End-Stage Renal Disease
Palliative care ( ELEC 302)
Dr. Faiza Al Jarmeez
Ms. Gnana Pushpa Mangi
Introduction
An irreversible loss in renal function that leads to death is
known as end-stage renal disease (ESRD). To get patients with
ESRD to the terminal phase of end-of-life planning, palliative
care integrates education, symptom treatment, advanced care
planning, and psychological support. The majority of patients
will have dialysis therapy since it is a life-limiting condition.
Case Scenario..
● The patient was 43-year-old woman who had a history of systemic
hypertension, sleep apnea, and ESRD due to glomerulonephritis. At the time of
her presentation, she was undergoing hemodialysis having dyspnea with
exercise as she reported “ l feel difficult to breath during the exercise”and open
wound on her right forearm. Ten years prior, a left femoral AV fistula had been
implanted. A 15 cm JVP was found during a physical examination (abnormal),
and there was no peripheral edema. The lap results found elevated levels of
BUN (19.9 mmol/l) and creatinine (1290 umol/l). The ECG showed left
ventricular pressure (LVH) and a normal sinus rhythm beating at 75 beats per
minute.
v Physical Assessment
The patient has a hemodialysis due to ESRD that was caused by glomerulonephritis. She
also had a history with hypertension and sleep apnea. It have been found that she had an
open wound on her right forearm. Moreover, the patient had an abnormal jugular vein
pressure. Also, she took lab tests that indicated an elevated in BUN and creatinine.
Finally, she suffered from left ventricular hypertrophy.
v Psychological Assessment
The client has depression due to the huge time she’s spent on hemodialysis
procedure. She is sad most of the time and thinking negatively.
v Spiritual Assessment
She is a Muslim, her spiritual beliefs are helping her a lot to adapt with the therapy
and medical condition. She knows that god is always with her so whenever she
remembers that or whenever she prays or hear Quran, she calm and feel peaceful.
Assessment throughout
3 phases:
I. Pre-treatment
II. During-treatment
III. Post-treatment
Pre-treatment:
All dialysis patients should be assess:
Ø Weight: to determine amount of fluid to be removed during dialysis.
Ø Vital signs: to detect blood pressure for any sign of hypotension and hypertension because dialysis patients
commonly have elevated blood pressure, which might require treatment prior to surgery. And temperature for
sepsis, also respiration for fluid overload.
Ø Review medication:
• Hold drugs that pass through the dialysis membrane, such as piperacillin, folic acid, and other water-soluble
vitamins.
• Hold antihypertensive drugs, especially if systolic pressure is below 100, per physician order.
Ø Assess fistula or graft for infection.
Ø Asses circulation in distal portion of extremity.
Ø No IV or blood draws in that arm.
During-treatment:
Ø Assess vital signs for monitoring hypotension.
Ø Monitoring the patient behavior, appearance, response and symptoms.
Ø Monitor the machine for alarms.
Ø Less commonly: disequilibrium syndrome, hypersensitivity reaction, arrhythmia, cardiac
tamponade, seizures, air embolism.
Post-treatment:
Ø Assess and document vital-signs, and vascular access site condition.
Ø Check weight.
Ø Assess for dialysis disequilibrium syndrome with headache, nausea and vomiting, altered level of
consciousness and hypertension.
Ø Assess for bleeding at the access site. Use standard precautions at all times.
Ø If transfusion is given during dialysis monitor for possible transfusion reaction.
Ø Provide psychological support and listen actively.
The Problem of Palliative
Care on Caring for Patients
in ESRD
o There is a shortage of palliative care specialists available to nephrology practices, making it difficult
for end-stage renal disease patients to access them. Clinical trials are needed to determine the
best methods of providing palliative care in ESRD.
o End-stage renal disease patients experience high rates of fatigue, dyspnea, pain, anxiety, and
depression, which have a significant impact on their health-related quality of life ( HRQL)
o Palliative care services are expected to reduce the suffering of patients with ESRD by identifying and
treating symptoms and improving their health-related quality of life (HRQL).
o Poor provider understanding, difficulty treating symptoms, and providers' perceptions of symptom
control are barriers to the diagnosis and treatment of these symptoms.
Interdisciplinary Team
Approach
Interdisciplinary team approach and their role for patients with end-stage renal disease:
One method for enhancing CKD therapy is the interdisciplinary care clinic (IDC). Other physicians, nurses, dietitians,
pharmacists, and social workers are part of this team. They all collaborate to provide end-stage renal disease patients
with effective care. Each member of this team has specialized skill sets aimed at preventing CKD progression, managing
complications, and enhancing the transition to dialysis, transplant, or conservative therapy.
Nursing role for patients with end-stage renal disease:
q Support the patient and family.
q Promote physical and psychosocial well-being .
q Enhance the patient's overall quality of life.
q Teach about lifestyle changes.
Nursing Car Plan (NCP)
Nursing Diagnosis
§ Ineffective cardiac tissue perfusion related to kidney damage as evidenced by high value
of creatinine and BUN. Creatinine was 1290 umol/l BUN was 19.9 mmol/l.
Nursing intervention:
1- Administer medication as ordered.
2- Note mentation status and review lab results such as creatinine and BUN.
3-Measure urine output on a regular schedule and weight daily.
Nursing Diagnosis
§ Activity intolerance related to dyspnea as evidenced by patient verbalized " I feel difficult
to breath during the exercise"
Nursing interventions:
1- provide frequent position change.
2-Explain importance of rest in the treatment plan.
3-Monitor vital signs throughout activities.
Nursing Diagnosis
§ Risk for infection related to open wound in the right forearm.
Nursing interventions:
1-Administer antibiotics as ordered.
2-Clean the skin around the wound with water and soap.
3-change dressing frequently.
Ethical issues related to patients with end-stage renal
disease:
The most important issues are the futility of dialysis,
the relative risks and benefits of kidney replacement
therapy (dialysis or transplantation) for an individual,
and the influence of various stakeholders as decision-
makers, particularly when patients are unable to make
decisions for themselves.
v A non-pharmacological intervention for
ESRD
Diet Modification
§ The purpose of diet modification is to keep
the levels of electrolytes, minerals and
fluids in your body balanced.
Diet Modification
§ Most patients with ESRD are encouraged to eat
high-quality protein by renal dietitians because it
results in less waste that needs to be removed
during dialysis , and helps wounds heal faster.
§ Also, Low-sodium diet will help control blood
pressure and fluid intake.
§ Low-potassium diet.
Advantages Disadvantages
Eat low sodium, potassium, and phosphorus food. Eating high sodium foods will negatively affect your
This help to control blood pressure. Also, Taking a health by causing high blood pressure and
right fluid amount. discomfort during dialysis.
Encourage high protein intake in your diet( meat, fish, Hypervolemia will occur if you take too much fluid
poultry, or eggs) at every meal. This will help in without dietitian order
enhancing overall health
Questions..
What is the appropriate diet for a patient with end-stage renal disease?
A. Low protein, high fat, low sodium
B. Low protein, low fat, high sodium.
C. High protein, low potassium, low sodium.
Questions..
What is the nursing role for the patient during dialysis?
Thanks for listening..
