Monitor your patient's blood glucose levels frequently. As her kidney function deteriorates, she may need less insulin or oral hypoglycemic drugs. That's because one-third of insulin is metabolized and excreted by the kidneys, and as her kidney function deteriorates, insulin is available in the bloodstream for a longer time. Monitor her for signs and symptoms of hypoglycemia, such as diaphoresis, nausea, or vomiting. If she shows signs of hypoglycemia, the physician may reduce her insulin dosage. Or, if your patient takes an oral antidiabetic drug, the physician may prescribe glipizide, which has a shorter half-life than other drugs and is metabolized by the liver to inactive metabolites for excretion by the kidneys.

If your patient has hypertension, assess her for factors, such as obesity or alcohol consumption, that may contribute to hypertension. Also, review her current drug use. Many drugs can increase blood pressure, including corticosteroids, NSAIDs, nasal decongestants, appetite suppressants, and tricyclic antidepressants. During physical examinations, monitor your patient's blood pressure and compare the readings to those in her medical record.

Assess your patient for signs and symptoms of UTI. Frequent infections can speed the progression of nephropathy. If diabetic neuropathy affects her bladder, she may not be able to empty it completely. This may result in urinary stasis, which can increase the risk of infection. To help prevent UTIs, encourage your patient to empty her bladder at least every 2 hours.

Determine whether your patient is taking any nephrotoxic drugs. If she is, inform her physician. If she must undergo a procedure that requires the use of radiographic dye, administer mannitol as prescribed to induce osmotic diuresis and minimize the dye's nephrotoxic effects. Also, make sure your patient drinks all prescribed fluids after the procedure to dilute her urine, which may decrease the chance of nephrotoxicity from the dye.

If your patient is receiving hemodialysis or peritoneal dialysis, help her adhere to the pre­scribed diet and fluid restrictions. If she must follow a low-protein diet, advise her to minimize her intake of eggs, meat, and milk products and to eat more starchy food, fats, fruits, and vegetables. If she has difficulty consuming sufficient calories to maintain her weight, suggest that she use a high-calorie nutritional supplement. Keep in mind, however, that peritoneal dialysis can increase calorie absorption from the dialysate as it sits in the peritoneum. If this causes your patient to gain excess weight, urge her to reduce her total calorie intake but not her protein intake. Monitor your patient's fluid and electrolyte status by checking her weight every day.

During each dialysis treatment, assess your patient's arteriovenous CAY or peritoneal access site for signs and symptoms of infection, such as redness, tenderness, or purulent drainage. Also, assess circulation at the AV shunt or fistula by checking for a palpable thrill; auscultating for a bruit, which should be present; and feeling for warmth over the access site. Don't take a blood pressure reading in the arm that has the AV access site because you may occlude it.

Remember that treatment options for end­stage renal disease may involve difficult choices for your patient and her family. Provide your patient with the information she'll need to make an informed choice. Keep in mind, however, that her ability to concentrate and think clearly may 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 her feelings and concerns. People respond in various ways when they hear the diagnosis of kidney disease. Your patient may develop depression, anxiety, or stress. So 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 her 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 strain on the patient and her family. After yourpatient undergoes the transplant, her physician will prescribe immunosuppressant drugs. 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.

The physician will probably adjust your patient's insulin dosage after a kidney transplant because of improved kidney function. And your patient will be taking drugs, such as glucocortiosteroids and cyclosporine, that will increase her blood glucose levels.