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NURSING PERFORMANCE IN PATIENTS WITH CHRONIC RENAL
FAILURE AND DIABETES MELLITUS
Jocinete F. Nascimento1
Abstract: The goal was to identify the importance of nursing care to the patient with renal
impairment and diabetes mellitus. As for the methodology, we opted for a bibliographic review
by searching in Latin American and Caribbean Health Sciences (Lilacs), Scientic Eletronic
Library Online (Scielo) and Nursing Database (BDEF). and Discussion: It was observed that
diabetes is a chronic disease that is characterized by changes in glucose metabolism, whether by
poor insulin production-type 1, or by resistance to its action, as it has happened in type 2. That
the performance of nursing in the care of patients with diabetes mellitus and chronic renal failure
is critical, where the professional employs a systematization of nursing care ensuring the patient
a whole and individualized care. It is concluded that the nursing team should act in the promotion
of health and/or prevention of diseases such as diabetes and their comorbidities. Also, it was
observed in this review that the actions of permanent education and orientation of patients for
self-care should be intensely promoted by nurses, among this population who, because they have
diabetes mellitus, are pre-discredted the risk factors for development of chronic renal failure.
Keywords: diabetes mellitus. Renal failure. Nursing performance.
1 Bachelor of Nursing from the University Center of Maranhão - Ceuma in 2019. Graduated in
Audit in Nursing, Urgency and Emergency, Nephrology, and Capture, Donation and Transplantation
of Bodies and Tissues, Oncology and Hematology, and Public Health. Acting as an educational advisor
and higher education teacher at the Nursing Course Guidance Aerea, at Estácio de Sá University in
Santa Catarina.
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INTRODUCTION
Diabetes mellitus (DM), characterized as a chronic and degenerative metabolic disorder and
evidenced by chronic hyperglycemia, is pointed out as a public health problem and of high prevalence
in a global dimension (WHO, 2019). In Brazil, the situation is no dierent, and this disease increasingly
aects a relevant portion of the population. According to the Ministry of Health (BRASIL, 2013),
diabetes causes changes in glucose metabolism, either due to decient production of insulin – type I,
or resistance to its action, as happens in type II.
DM is associated with many comorbidities and a high risk of developing acute and chronic
complications, including renal failure (AMORIM et al., 2019). As fundamental organs for the body,
the kidneys are responsible for maintaining and sustaining the homeostasis of the human body.
With the progressive cooling of the glomerular ltration rate (GFR) observed in chronic
kidney disease (CKD) “and the consequent loss of regulatory, excretory and endocrine functions, all
other organs of the human body are compromised” (SILVA et al., 2015, p. 149).
Renal failure (RI) is characterized by the gradual and irreversible impairment of a large
number of functional nephrons. High sugar levels overload the kidneys, causing it to lter a larger
volume of blood, impairing its functioning and causing kidney diseases, such as diabetic nephropathy
(BOUÇA et al., 2021).
The contribution of nursing to renal patients and patients with diabetes mellitus is fundamental.
It is this professional who is responsible for guiding diabetic patients and their caregivers and family
members regarding self-care for their health, including monitoring blood glucose levels, eating habits,
physical activity, and blood pressure (OLIVEIRA et al., 2019).
This research is justied by the importance of discussing the role of nurses in the care of
patients with diabetes mellitus with chronic renal failure. It is also justied by demonstrating actions
to prevent diabetic nephropathy in patients with diabetes mellitus.
Thus, the research question is: How should nurses act in the care and guidance of renal
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patients with diabetes mellitus?
To support the work and answer the research problem, the general objective of this study is:
To identify the importance of nursing care for patients with renal failure and diabetes mellitus.
DEVELOPMENT
Methodology
As for the methodology, this research is a bibliographic review of the literature. This
methodology was chosen because, according to Gil (2010), it provides the synthesis of knowledge
and the inclusion of the applicability of the results of expressive studies in professional and academic
practice. This is an exploratory research, applied to a literature review.
The approach is qualitative, focusing subjectively when analyzing the selected articles and
discussing the results. This type of approach demands a broad study of the object to be researched,
considering the context and characteristics of what one wants to analyze (GIL, 2010).
The search was carried out through the following databases: 1) LILACS; 2) SCIELO; 3)
Pubmed; 4) Nursing Database (BDENF). The inclusion criteria were: complete articles, with abstract,
results and conclusion, research with humans. Exclusion criteria: Incomplete articles; with more than
15 years of publication; studies that did not contemplate the theme and objectives of the research.
