Plan of Nursing Care The Patient With Chronic Renal Failure
Nursing Diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and
retention of sodium and water
Goal: Maintenance of ideal body weight without excess fluid
Nursing Interventions
1. Assess fluid status:
a. Daily weight
b. Intake and output balance
c. Skin turgor and presence
of edema
d. Distention of neck veins
e. Blood pressure, pulse rate,
and rhythm
f. Respiratory rate and effort
2. Limit fluid intake to prescribed
volume.
3. Identify potential sources of fluid:
a. Medications and fluids
used to take or administer
medications: oral and
intravenous
b. Foods
4. Explain to patient and family
rationale for fluid restriction.
5. Assist patient to cope with the
discomforts resulting from fluid
restriction.
6. Provide or encourage frequent
oral hygiene.
Rationale
1. Assessment provides
baseline and ongoing
database for monitoring
changes and evaluating
interventions.
2. Fluid restriction will be
determined on basis of
weight, urine output,
and response to
therapy.
3. Unrecognized sources of
excess fluids may be
identified.
4. Understanding promotes
patient and family
cooperation with fluid
restriction.
5. Increasing patient comfort
promotes compliance
with dietary restrictions.
6. Oral hygiene minimizes
dryness of oral mucous
membranes.
Expected Outcomes
 Demonstrates no
rapid weight
changes
 Maintains dietary
and fluid
restrictions
 Exhibits normal
skin turgor
without edema
 Exhibits normal
vital signs
 Exhibits no neck
vein distention
 Reports no
difficulty
breathing or
shortness of
breath
 Performs oral
hygiene
frequently
 Reports
decreased thirst
 Reports
decreased
dryness of oral
mucous
membranes
Nursing Diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea,
vomiting, dietary restrictions, and altered oral mucous membranes
Goal: Maintenance of adequate nutritional intake
1. Assess nutritional status:
a. Weight changes
b. Laboratory values (serum
electrolyte, BUN,
creatinine, protein,
transferrin, and iron
levels)
2. Assess patient's nutritional dietary
patterns:
1. Baseline data allow for
monitoring of changes
and evaluating
effectiveness of
interventions.
2. Past and present dietary
patterns are considered
in planning meals.
3. Information about other
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Consumes
protein of high
biologic value
Chooses foods
within dietary
restrictions that
are appealing
Consumes highcalorie foods
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
a. Diet history
b. Food preferences
c. Calorie counts
Assess for factors contributing to
altered nutritional intake:
a. Anorexia, nausea, or
vomiting
b. Diet unpalatable to
patient
c. Depression
d. Lack of understanding of
dietary restrictions
e. Stomatitis
Provide patient's food preferences
within dietary restrictions.
Promote intake of high biologic
value protein foods: eggs, dairy
products, meats.
Encourage high-calorie, lowprotein, low-sodium, and lowpotassium snacks between meals.
Alter schedule of medications so
that they are not given
immediately before meals.
Explain rationale for dietary
restrictions and relationship to
kidney disease and increased urea
and creatinine levels.
Provide written lists of foods
allowed and suggestions for
improving their taste without use
of sodium or potassium.
Provide pleasant surroundings at
meal-times.
Weigh patient daily.
Assess for evidence of inadequate
protein intake:
a. Edema formation
b. Delayed wound healing
c. Decreased serum albumin
levels
factors that may be
altered or eliminated to
promote adequate
dietary intake is
provided.
4. Increased dietary intake
is encouraged.
5. Complete proteins are
provided for positive
nitrogen balance needed
for growth and healing.
6. Reduces source of
restricted foods and
proteins and provides
calories for energy,
sparing protein for
tissue growth and
healing.
7. Ingestion of medications
just before meals may
produce anorexia and
feeling of fullness.
8. Promotes patient
understanding of
relationships between
diet and urea and
creatinine levels to renal
disease.
9. Lists provide a positive
approach to dietary
restrictions and a
reference for patient
and family to use when
at home.
10. Unpleasant factors that
contribute to patient's
anorexia are eliminated.
11. Allows monitoring of
fluid and nutritional
status.
12. Inadequate protein
intake can lead to
decreased albumin and
other proteins, edema
formation, and delay in
wound healing.
