Monitor your patient’s blood glucose levels frequently. As your kidney function deteriorates, you may need less insulin or oral hypoglycemic agents. This is because one third of the insulin is metabolized and excreted by the kidneys, and as kidney function deteriorates, insulin is available in the bloodstream for longer. Monitor her for signs and symptoms of hypoglycemia, such as sweating, nausea, or vomiting. If you show signs of hypoglycemia, your doctor may lower your insulin dose. Or, if your patient is taking an oral antidiabetic drug, the doctor may prescribe glipizide, which has a shorter half-life than other drugs and is metabolized in the liver to inactive metabolites for renal excretion.
If your patient has hypertension, evaluate her for factors, such as obesity or alcohol use, that may contribute to hypertension. Also, review 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 those in their medical records.
Evaluate your patient for signs and symptoms of a UTI. Frequent infections can accelerate the progression of nephropathy. If diabetic neuropathy affects your bladder, you may not be able to empty it completely. This can lead to urinary stasis, which can increase the risk of infection. To help prevent UTIs, encourage your patient to empty their bladder at least every 2 hours.
Determine if your patient is taking any nephrotoxic medications. If so, tell your doctor. If you must undergo a procedure that requires the use of 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 prescribed fluids after the procedure to dilute the urine, which may decrease the chance of nephrotoxicity from the dye.
If your patient is receiving hemodialysis or peritoneal dialysis, help her adhere to prescribed diet and fluid restrictions. If she must follow a low-protein diet, advise her to minimize her intake of eggs, meat, and dairy products and to eat more starchy, fatty foods, fruits, and vegetables. If she is having trouble consuming enough calories to maintain her weight, suggest that she use a high-calorie nutritional supplement. Be aware, however, that peritoneal dialysis can increase the absorption of calories from the dialysate as it sits in the peritoneum. If this causes your patient to gain excessive weight, ask him to reduce his total caloric intake but not his protein intake. Monitor your patient’s fluid and electrolyte status by checking their 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 pus-like drainage. Also, assess circulation in the AV shunt or fistula by checking for a palpable thrill; auscultating for a noise, which must be present; and sensation of heat over the access site. Do not take a blood pressure reading on the arm with the AV access site because it may occlude the AV access site.
Remember that treatment options for end-stage renal disease can involve difficult choices 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. Therefore, if appropriate, delay 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 various 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 is time consuming and puts a lot of pressure on the patient and her family. After your patient undergoes the transplant, his doctor will prescribe immunosuppressive drugs. The patient will have to take them for the rest of her life and they can have serious adverse effects, such as an 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 be taking medications, such as glucocortiosteroids and cyclosporine, that will increase their blood glucose levels.
