than normal, stage I: greater than or equal to 90 mL/min/1.73 m2; or somewhat less than normal, stage II: 60 to 89 mL/min/1.73 m2. Kidney dysfunction is present, however, it may be undiagnosed due to lack of symptoms blood urea nitrogen/creatinine (BUN/Cr) ratio is normal and nephron loss at less than 75%.
• Renal insufficiency, Nephron loss at 75% to 90%; GFR is moderately (stage III: 30 to 59 mL/min/1.73 m2) to severely (stage IV: 15 to 29 mL/min/1.73 m2) reduced. Slight elevation in BUN/Cr. Polyuria and nocturia present high output failure
• Renal Failure (GFR 20% to 25% of normal)
• End Stage Renal Disease (ESRD). Nephron loss at greater than 90% with a GFR of only 10% to 15% (stage V: less than 15 mL/min/1.73 m2). Fluid and electrolyte abnormalities, Azotemia and uremia present Dialysis required

Clinical Manifestations of Chronic renal failure

• Gastrointestinal GI anorexia, nausea, vomiting, hiccups, ulceration of Gastrointestinal GI tract, and hemorrhage 
• Cardiovascular hyperkalemic ECG changes, hypertension, pericarditis, pericardial effusion, pericardial tamponade 
• Respiratory pulmonary edema, pleural effusions, pleural rub 
• Neuromuscular fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma 
• Metabolic and endocrine glucose intolerance, hyperlipidemia, sex hormone disturbances causing decreased libido, impotence, amenorrhea 
• Fluid, electrolyte, acid base disturbances usually salt and water retention but may be sodium loss with dehydration, acidosis, hyperkalemia, hypermagnesemia, hypocalcemia 
• Dermatologic pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost 
• Skeletal abnormalities renal osteodystrophy resulting in osteomalacia 
• Hematologic anemia, defect in quality of platelets, increased bleeding tendencies 
• Psychosocial functions personality and behavior changes, alteration in cognitive processes

Etiology Causes Renal Failure Chronic CRF

Multiple causes;

• Acute tubular necrosis (ATN) from unresolved acute renal failure (ARF) 
• Chronic infections: glomerulonephritis, pyelonephritis, beta hemolytic streptococci infection 
• Vascular diseases: hypertensive nephrosclerosis, renal artery stenosis, renal vein thrombosis, vasculitis 
• Obstructive processes: long-standing renal calculi, Benign Prostatic Hyperplasia (BPH) 
• Cystic disorders: polycystic or medullary kidney disease 
• Collagen diseases: systemic lupus erythematosus (SLE) and collagen vascular disease 
• Tumors: malignant (multiple myeloma) or benign 
• Nephrotoxic agents: drugs, such as aminoglycosides, tetracyclines, contrast dyes, heavy metals 
• Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism 
• Long-standing systemic hypertension

Such comorbidities as diabetes and hypertension are responsible for more than 70% of all cases of End Stage Renal Disease ESRD. Highest incidence of End Stage Renal Disease ESRD occurs in individuals older than age 65 years. over the last decade, there has been a 98% increase in incidence in those aged 75 years and older

Complications

If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. Even in patient with life sustaining maintenance Renal dialysis or a kidney transplant, the patient may still have:

• Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) 
• Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis 
• Hypertension due to sodium and water retention and malfunction of the rennin angiotensin aldosterone system 
• Anemia due to decreased erythropoietin production, decreased Red Blood Cell RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis 
• Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels 
• Peripheral neuropathy, Restless leg syndrome, one of the first symptoms of peripheral neuropathy, causes pain, burning, and itching in the legs and feet. Eventually, this condition progresses to paresthesia and motor nerve dysfunction unless dialysis is initiated 
• Sexual dysfunction 

Treatment Goal for Chronic renal failure CRF End Stage Renal Disease ESRD conservation of renal function as long as possible. Correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.