Nursing Diagnosis: Deficient knowledge regarding condition and treatment
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within dietary
restrictions
Explains in own
words rationale
for dietary
restrictions and
relationship to
urea and
creatinine levels
Takes
medications on
schedule that
does not produce
anorexia or
feeling of fullness
Consults written
lists of acceptable
foods
Reports increased
appetite at meals
Exhibits no rapid
increases or
decreases in
weight
Demonstrates
normal skin
turgor without
edema; wound
healing and
acceptable
plasma albumin
levels
Goal: Increased knowledge about condition and related treatment
1. Assess understanding of cause of
renal failure, consequences of
renal failure, and its treatment:
a. Cause of patient's renal
failure
b. Meaning of renal failure
c. Understanding of renal
function
d. Relationship of fluid and
dietary restrictions to
renal failure
e. Rationale for treatment
(hemodialysis, peritoneal
dialysis, transplantation)
2. Provide explanation of renal
function and consequences of
renal failure at patient's level of
understanding and guided by
patient's readiness to learn.
3. Assist patient to identify ways to
incorporate changes related to
illness and its treatment into
lifestyle.
4. Provide oral and written
information as appropriate about:
a. Renal function and failure
b. Fluid and dietary
restrictions
c. Medications
d. Reportable problems,
signs, and symptoms
e. Follow-up schedule
f. Community resources
g. Treatment options
1. Provides baseline for
further explanations and
teaching.
2. Patient can learn about
renal failure and
treatment as he or she
becomes ready to
understand and accept
the diagnosis and
consequences.
3. Patient can see that his
or her life does not have
to revolve around the
disease.
4. Provides patient with
information that can be
used for further
clarification at home.
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Verbalizes
relationship of
cause of renal
failure to
consequences
Explains fluid and
dietary
restrictions as
they relate to
failure of kidney's
regulatory
functions
States in own
words
relationship of
renal failure and
need for
treatment
Asks questions
about treatment
options,
indicating
readiness to learn
Verbalizes plans
to continue as
normal a life as
possible
Uses written
information and
instructions to
clarify questions
and seek
additional
information
Nursing Diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products,
and dialysis procedure
Goal: Participation in activity within tolerance
1. Assess factors contributing to
activity intolerance:
a. Fatigue
b. Anemia
c. Fluid and electrolyte
imbalances
d. Retention of waste
products
1. Indicates factors
contributing to severity
of fatigue.
2. Promotes improved selfesteem
3. Promotes activity and
exercise within limits
and adequate rest.
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Participates in
increasing levels
of activity and
exercise
Reports increased
sense of wellbeing
Alternates rest
e. Depression
2. Promote independence in selfcare activities as tolerated; assist if
fatigued.
3. Encourage alternating activity with
rest.
4. Encourage patient to rest after
dialysis treatments.
4. Adequate rest is
encouraged after dialysis
treatments, which are
exhausting to many
patients.

and activity
Participates in
selected self-care
activities
Nursing Diagnosis: Risk for situational low self-esteem related to dependency, role changes,
change in body image, and change in sexual function
Goal: Improved self-esteem
1. Assess patient's and family's
responses and reactions to illness
and treatment.
2. Assess relationship of patient and
significant family members.
3. Assess usual coping patterns of
patient and family members.
4. Encourage open discussion of
concerns about changes produced
by disease and treatment:
a. Role changes
b. Changes in lifestyle
c. Changes in occupation
d. Sexual changes
e. Dependence on health
care team
5. Explore alternate ways of sexual
expression other than sexual
intercourse.
6. Discuss role of giving and receiving
love, warmth, and affection.
1. Provides data about
problems encountered
by patient and family in
coping with changes in
life.
2. Identifies strengths and
supports of patient and
family.
3. Coping patterns that
may have been effective
in past may be harmful
in view of restrictions
imposed by disease and
treatment.
4. Encourages patient to
identify concerns and
steps necessary to deal
with them.
5. Alternative forms of
sexual expression may
be acceptable.
6. Sexuality means
different things to
different people,
depending on stage of
maturity.
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Identifies
previously used
coping styles that
have been
effective and
those no longer
possible due to
disease and
treatment
(alcohol or drug
use; extreme
physical exertion)
Patient and
family identify
and verbalize
feelings and
reactions to
disease and
necessary
changes in their
lives
Seeks
professional
counseling, if
necessary, to
cope with
changes resulting
from renal failure
Reports
satisfaction with
method of sexual
expression
Collaborative Problems: Hyperkalemia; pericarditis, pericardial effusion, and pericardial
tamponade; hypertension; anemia; bone disease and metastatic calcifications
Goal: Absence of complications
Hyperkalemia
1. Monitor serum potassium levels.
Notify physician if level greater
than 5.5 mEq/L, and prepare to
treat hyperkalemia.
2. Assess patient for muscle
weakness, diarrhea, ECG changes
(tall-tented T waves and widened
QRS).
