Care of the Patient with Kidney and Renal Disease

Kidney disease can be acute or chronic. Chronic kidney disease can lead to End-Stage Renal Disease (ESRD). The Certified Nursing Assistant (CNA) often cares for patients with diabetes and other conditions that can lead to kidney failure. Healthcare professionals can influence the health of patients at risk for kidney disease as well as patients who already have kidney disease or ESRD.

The renal system includes the kidneys, ureters, bladder, and urethra. It works to maintain the body’s fluid volume, control blood pressure, and excrete waste products from the blood(National Kidney Foundation, 2024a). The kidneys are bean-shaped and are located in the upper abdomen on either side of the spine. Figure 1 shows the location of the kidneys and bladder in the body.

Image 1

The kidney is responsible for regulating fluid volume throughout the body, blood pressure, and urine production. Waste products, such as urea and salts, as well as excess water, are removed and processed in the outer layer of the kidney to produce urine. Urine then flows down the ureters and into the bladder, where it is stored. Figure 2 shows the anatomy of the urinary system.

Image 2

When the bladder is full, nerve cells send a message to the brain to tell the bladder to contract to stimulate the need to urinate. Urine travels down the urethra and out of the body—figure 3 shows where the bladder lies in the pelvis.

Image 3

The average person urinates as much as 3 pints of urine daily. (Sorrentino & Remmert, 2021). Changes happen to the renal system as people age. These changes may increase or decrease how often the person urinates. The bladder decreases in size and can hold less urine. Bladder muscles can weaken, causing leakage or inadequate emptying. Prostate glands in men can enlarge, causing dribbling, obstruction, or retention. These are important considerations to understand when working with all patients.

In kidney disease, the kidneys are not able to remove waste products from the blood. When waste builds up in the bloodstream, most organs are affected. When the kidneys fail to maintain fluid balance and remove waste from the blood, the patient is in kidney failure. Kidney failure can be acute or chronic and can lead to End-Stage Renal Disease (ESRD), where the kidneys can no longer work. (National Kidney Foundation, 2024b).

Several common conditions can lead to permanent damage to the kidneys and cause kidney disease if not treated. Below is a list of these conditions with their definitions:

• Cystitis is inflammation of the bladder.
• Dysuria is pain or burning during urination.
• Hematuria is blood in the urine.
• Hydronephrosis is too much fluid in the kidneys.
• Nephritis is inflammation of the kidney.
• Oliguria is decreased urine production, which is shown as a small amount of urine.
• Renal calculi are kidney stones.
• Urinary incontinence is a loss of control over urination.

Each of these can happen alone or as part of the kidney disease process.

In kidney disease, the most common signs to look for are low urine output and low oral intake. Output may exceed intake. Symptoms of dehydration are dark-colored urine, a strong odor to the urine, weight loss, dry skin, dry mouth, drowsiness, or confusion. Edema can be present and is usually seen in the face, legs, ankles, or feet. The urine may also have substances, such as small particles or blood. The patient may complain of difficulty urinating or pain during urinating. They may also state that they have pain in their lower back. Frequent, small amounts of urine, incontinence, sudden weight loss or weight gain, respiratory stress, changes in mental status, and complaints of not being able to empty the bladder are often described. When the kidneys do not work correctly, waste material may be sweated out. This waste has a lot of irritants, so itching may be a problem (National Kidney Foundation, 2024b).

Renal dialysis is the removal of waste substances from the blood (Sorrentino & Remmert, 2021). The process is used with patients with ESRD. Hemodialysis is when a machine is used to filter the blood. Typically, patients on hemodialysis have a tube permanently placed in their arm for the procedure, called a fistula. The fistula can be in the upper or lower arm. Never measure blood pressure on the arm with a fistula. Although the nurse cares for a fistula, observations of redness or swelling at the fistula area should be reported. Figure 4 shows a fistula.

Image 4

Another process is peritoneal dialysis. It works by using the lining of the abdominal cavity to remove waste from the blood (Sorrentino & Remmert, 2021). This procedure can take a long time to administer and is done by a nurse. The patient may need vital signs taken every 15 minutes for the first two hours and then every two hours during the procedure. Any changes in blood pressure, complaints of abdominal pain, leaking around the site, or respiratory distress should be reported immediately. Figure 5 shows peritoneal dialysis.

Image 5

Be sure there is a clear understanding of all orders, including positioning, monitoring and limiting fluid intake, diet restriction, weight monitoring, vital signs schedule, and activity. The CNA may be asked to strain the urine for particles, help with urination, or collect urine samples.

Knowing how to limit fluid is also very important. Most adults take in 2 1/2 to 3 quarts of fluid a day (National Kidney Foundation, 2024b). This would be approximately 600 to 800 mL of fluid in an eight-hour shift. However, there is typically more fluid intake in the morning. Be sure to observe for edema and dehydration. Output of fluid consists of urine, sweat, lung exhalation, and bowel movements. So, include diarrhea, vomiting, or blood loss as output. A normal adult loses approximately 2 1/2 quarts a day of fluid (Sorrentino & Remmert, 2021).