Treatment For Chronic renal failure CRF End Stage Renal Disease ESRD

• Detection and treatment of reversible causes of renal failure (e.g. bring Diabetes Mellitus under control, treat hypertension) 
• Dietary regulation low-protein diet supplemented with essential amino acids or their keto analogues to minimize uremic toxicity and to prevent wasting and malnutrition 
• Fluid status maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume. Loop diuretics, such as furosemide only if some renal function remains, and fluid restriction can reduce fluid retention. 
• A cardiac glycoside may be used to mobilize edema fluids; an antihypertensive, especially an angiotensin-converting enzyme inhibitor, to control blood pressure and associated edema. 
• Treatment of associated conditions to improve renal dynamics 
• Anemia recombinant human erythropoietin (Epo-gen), a synthetic hormone. Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells. 
• Acidosis replacement of bicarbonate stores by infusion or oral administration of sodium bicarbonate 
• Hyperkalemia restriction of dietary potassium; administration of cation exchange resin 
• Phosphate retention decrease dietary phosphorus (chicken, milk, legumes, carbonated beverages); administer phosphate-binding agents because they bind phosphorus in the intestinal tract 
• Drug therapy, surgery, and dialysis Maintenance renal dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management. Antiemetic taken before meals may relieve nausea and vomiting, and cimetidine, omeprazole, or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.

Nursing Assessment

• Patient History, Obtain history of chronic disorders and underlying health status. The patient’s history may include a disease or condition that can cause renal failure, but he may not have any symptoms for a long time. Symptoms usually occur by the time the GFR is 20% to 35% of normal, and almost all body systems are affected. Assessment findings reflect involvement of each system; many findings reflect involvement of more than one system. The patient may report a history of Acute Renal Failure ARF 
• Assess degree of renal impairment and involvement of other body systems by obtaining a review of systems and reviewing laboratory results. Patient’s description of any central nervous system (CNS) symptoms. Blurred vision is common. Patients may have impaired decision making and judgment, irritability, decreased alertness, insomnia, increased extremity weakness, and signs of increasing peripheral neuropathy (decreased sensation in the extremities, hands, and feet; pain; and burning sensations). 
• CRF affects all body systems Perform thorough physical examination, including vital signs, cardiovascular, pulmonary, GI, neurologic, dermatologic, and musculoskeletal systems. Hypertension is usually noted in the patient with CRF and may indeed be its cause. Patients often have rapid, irregular heart rates; distended jugular veins; and if pericarditis is present, pericardial frictions rub and distant heart sounds. Respiratory symptoms include hyperventilation, Kussmaul breathing, Dyspnea, orthopnea, and pulmonary congestion. 
• Assess psychosocial response to disease process including availability of resources and support network. Some patient may have personality and cognitive changes. Sexual dysfunction usually occur in patient with chronic renal failure, carefully assess of the patient’s capabilities, home situation, available support systems, financial resources, and coping abilities is important before any nursing interventions for Chronic Renal Failure CRF can be planned. 

Diagnostic Test Chronic Renal Failure CRF 

• Complete blood count (CBC) anemia (a characteristic sign), Elevated serum creatinine, BUN, phosphorus. Decreased serum calcium, bicarbonate, and proteins, especially albumin. ABG levels low blood pH, low carbon dioxide, low bicarbonate. show elevated blood urea nitrogen, creatinine, and potassium levels; decreased arterial pH and bicarbonate levels, and low hemoglobin (Hb) levels and hematocrit (HCT). 
• Computed tomography scan, Renal or abdominal X-ray, magnetic resonance imaging, or Ultrasonography shows reduced kidney size. 
• Kidney biopsy allows histological identification of underlying pathology 

Nursing Diagnosis 

Common Nursing diagnosis that could be found in patient with Chronic Renal Failure CRF: 

Risk for decreased Cardiac Output 

Risk for ineffective Protection 

Disturbed Thought Processes 

Risk for impaired Skin Integrity 

Risk for impaired Oral Mucous Membrane 

Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs 

Acute pain 

Disabled family coping 

Excess fluid volume 

Imbalanced nutrition: Less than body requirements

Impaired gas exchange 

Impaired oral mucous membrane 

Impaired urinary elimination 

Ineffective coping 

Ineffective sexuality patterns 

Ineffective tissue perfusion: Renal 

Interrupted family processes 

Powerlessness 

Risk for infection 

Risk for injury 

Nursing Intervention  

Nursing diagnosis Risk for decreased Cardiac Output 

Risk factors may include 

• Fluid imbalances affecting circulating volume, myocardial workload, and systemic vascular resistance (SVR) 
• Alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia) 
• Accumulation of toxins (urea), soft tissue calcification (deposition of calcium phosphate) 

Desired Outcomes/Evaluation Criteria Client Will Circulation Status: 

Maintain cardiac output as evidenced by blood pressure (BP) and heart rate within client’s normal range; peripheral pulses strong and equal with prompt capillary refill time. 