1. Hyperkalemia causes
potentially lifethreatening changes in
the body.
2. Cardiovascular signs and
symptoms are
characteristic of
hyperkalemia.
Pericarditis, Pericardial Effusion, and Pericardial Tamponade
1. Assess patient for fever, chest
1. About 30%–50% of
pain, and a pericardial friction rub
chronic renal failure
(signs of pericarditis) and, if
patients develop
present, notify physician.
pericarditis due to
2. If patient has pericarditis, assess
uremia; fever, chest
for the following every 4 hours:
pain, and a pericardial
a. Paradoxical pulse > 10 mm
friction rub are classic
Hg
signs.
b. Extreme hypotension
2. Pericardial effusion is a
c. Weak or absent peripheral
common fatal sequela of
pulses
pericarditis. Signs of an
d. Altered level of
effusion include a
consciousness
paradoxical pulse (> 10
e. Bulging neck veins
mm Hg drop in blood
3. Prepare patient for cardiac
pressure during
ultrasound to aid in diagnosis of
inspiration) and signs of
pericardial effusion and cardiac
shock due to
tamponade.
compression of the
heart by a large effusion.
4. If cardiac tamponade develops,
Cardiac tamponade
prepare patient for emergency
exists when the patient
pericardiocentesis.
is severely compromised
hemodynamically.
3. Cardiac ultrasound is
useful in visualizing
pericardial effusions and
cardiac tamponade.
4. Cardiac tamponade is a
life-threatening
condition, with a high
mortality rate.
Immediate aspiration of
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Patient has
normal potassium
level
Experiences no
muscle weakness
or diarrhea.
Exhibits normal
ECG pattern
Vital signs are
within normal
limits
Has strong and
equal peripheral
pulses
Absence of a
paradoxical pulse
Absence of
pericardial
effusion or
tamponade on
cardiac
ultrasound
Patient has
normal heart
sounds
fluid from the pericardial
space is essential.
Hypertension
1. Monitor and record blood
pressure as indicated.
2. Administer antihypertensive
medications as prescribed.
3. Encourage compliance with
dietary and fluid restriction
therapy.
4. Teach patient to report signs of
fluid overload, vision changes,
headaches, edema, or seizures.
Anemia
1. Monitor RBC count, hemoglobin,
and hematocrit levels as indicated.
2. Administer medications as
prescribed, including iron and folic
acid supplements, Epogen, and
multivitamins.
3. Avoid drawing unnecessary blood
specimens.
4. Teach patient to prevent bleeding:
avoid vigorous nose blowing and
contact sports, and use a soft
toothbrush.
5. Administer blood component
therapy as indicated.
Bone Disease and Metastatic Calcifications
1. Administer the following
1. Provides objective data
for monitoring. Elevated
levels may indicate nonadherence to the
treatment regimen.
2. Antihypertensive
medications play a key
role in treatment of
hypertension associated
with chronic renal
failure.
3. Adherence to diet and
fluid restrictions and
dialysis schedule
prevents excess fluid
and sodium
accumulation.
4. These are indications of
in-adequate control of
hypertension and the
need to alter therapy.
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1. Provides assessment of
degree of anemia.
2. RBCs need iron, folic
acid, and vitamins to be
produced. Epogen
stimulates the bone
marrow to produce RBC.
3. Anemia is worsened by
drawing numerous
specimens.
4. Bleeding from anywhere
in the body worsens
anemia.
5. Blood component
therapy may be needed
if the patient has
symptoms.

1. Chronic renal failure
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Blood pressure
within normal
limits
Reports no
headaches, visual
problems, or
seizures
Edema is absent
Demonstrates
compliance with
dietary and fluid
restrictions
Patient has a
normal skin color
without pallor
Exhibits
hematology
values within
acceptable limits
Experiences no
bleeding from
any site
Exhibits serum
medications as prescribed:
phosphate binders, calcium
supplements, vitamin D
supplements.
2. Monitor serum lab values as
indicated (calcium, phosphorus,
aluminum levels) and report
abnormal findings to physician.
3. Assist patient with an exercise
program.
causes numerous
physiologic changes
affecting calcium,
phosphorus, and vitamin
D metabolism.
2. Hyperphosphatemia,
hypocalcemia, and
excess aluminum
accumulation are
common in chronic renal
failure.
3. Bone demineralization
increases with
immobility.
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calcium,
phosphorus, and
aluminum levels
within acceptable
ranges
Exhibits no
symptoms of
hypocalcemia
Has no bone
demineralization
on bone scan
Discusses
importance of
maintaining
activity level and
exercise program