V. Medical Management
Goal of management are to retain kidney function and maintain homeostasis for as long as possible. All factors that contribute to ESRD and those that are reversible (e.g. obstruction) are identified and treated.
Complications can be prevented or delayed by administering prescribed antihypertensives, cardiovascular agents, anticonvulsants, erythropoietin (Epogen), iron supplements, phosphate-binding agents (antacids), and calcium supplements.
Dietary intervention is needed, with careful regulation of protein intake, fluid intake to balance fluid losses, and sodium intake and with some restrictions of potassium.
Adequate intake of calories and vitamins is ensured. Calories are supplied with carbohydrates and fats to prevent wasting.
Protein is restricted; protein must be of high biologic value (dairy products, eggs, meats)
Vitamin supplementation
Fluid allowance is 500 to 600 mL of fluid or more than the 24-hour urine output
Pharmacologic Management
• Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids or calcium carbonate; both must be given with food
• Hypertension is managed by intravascular volume control and antihypertensive medication
• Heart failure and pulmonary edema are treated with fluid restriction, low-sodium diet, diuretics, inotropoic agents (eg. Digitalis or dobutamine) and dialysis
• Metabolic acidosis is treated, if necessary, with sodium bicarbonate supplements or dialysis.
• Hyperkalemia is treated with dialysis; medications are monitored for potassium content; patient is placed on potassium-restricted diet; Kayexalate is administered as needed.
• Patient is observed for early evidence of neurologic abnormalities (eg. Slight twitching, headache, delirium, or seizure activity)
• The onset of seizures, type, duration and general effect on patient are recorded; physician is notified immediately and patient is protected from injury with padded side rails. Intravenous diazepam (Valium) or phenytoin (Dilantin) is administered to control seizures.
• Anemia is treated with recombinant human erythropoietin (Epogen); hematocrit is monitored frequently
• Heparin is adjusted as necessary to prevent clotting of dialysis lines during treatments.
• Serum iron and transferring levels are monitored to assess iron states (iron is necessary for adequate response to erythropoietin)
• Blood pressure and serum potassium levels are monitored
• Patient is referred to a dialysis and transplantation center early in the course of progressive renal disease. Dialysis is initiated when patient cannot maintain a reasonable lifestyle with conservative treatment.
VI. Nursing Diagnosis
• Excess fluid volume related to decreased urine output, dietary excess, and retention of sodium and water.
• Imbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting, dietary restriction and altered oral mucous membranes
• Deficient knowledge regarding condition and treatment regimen
VII. Nursing Management
Provide conservative therapy, as indicated.
• Maintain strict fluid control; daily fluid intake should equal 500 ml (insensible loss) plus the amount of the previous 24 hours urine output; daily weight; and strict intake and output
• Encourage intake of high biologic value protein foods such as eggs, dairy products, and meats (causes positive nitrogen balance needed for growth and healing)
• Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals.
• Encourage alternating activity with rest. Encourage independence as much as possible.
• Assess the client and family’s response to chronic illness. Encourage therapeutic conversations to help cope with chronic illness.
• Provide symptomatic treatment.
• Be prepared to identify and treat complications, which include hyperkalemia, pericarditis, pericardial effusion, pericardial tamponade, hypertension, anemia, and bone disease.
Administer prescribed medication, which may include ion exchange resin, alkalizing agents, antibiotics, erythropoeitin, folic acid supplements, iron supplements, phosphate-binding agents, calcium supplements, histamine receptor antagonists, and proton-pump inhibitors.
Prepare the client for peritoneal dialysis, if indicated.
• Assist with the procedure as instructed, maintaining septic technique and monitoring for signs and symptoms of peritonitis. (rigid, boardlike abdomen, fever, cloudy peritoneal fluid)
Prepare the client for and assist with hemodialysis, if indicated.
• Provide proper shunt care, and assess for possible complications. (bleeding due to heparinization, hypovolemia, hypotension due to excessive water removal, dialysis disequilibrium syndrome (headache, confusion, and seizures) due to rapid removal of urea from plasma.)
Prepare the client for kidney transplantation, if indicated.
• Provide postoperative care for any client who has undergone major surgery with special attention to catheter patency and adequacy, intake and output, fluid replacement, and protection from infection.
• Monitor for signs and symptoms of complications such as:
1)Graft rejection (fever, elevated white blood cell count, electrolyte abnormalities, abnormal renogram)
2)Infection stemming from immunosuppressive therapy (sepsis pneumonia, wound infection, and urinary tract infection)