Nursing Intervention Risk for decreased Cardiac Output: 

• Auscultate heart and lung sounds. Evaluate presence of peripheral edema, vascular congestion, and reports of Dyspnea. Rationale S3/S4 heart sounds with muffled tones, tachycardia, irregular heart rate, Tachypnea, Dyspnea, crackles, wheezes, and edema or jugular distention suggest heart failure (HF). 
• Assess presence and degree of hypertension Monitor Blood Pressure and note postural changes, such as sitting, lying, and standing. Rationale Significant hypertension can occur because of disturbances in the rennin angiotensin aldosterone system caused by renal dysfunction. Although hypertension is common, orthostatic hypotension may occur because of intravascular fluid deficit, response to effects of antihypertensive medications or uremic pericardial tamponade. 
• Investigate reports of chest pain, noting location, radiation, severity (0 to 10 scale), and whether or not it is intensified by deep inspiration and supine position. Rationale: Although hypertension and chronic HF may cause myocardial infarction (MI), approximately half of CRF clients on dialysis develop pericarditis, potentiating risk of pericardial effusion and tamponade. 
• Evaluate heart sounds for friction rub, BP, peripheral pulses, JVD, capillary refill, and mentation. Rationale: Presence of sudden hypotension with paradoxical pulse, narrow pulse pressure, diminished or absent peripheral pulses, marked JVD, pallor, and a rapid mental deterioration indicate tamponade, which is a medical emergency. 
• Assess activity level and response to activity. Rationale: Weakness can be attributed to heart failure and anemia. 
• Collaborate in treatment of underlying disease or conditions, where possible. Rationale Delaying or halting progression of CRF in early stages can be aided by interventions, such as controlling BP, managing diabetes, treating hyperlipidemia, and avoiding toxins such as NSAIDs, intravenous (IV) contrast dye, amino glycosides, and so on. 
• Administer oxygen, as indicated. Rationale: Cardiac function can be improved with use of oxygen if client is severely anemic or metabolic acidosis and electrolyte abnormalities are causing Dysrhythmias. 
• Prepare for renal replacement therapy, such as hemodialysis. Rationale: Reduction of uremic toxins and correction of electrolyte imbalances and fluid overload may limit or prevent cardiac manifestations, including hypertension and pericardial effusion. 

Nursing Diagnosis Risk for ineffective Protection 

Risk factors may include: 

• Abnormal blood profile decreased RBC production and survival, altered clotting factors (suppressed erythropoietin production or secretion). 
• Increased capillary fragility 

Desired Outcomes/Evaluation Criteria Client Will 

• Experience no signs and symptoms of bleeding or hemorrhage. 
• Maintain or demonstrate improvement in laboratory values. 

Nursing Intervention: 

