A patient with chronic renal failure on dialysis is being cared for by a nurse on the renal floor. A review of morning laboratory results reveals a serum calcium level of 8 mg/dL and hyperphosphatemia. The patient has complaints of pruritus. Which of the following are appropriate interventions? 

Administer aluminum hydroxide with meals, as ordered.
Provide frequent skin care with emollient skin cream.
Restrict intake of milk, soda, and beans.

Explanation

• Normal calcium levels are 9.0 to 10.5 mg/dL

• Normal phosphate levels are 3.0- 4.5 mg/dL

• An increased phosphate level (hyperphosphatemia) can cause pruritus (skin itching). Appropriate nursing interventions include frequent skin care with the application of emollient skin creams to reduce itching. 

• Meals with low protein and low phosphorus should be provided due to decreased kidney functioning. Beans, milk, chocolate, and soda contain phosphorus and should be avoided.

• Aluminum hydroxide (Amphojel) should be administered with meals to help bind phosphate in the gastrointestinal tract, contributing to lower phosphate levels.

• Excess phosphate leads to blood vessel disease and bone weakening. With hyperphosphatemia, phosphate binds with calcium in the blood, forming crystals that adhere to the endometrial lining and create deposits in the joints. Because calcium is bound to the phosphate in these clumps, the blood level of calcium goes down. This stimulates the parathyroid gland to produce more PTH, which releases calcium and phosphate from bones into the blood, worsening the problem.

• Phosphate binders are drugs that act to work by binding dietary phosphate in the gastrointestinal tract. These compounds that cannot be absorbed and are excreted in the feces. These drugs are most often used in patients with end-stage renal disease (ESRD) or are on dialysis. However, they may be used to manage stages 3 and 4 chronic kidney disease (CKD).  Phosphate binders must be taken within 30 minutes of meals to work. 

Never withhold the patient's ordered sodium bicarbonate without doctor's orders because it helps prevent metabolic acidosis in renal patients.

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