There may be an order to monitor and record intake and output for the patient. Measuring is typically done in liters or milliliters. The CNA must know how many ounces are in milliliters. For example, eight ounces equals 240 mL, sixteen ounces equals 480 mL, and four ounces equals 120 mL. If the patient has an IV or gastric tube, it is recorded separately. If the patient is incontinent, weighing the briefs or sheets can give an estimated output. If the output of urine falls below 30 mL in an hour, it is important to notify the nurse immediately because it may be a sign of dehydration or renal failure(Sorrentino & Remmert, 2021).

Vital signs should be taken daily. Orthostatic blood pressure may be ordered. This means the blood pressure is taken in supine, sitting, and standing positions. The reason for using different positions is to see if the blood pressure drops when the position is changed. A big drop when a position is changed indicates that the circulatory system is not working correctly.

Daily weights are important to measure whether the patient is retaining fluid. For accuracy, weigh the patient at the same time every day using the same scales. If the weight increases or decreases by a certain amount, be sure to inform the nurse immediately. (National Kidney Foundation, 2024b). The amount may be different for different people. A weight change of ten pounds in one day is a common amount to report to the nurse.

If the patient is bedridden, prevention of pressure ulcers and range of motion may be ordered. Measures to prevent itching, such as bath oils, lotions, or creams, can be used on dry skin. Frequent oral hygiene should also be performed since dry mouth can happen. Providing frequent rest periods and emotional support is also important.

Additionally, foods should be low in protein, potassium, and sodium. (National Kidney Foundation, 2024b). Protein can build up and cause more waste in the bloodstream. Sources of protein are typically from animals and legumes. Examples are eggs, beans, fish, and chicken. Sodium can cause fluid buildup and should be monitored carefully.

Sources of sodium are salt, tenderizers, steak sauce, or barbecue sauce. Other sources are crackers, nuts, bacon, and most processed foods or lunchmeat. Instead, the patient can use fresh onion, garlic, lemon juice, and salt-free or low-sodium salts. Foods high in potassium can affect the heart and muscles. These foods include squash, artichoke, bananas, cantaloupe, oranges, black beans, carrots, and chocolate (Sorrentino & Remmert, 2021).

Report to the nurse any observations of confusion, change in mental status, blood pressure change, weight change, or any changes in intake or output.Report any changes to the patient's current health status, including bleeding, bruising, or problems with urination.Report any new information given to you or that you observe, such as blood in the urine, difficulty urinating, or painful urination. Describe any edema or skin changes as well. Any changes in the patient’s medical condition should also be reported. This may include sudden incontinence, mood changes, injury, or respiratory distress. Observation is important when administering care to the patient. Also, observe for any safety issues such as dizziness when ambulating or pain in the abdomen or lower back.

Mrs. G is a new patient in your care. She is living at home with her daughter. When you arrive for your first visit, you notice that Mrs. G seems confused. Her daughter has not been getting daily weights. She tells you that it is tough for her to get her mother to the scale every day. Upon further observation, you notice that Mrs. G has very dry skin. The daughter also reports that she has been incontinent at times and has been drinking a lot of water since yesterday. What do you do?

Record the baseline vital signs and weight. Check the order and treatment plan for Mrs. G. Is she on a fluid restriction? A food restriction? Should intake and output be monitored? Is she on daily weights? Report your observations to the nurse. Support and educate the daughter about how to care for her mother.

When working with Mrs. G, watch for skin dryness, itching, edema, and pressure ulcers. Observe her behavior and speech. Does she seem confused? Is she restless or calm? Be accurate with daily weights and vital signs. Report changes to the nurse. Your observations and documentation are very important for this patient. The nurse will use your information to make decisions about Mrs. G’s care plan. The nurse may need to call the provider to discuss placement in another care setting.

Mr. C is a patient you are caring for today. He is diagnosed with ESRD and has a fistula in his right arm. You notice that there are new orders to monitor and record intake and output as well as get daily weights and blood pressure. His diet is low in sodium, potassium, and protein. His breakfast was bacon, banana, three eggs, and crackers. He drinks an 8oz cup of coffee and 4oz of water. He has a urinal at his bedside, and you note that it contains about 200ml of urine from last night. What do you do?

The breakfast of bacon, banana, three eggs, and crackers is not correct for Mr. C. Report the diet problem to the nurse to get it corrected. Document his intake and output as well as his daily weight. Be sure to document the time you took his weight so others know to get his weight at the same time. Document output as urine/200mL. Document his intake of fluid at breakfast as 360mL. Next, you will get his blood pressure and document it along with the time it was taken. You will not have to clean the fistula, but make sure you do not take the blood pressure in the right arm where the fistula is located.

When caring for a patient with kidney disease, several factors need to be considered. The age and condition of the patient need to be observed, and any comorbid diagnosis noted. Understanding and following orders given to each patient is important in their care. Each patient may have a different care plan according to their needs and disease process. To provide appropriate care, the CNA should understand the disease process and what symptoms to observe in each patient. Observing the patient for signs and symptoms of distress or discomfort and offering allowed interventions will help the patient live a productive and happier life.

• National Kidney Foundation. (2024). How your Kidneys Work. National Kidney Foundation.
• National Kidney Foundation. (2024). Kidney Failure. Visit Source.
• Sorrentino, S., & Remmert, L. (2021). Mosby’s Textbook for Nursing Assistants (10th ed.). Elsevier.