• Note reports of increasing fatigue and weakness. Observe for tachycardia, pallor of skin and mucous membranes, Dyspnea, and chest pain. Plan client activities to avoid fatigue. Rationale May reflect effects of anemia and cardiac response necessary to keep cells oxygenated. 
• Monitor level of consciousness (LOC) and behavior. Rationale Anemia may cause cerebral hypoxia manifested by changes in mentation, orientation, and behavioral responses. 
• Evaluate response to activity and ability to perform tasks. Assist as needed and develop schedule for rest. Rationale Anemia decreases tissue oxygenation and increases fatigue, which may require intervention, changes in activity, and rest. 
• Observe for oozing from venipuncture sites, bleeding or ecchymosis areas following slight trauma, petechiae, and joint swelling or mucous membrane involvement bleeding gums, recurrent epitasis, hematemesis, melena, and hazy or red urine. Rationale Bleeding can occur easily because of capillary fragility and altered clotting functions and may worsen anemia. 
• Provide soft toothbrush and electric razor. Use smallest needle possible and apply prolonged pressure following injections or vascular punctures. Rationale Reduces risk of bleeding and hematoma formation. 
• Administer fresh blood and packed red cells (PRCs), as indicated. Rationale May be necessary when client is symptomatic with anemia. PRCs are usually given when client is experiencing fluid overload or receiving dialysis treatment. Washed RBCs are used to prevent hyperkalemia associated with stored blood. 
• Administer medications, as indicated, for example: Erythropoietin preparations (Epogen, EPO, Procrit) Rationale Stimulates the production and maintenance of RBCs, thus decreasing the need for transfusion. Iron preparations, such as folic acid and cyanocobalamin Rationale Useful in managing symptomatic anemia related to nutritional and dialysis-induced deficits. Note: Iron should not be given with phosphate binders because they may decrease iron absorption. Cimetidine, ranitidine, and antacids Rationale May be given prophylactically to reduce or neutralize gastric acid and thereby reduce the risk of GI hemorrhage. Hemostatics or fibrinolysis inhibitors, such as aminocaproic acid Rationale Inhibits bleeding that does not subside spontaneously or respond to usual treatment. Stool softeners, such as Colace and bulk laxative, such as Metamucil Rationale straining to pass hard formed stool increases likelihood of mucosal or rectal bleeding. 

Nursing Diagnosis Disturbed Thought Processes 

May be related to: Physiological changes accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances; calcifications in the brain 

Desired Nursing Outcomes Evaluation Criteria Client Will: 

• Regain or maintain optimal level of mentation. 
• Identify ways to compensate for cognitive impairment and memory deficits. 

Nursing Intervention nursing diagnosis Disturbed Thought Processes: 

• Assess extent of impairment in thinking ability, memory, and orientation. Rationale Uremic syndrome’s effect can begin with minor confusion or irritability and progress to altered personality, inability to assimilate information or participate in care. Awareness of changes provides opportunity for evaluation and intervention. 
• Provide quiet, calm environment and judicious use of TV, radio, and visitation. Rationale Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation. 
• Reorient to surroundings, person, and so forth. Provide calendars, clocks, and outside window. Rationale Provides clues to aid in recognition of reality. 
• Present reality concisely and briefly, and do not challenge illogical thinking. Rationale Confrontation potentiates defensive reactions and may lead to client mistrust and heightened denial of reality. 
• Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary. Rationale May aid in reducing confusion and increases possibility that communications will be understood and remembered. 
• Establish a regular schedule for expected activities. Rationale Aids in maintaining reality orientation and may reduce fear and confusion. 
• Promote adequate rest and undisturbed periods for sleep Rationale Sleep deprivation may further impair cognitive abilities. 
• Provide supplemental oxygen (O2) as indicated. Rationale Correction of hypoxia alone can improve cognition. 
• Avoid use of barbiturates and opiates. Rationale Drugs normally detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion. 

Nursing diagnosis Risk for impaired Skin Integrity 

Risk factors may include: 

• Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy) 
• Changes in fluid status; alterations in skin turgor edema 
• Reduced activity, immobility Accumulation of toxins in the skin 

Desired Outcomes/Evaluation Criteria Client Will: 

• Maintain intact skin. 
• Risk Management 
• Demonstrate behaviors and techniques to prevent skin breakdown or injury. 

Intervention Nursing diagnosis Risk for impaired Skin Integrity: 

• Inspect skin for changes in color, turgor, and vascularity. Note redness and excoriation. Observe for ecchymosis and purpura. Rationale Indicates areas of poor circulation and early breakdown that may lead to decubitus formation and infection. 
• Monitor fluid intake and hydration of skin and mucous membranes. Rationale Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level. 
• Inspect dependent areas for edema. Elevate legs, as indicated. Rationale Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. 
• Change position frequently, move client carefully, pad bony prominences with sheepskin, and use elbow and heel protectors. Rationale Decreases pressure on edematous, poorly perfused tissues to reduce ischemia. 
• Provide soothing skin care, restrict use of soaps, and apply ointments or creams such as lanolin or Aquaphor. Rationale Baking soda and cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin. 
• Keep linens dry and wrinkle free. Rationale Reduces dermal irritation and risk of skin breakdown. 
• Investigate reports of itching. Rationale Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products, such as phosphate crystals associated with hyperparathyroidism in ESRD. 
• Recommend client use cool, moist compresses to apply pressure to, rather than scratch, pruritic areas. Keep fingernails short; encourage use of gloves during sleep, if needed. Rationale Alleviates discomfort and reduces risk of dermal injury. 
• Suggest wearing loose-fitting cotton garments. Rationale Prevents direct dermal irritation and promotes evaporation of moisture on the skin. 
• Provide foam or flotation mattress. Rationale Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis. 

