Nursing Care of Diabetic Nephropathy

The nurse can take an active role in encouraging lifestyle changes, monitoring medication regimens, and advocating for appropriate screening tools and frequency for patients with diabetic nephropathy. The nurse and patient working together should aim for:

·      A regular exercise program.

·      Weight loss if indicated by BMI greater than 25.

·      Cessation of smoking

·      A low Sodium Diet

o   Advise patient to check food labels

·      Avoid NSAIDS & other nephrotoxins

·      Target Blood pressure less than 130/80

·      Target HgbA1C less than 7%

o   Check every 3 months

·      Reduce LDL cholesterol levels

·      Consider prescribing aspirin

·      Adjust medication dosing for level of eGFR

·      Discontinue metformin for eGFR ≤ 30. Use with caution or discontinue for eGFR < 60.

•            Monitor glucose closely and consider stopping long acting glyburide in patients with declining eGFR

The following is a great resource for nursing managements of diabetic nephropathy. This document provides tangible tasks that a RN can work towards together with her patient:

http://www.kidneyhealth.ca/wp/wp-content/uploads/pdfs/MRP-diabetic-guidelines.pdf

Diabetic Nephropathy Management Guidelines – to be used concomitantly with Kidney Disease Referral Pathway. Manitoba Renal Program.

http://www.kidneyhealth.ca/wp/wp-content/uploads/pdfs/MRP-diabetic-guidelines.pdf

Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. St. Louis, Missouri: Elsevier. 

Nursing Diagnoses

Today, I am going to summarize five different nursing diagnoses that might be used for patients with diabetic nephropathy. For the last nursing diagnosis, I will detail the plan, nursing interventions and desired outcomes.

1.    Adult failure to thrive related to undetected disease process

·      In patients with chronic disease physical function progressively deteriorates and the patient’s ability to cope and manage his or her care is diminished.

2.    Noncompliance related to restrictive lifestyle; changes in diet, medication, exercise

·      The patient’s behavior may fail to comply with the plan of care that was agreed upon in conjunction with the healthcare professional.

3.   Risk for Infection related to chronic disease.

·      Patients with chronic disease are at increased risk of being immunocompromised.

4.    Risk for electrolyte imbalance related to renal dysfunction

·      This diagnosis is relevant for any patient that has kidney dysfunction, a defining factor of diabetic nephropathy.  As a nurse, I want to monitor electrolyte & acid base balance, fluid balance and nutritional status. 

5.    Ineffective health maintenance related to complexity of therapeutic regimen

·      Patients with diabetic nephropathy are managing complex medical needs and medication regimens.

Diagnosis:	Ineffective health maintenance r/t complexity of therapeutic regimen
Plan:	The healthcare provider will work with the patient on an individual basis to identify obstacles to following a therapeutic regimen and together they will develop strategies to help the patient be successful.
Nursing Interventions:	·      Assess for family patterns, economic issues and cultural patterns that influence compliance with a given medical regimen ·      Help client to choose a healthy lifestyle and to have appropriate diagnostic screening tests. ·      Help the client determine how to manage complex medication schedules ·      Identify support groups related to the disease process
Desired Outcomes:	·      Discuss fear of or blocks to implementing health regimen ·      Follow mutually agreed on healthcare maintenance plan ·      Meet goals for healthcare maintenance

For further information on nursing management of diabetic nephropathy, please see the following article written by Ahmed Abdelhafiz, Meguid Nahas, Jose de Oliveira: Management of Diabetic Nephropathy in Older Patients: A Need for Flexible Guidelines


Ackley, B.J. & Ladwig, G.B. (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. St. Louis, Missouri: Elsevier. 

Treatment Goals

Remember – prevention is the best medicine. Today we’ll be tackling the treatment options for diabetic nephropathy. Really though, diabetic nephropathy cannot be treated; only the symptoms can be treated. So the best solution here is to prevent the need for treatment.

The basis for the prevention of diabetic nephropathy is the treatment of the risk factors. As you may recall from a previous entry, the risk factors are hypertension (high blood pressure), hyperglycemia (high blood sugar), smoking and dyslipidemia (high cholesterol levels). These same risk factors are also significant contributors to heart disease. Let’s discuss these one by one.

1.     Blood pressure control

·      It is important to maintain blood pressure below 140/80 mmHg.

·      40% of type 1 and 70% of type 2 diabetes patients have high blood pressure.

2.     Blood Glucose control

·      The goal here is to keep a1c levels less than 7%. A1c levels are an indicator of diabetes and blood sugar levels.

·      The goal for blood sugar will vary from person to person. This should be determined in conjunction with your provider.

3.     Smoking

·      It is important to discuss a smoking cessation program with your healthcare provider.

4.     High cholesterol

·      Modified through diet – reduce cholesterol intake. Your provider may have you on a medication that lowers LDL cholesterol, a statin.

Basically diabetic nephropathy is treated with medications that lower blood pressure and protect the kidneys. Medications that might be administered:

·      ACE inhibitors – these meds can lower the amount of protein lost in the urine and make it easier for blood to flow through our vessels

·      Angiotensin – receptor blockers – these meds make it easier for blood to flow through vessels and reduce blood pressure

·      Diuretics – these meds get rid of excess sodium and water and decrease our blood volume and pressure  

·      Calcium channel blockers – these meds lower blood pressure

To summarize, here are the takeaways for prevention and treatment of diabetic nephropathy:

1.     Maintain blood pressure below 140/80 mmHg.

2.     Strict blood glucose monitoring. Set goals with your doctor.

3.     Reduce or stop smoking

4.     Change diet to decrease cholesterol

Reinhartz, L., Crowell, K., Ludolph, K., Roberts, C., Wargo, R., & Campbell, M. (2013). American Diabetes Association Revises Standards of Care. LECOM School of Pharmacy. http://lecom.edu/cdir/news.php/american-diabetes-association-revises-standards-of-care/240/0/2794/23009

Gross, J.L., Azevedo, Silveiro, Canani, Caramori, Zelmanovitz. (January 2005). Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care, 28 (1) doi:10.2337/diacare.28.1.164