Conditions › Renal & urinary
Chronic Kidney Disease Nursing Care Plan and Interventions
Chronic kidney disease nursing care manages fluid, BP, potassium, phosphorus and anemia while protecting the remaining kidney function. Check every drug for renal dosing, protect the AV fistula arm, give phosphate binders with meals and teach the renal diet and dialysis care.
Chronic kidney disease nursing care plan
| Nursing problem | Goal | Key interventions |
|---|---|---|
| Excess fluid volume | Weight and BP at target; no crackles or new edema. | |
| Risk for electrolyte imbalance | Potassium and phosphorus in the ordered range. | |
| Risk for injury (drug toxicity, access problems) | Doses adjusted for kidney function; fistula has a bruit and thrill. | |
| Fatigue (anemia of CKD) | Hemoglobin at goal; paces activity. |
Problem wording is plain-language nursing diagnosis style. Your program may require NANDA-I labels and your own assessment data.
What it is
CKD: what it is
Kidney damage or an eGFR under 60 for 3 months or more. Nephrons are lost slowly and for good; eGFR under 15 is kidney failure. 1,2
Diabetes is the top cause, then high blood pressure.
CKD stages by eGFR
Stage 1: 90 or more, with kidney damage. Stage 2: 60 to 89. Stage 3a: 45 to 59. 3b: 30 to 44. Stage 4: 15 to 29. Stage 5: under 15. 2
Dialysis access is planned in stage 4, so a fistula has time to mature before it's needed.
Assessment: what you will see
Uremia: what you see
Early CKD is often silent. As wastes build up: fatigue, poor appetite, nausea, itching, trouble focusing and muscle cramps. 2
Advanced CKD can inflame the pericardium: report chest pain or a new friction rub.
Fluid and blood pressure
Failing kidneys retain salt and water: hypertension, edema, weight gain, crackles, even heart failure. Track daily weights and BP. 2
Most clients with advanced CKD have hypertension, and high BP speeds kidney loss.
CKD labs: up and down
Up: creatinine, BUN, potassium, phosphorus. Down: eGFR, calcium, bicarbonate (metabolic acidosis) and hemoglobin. 2,3
High K+ is the deadly one: peaked T waves need a cardiac monitor and a call to the provider.
Anemia of CKD
Less erythropoietin means fewer red cells: fatigue, pallor, low hemoglobin. Treated with an ESA such as epoetin alfa, plus iron. 2
Use the lowest ESA dose that keeps Hgb about 10 to 11 g/dL. Higher targets raise stroke and clot risk.
Phosphorus, calcium and bone
Phosphate can't be excreted and vitamin D isn't activated: phosphorus rises, calcium falls, and PTH rises and pulls calcium from bone. 2
The bone damage is renal osteodystrophy. Itching often eases when phosphorus comes down.
Priority: what the nurse does first
Drug safety in CKD
Avoid NSAIDs (they worsen kidney function and BP). Kidney-cleared drugs such as vancomycin, aminoglycosides and digoxin need lower doses. 2
Check the eGFR before a kidney-cleared drug and confirm the dose with pharmacy.
AV fistula care
An artery joined to a vein for long-term hemodialysis. Feel a thrill, hear a bruit. No BP cuff, IV, blood draw or tight sleeve on that arm. 4
Thrill or bruit gone: possible clot. Report to the provider and the dialysis unit right away.
Nursing interventions and treatment
Slowing CKD
Control BP and glucose. An ACE inhibitor or ARB, often with an SGLT2 inhibitor, slows loss of function, especially with proteinuria. 2
On an ACE inhibitor or ARB, check K+ and creatinine, and teach: no salt substitutes.
Phosphate binders
Sevelamer or calcium acetate binds phosphorus from food in the gut so it leaves in the stool instead of being absorbed. Give with meals. 3,5
No meal, nothing to bind: an empty-stomach dose does little.
Renal diet
Limit sodium and phosphorus, and potassium when it runs high (common in late CKD). Protein: limited before dialysis, raised on it. 6,7,2
Salt substitutes are potassium chloride, which can push K+ to dangerous levels. Use herbs instead.
