Check your patient’s blood glucose levels frequently. As your kidney function deteriorates, you may need less insulin or oral hypoglycemic medications. This is because one third of insulin is metabolized and excreted by your kidneys, and as your kidney function deteriorates, insulin is available in your bloodstream for a longer time. Monitor her for signs and symptoms of hypoglycemia, such as sweating, nausea, or vomiting. If you show signs of hypoglycemia, your doctor may reduce your insulin dose. Or, if your patient takes an oral antidiabetic medication, the doctor may prescribe glipizide, which has a shorter half-life than other medications and is metabolized by the liver to inactive metabolites for excretion by the kidneys.
If your patient has hypertension, evaluate him for factors, such as obesity or alcohol consumption, that may contribute to hypertension. Also, check your current drug use. Many medications can increase blood pressure, including corticosteroids, NSAIDs, nasal decongestants, appetite suppressants, and tricyclic antidepressants. During physical exams, monitor your patient’s blood pressure and compare the readings with their medical history.
Assess your patient for signs and symptoms of a UTI. Frequent infections can accelerate the progression of kidney disease. If diabetic neuropathy affects your bladder, you may not be able to empty it completely. This can result in urinary stasis, which can increase the risk of infection. To help prevent UTIs, encourage your patient to empty his bladder at least every 2 hours.
Determine if your patient is taking any nephrotoxic drugs. If so, inform your doctor. If you must undergo a procedure that requires the use of a radiographic dye, administer mannitol as prescribed to induce osmotic diuresis and minimize the nephrotoxic effects of the dye. Also, make sure your patient drinks all of the prescribed fluids after the procedure to dilute their urine, which can decrease the chance of nephrotoxicity from the dye.
If your patient is on hemodialysis or peritoneal dialysis, help her adhere to the prescribed diet and fluid restrictions. If he must eat a low-protein diet, advise him to minimize his intake of eggs, meat, and dairy products and to eat more starchy foods, fats, fruits, and vegetables. If he is having difficulty consuming enough calories to maintain his weight, suggest that he use a high-calorie nutritional supplement. However, keep in mind that peritoneal dialysis can increase the absorption of calories from the dialysate when it is in the peritoneum. If this causes your patient to gain excess weight, urge him to reduce his total calorie intake but not his protein intake. Monitor your patient’s fluid and electrolyte status by monitoring her weight every day.
During each dialysis treatment, evaluate your patient’s arteriovenous CAY or peritoneal access site for signs and symptoms of infection, such as redness, tenderness, or purulent drainage. Also, assess the circulation in the fistula or AV shunt for palpable thrill; listen for a noise, which should be present; and a feeling of warmth about the access site. Do not take a blood pressure reading on the arm that has the AV access site because it can occlude it.
Remember that end-stage renal disease treatment options can make difficult decisions for your patient and family. Provide your patient with the information they will need to make an informed decision. However, keep in mind that your ability to focus and think clearly can be affected by uremia. So, if appropriate, put off important decisions about treatment options until after a dialysis treatment.
Provide support and encourage your patient to talk about their feelings and concerns. People respond in different ways when they hear the diagnosis of kidney disease. Your patient may develop depression, anxiety, or stress. Therefore, include meetings with a mental health professional, such as a psychiatric clinical nurse specialist or psychologist, as part of your treatment plan. If appropriate, refer your patient and family to support groups.
If your patient is waiting for a kidney transplant, keep in mind that finding a suitable organ donor takes a long time and places a significant burden on the patient and their family. After your patient undergoes the transplant, your doctor will prescribe immunosuppressive medications. The patient will need to take them for the rest of her life and they can have serious adverse effects, such as increased risk of infection, weight gain, hallucinations, and increased kidney damage.
Your doctor will likely adjust your patient’s insulin dose after a kidney transplant due to improved kidney function. And your patient will take medications, such as glucocortiosteroids and cyclosporine, that will increase his blood glucose levels.