Nursing Diagnosis Risk for impaired Oral Mucous Membrane 

Risk factors may include 

• Lack of or decreased salivation, fluid restrictions 
• Chemical irritation, conversion of urea in saliva to ammonia 

Desired Outcomes/Evaluation Criteria Client Will 

• Maintain Oral Health 
• Maintain integrity of mucous membranes. 
• Identify and initiate specific interventions to promote healthy oral mucosa. 

Nursing Intervention Nursing diagnosis Risk for impaired Oral Mucous Membrane: 

• Inspect oral cavity: note moistness, character of saliva, presence of inflammation, ulcerations, and leukoplakia. Rationale Provides opportunity for prompt intervention and prevention of infection. 
• Provide fluids throughout 24-hour period within prescribed limit. Rationale Prevents excessive oral dryness from prolonged period without oral intake. 
• Offer frequent mouth care or rinse with 0.25% acetic acid solution. Provide gum, hard candy, or breathe mints between meals. Rationale Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea. 
• Encourage good dental hygiene after meals and at bedtime. Recommend avoidance of dental floss. Rationale Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding. 
• Recommend client stop smoking and avoid lemon and glycerin products or mouthwash containing alcohol. Rationale These substances are irritating to the mucosa and have a drying effect, potentiating discomfort. 
• Provide artificial saliva as needed, such as Oral-Lube. Rationale Prevents dryness, buffers acids, and promotes comfort. 

Patient Teaching Discharge and Home Healthcare Guidelines 

Patient teaching discharge and home healthcare guidelines for patient with Chronic Renal Failure CRF End Stage Renal Disease ESRD. CRF or ESRD are disorders that affect the patient’s total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. To promote adherence to the therapeutic program, and Encourage all people with the following risk factors to obtain screening for chronic kidney disease: elderly people, ethnic minorities, diabetics, and people with hypertension, those with autoimmune disease, and those with family history of kidney disease. Nurses may need to work collaboratively with social services to arrange for the patient’s dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important. 

Patient Teaching Discharge and Home Healthcare Guidelines Chronic Renal Failure CRF 

• Teach the patient how to take his medications and what adverse effects to watch for. Suggest taking diuretics in the morning so that sleep isn’t disturbed. Topics to cover include reason for the procedure; complications; signs and symptoms of the related disease; how to check for bleeding, electrolyte imbalance, and changes in blood pressure; diet; exercise; and the use of equipment. 
• In patient that requires dialysis, instruct him on how to adjust his medication schedule as needed in relation to dialysis care plan. 
• Instruct the anemic patient to conserve energy by resting frequently. 
• Tell the patient to report leg cramps or excessive muscle twitching. 
• Explained to patients and family the importance of keeping follow-up appointments to have his electrolyte levels monitored. 
• Explained to patients and family to avoid high-sodium and high-potassium foods. Encourage adherence to fluid and protein restrictions. To prevent constipation, stress the need for exercise and sufficient dietary fiber. 
• Eat food before drinking fluids to alleviate dry mouth. If the patient requires dialysis, remember that he and family members are under extreme stress. 
• If the facility doesn’t offer a course on dialysis nurses need to teach the patient and family members. 
• A patient undergoing dialysis is under a great deal of stress, as is his family. Refer them to appropriate counseling agencies for assistance in coping with chronic renal failure. 
• Demonstrate how to care for the shunt, fistula, or other vascular access device and how to perform meticulous skin care. Discourage activity that might cause the patient to bump or irritate the access site. 
• Suggest that the patient wear a medical identification bracelet or carry pertinent information with him. 
• Weigh self every morning to avoid fluid overload. 
• Drink limited amounts of fluids only when thirsty. 
• Measure allotted fluids, and save some for ice cubes; sucking on ice is thirst quenching. 
• Use hard candy or chewing gum to moisten mouth.

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