Hemodialysis: before and after
Dialysis pulls off fluid fast, so BP can drop: ask about holding antihypertensives before. Weigh before and after; watch for dysrhythmias. 3,2
Dialysis removes some drugs, so ask which doses should be given after the run.
Peritoneal dialysis
Dialysate is instilled into the abdomen, dwells, then drains with wastes and extra fluid. Outflow should be clear and more than went in. 4,2
Cloudy outflow, fever or belly pain means peritonitis until proven otherwise: report it now.
Client teaching
CKD teaching
Weigh daily, log BP, follow the renal diet, take binders with meals, protect the access arm, and avoid NSAIDs and salt substitutes. 3,7
Goal: stay near dry weight. Report fast weight gain, swelling or shortness of breath.
NCLEX traps
CKD or AKI?
CKD: 3 months or more, irreversible, usually small kidneys, chronic symptoms. AKI: sudden, often reversible, creatinine rising day by day. 2
Both raise K+ and creatinine. A client with CKD can also get AKI on top of it (acute on chronic).
Try 2 chronic kidney disease questions
NCLEX-style, approved by a licensed RN. Pick an answer, check it, then read the rationale.
Question 1 · Physiological Adaptation
A nurse is teaching a client with chronic kidney disease about expected changes in laboratory values. Which statement by the client indicates correct understanding?
Show answer and rationale
Answer: B. In kidney failure, phosphorus increases because the kidneys can no longer excrete it, and calcium decreases due to impaired activation of vitamin D and binding with the excess phosphorus. Stating calcium will increase is incorrect, since it typically falls. Stating phosphorus will decrease is incorrect, since it rises. Saying both levels decrease is also incorrect, since phosphorus rises rather than falls.
Checked against: OpenStax Medical-Surgical Nursing, 10.3; OpenStax Pharmacology for Nurses, 5.2
Question 2 · Physiological Adaptation
A client receiving peritoneal dialysis reports abdominal discomfort, and the nurse notes the dialysate effluent is cloudy. What is the nurse's priority action?
Show answer and rationale
Answer: B. Cloudy effluent in a client on peritoneal dialysis is the earliest and most common sign of peritonitis and must be reported immediately so treatment can begin promptly. Simply documenting or continuing the exchange as usual delays diagnosis of a potentially serious infection. Warming the dialysate bag is a routine step and does not address the infection concern. Increasing dwell time does not treat the underlying infection risk and could delay needed care.
Checked against: OpenStax Clinical Nursing Skills, 19.4
Keep studying chronic kidney disease in NurseLingo Pro
Pro has 52 chronic kidney disease questions like these, with a rationale for every answer. Everything for chronic kidney disease in one place. A free account gets 5 free opens of any condition; Pro opens all 277.
Test yourself: free fluid and electrolyte practice questions with answers and rationales.
Frequently asked questions
What are the priority nursing diagnoses for chronic kidney disease?
Common nursing problems for chronic kidney disease include excess fluid volume; risk for electrolyte imbalance; risk for injury (drug toxicity, access problems); fatigue (anemia of ckd). Choose the ones your assessment supports and rank airway, breathing and circulation problems first.
What does the nurse do first for chronic kidney disease?
Avoid NSAIDs (they worsen kidney function and BP). Kidney-cleared drugs such as vancomycin, aminoglycosides and digoxin need lower doses. An artery joined to a vein for long-term hemodialysis. Feel a thrill, hear a bruit. No BP cuff, IV, blood draw or tight sleeve on that arm.
More renal & urinary
Related cheat sheets
Sources
- OpenStax Pharmacology for Nurses, 34.1
- merckmanuals.com
- OpenStax Medical-Surgical Nursing, 20.7
- OpenStax Clinical Nursing Skills, 19.4
- dailymed.nlm.nih.gov
- OpenStax Nutrition for Nurses, 2.3
- OpenStax Nutrition for Nurses, 16.2
For study only, not medical advice. Follow your program, your facility's policies and the provider's orders.