The main authors researched to discuss the results are: Azevedo et al. (2022); Bouça et al.
(2021); Carneiro, Santos and Silva (2021); Amorim et al. (2019). Castro (2019); Grossi and Pascali
(2009); Mascarenhas et al. (2011); Oliveira et al. (2019), Silva et al. (2015); Vieira et al. (2017).
Scientic articles, theses, dissertations and monographs, as well as books published and
indexed, in the last 15 years were selected. The languages selected for the search were Portuguese
and English, using the following descriptors: diabetes mellitus, diabetes and renal system, diabetic
nephropathy.
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Results and Discussions
To know and understand the disease diabetes, it is necessary to conceptualize it and describe
its characteristics. Diabetes mellitus (DM), according to the Brazilian Diabetes Society (SBD, 2019),
Brazil (2013) and WHO (2019), is a metabolic disease characterized mainly by peripheral insulin
resistance, being the main triggering factor for obesity.
According to SBD (2019, p. 19) “diabetes mellitus (DM) consists of a metabolic disorder
characterized by persistent hyperglycemia, resulting from a deciency in insulin production or its
action, or in both mechanisms”.
Several authors such as Almeida, Souza and Souza (2013), Mascarenhas et al. (2011), Grossi
and Pascali (2009), describe DM as a chronic disease dened by a high glycemic level. As can be read,
for example, in the denition of diabetes mellitus:
Diabetes Mellitus is a disease of multifactorial etiology that can be explained
by hyperglycemia resulting from the absence or inability of insulin to perform
its functions (ALMEIDA; SOUZA; SOUZA, 2013, p. 02).
According to Almeida et al. (2013) and Carneiro, Santos, and Silva (2021), manifestations
such as relative chronic hyperglycemia, with alterations in the metabolism of carbohydrates, lipids,
and proteins, as well as macrovascular, microvascular, and neuropathic complications are the result of
defects in insulin production. These complications are typical of patients with type 1 and 2 diabetes
mellitus.
According to the World Health Organization (WHO, 2019), diabetes mellitus (DM) is mainly
characterized by the presence of chronic hyperglycemia. This is often accompanied by dyslipidemia,
abdominal obesity, hypertension and endothelial dysfunction and kidney diseases.
According to Viana and Rodriguez (2011, p. 291), diabetes “is an endocrine disorder that
consists of a defect in the secretion and/or action of insulin produced by the pancreas, manifested by
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the inadequate use of glucose by the tissues that causes hyperglycemia in the body”.
The combination of these factors can increase the risk of developing other comorbidities, such
as cardiovascular diseases and kidney failure. Still, it is worth remembering that diabetes mellitus can
aect people at any age, but it is usually diagnosed after the age of forty (WHO, 2019).
The SBD (2019) classies type 1 diabetes mellitus as an autoimmune disease due to the
destruction of β cells and insulin deciency of an idiopathic nature. Explaining the particularities of
type 1 DM, the Brazilian Diabetes Society explains that: “[...] type 1 diabetes mellitus (DM1) is an
autoimmune, polygenic disease resulting from the destruction of pancreatic β cells, causing complete
deciency in insulin production” (SBD, 2019 p, 19). “In symptomatic patients, polyuria, polyphagia,
polydipsia, weight loss and visual alterations are common” (VIANA; RODRIGUEZ, 2011, p. 291).
Type 2 diabetes mellitus (DM2) is a complex metabolic disease. It is characterized by a
decrease in pancreatic insulin secretion and a decrease in insulin action or insulin resistance in
peripheral organs, resulting in hyperglycemia and glycotoxicity (BRASIL, 2013; SBD, 2019).
According to Carlesso, Gonçalves and Moreschi Júnior, (2017) and Carneiro, Santos and Silva
(2021), type 2 diabetes mellitus (DM2), also known as adult diabetes, is classied as multifactorial,
as it encompasses other elements, involving genetic components, such as family history of the disease
and environmental components, such as obesity and sedentary lifestyle. According to these authors,
DM2 causes comorbidities such as dysfunctions and failure of several organs, especially eyes, kidneys,
nerves, brain, heart, and blood vessels, for example.
According to Viana and Rodriguez (2011) and Brasil (2013), the most common symptoms
of DM2 are excessive thirst, frequent urination, and unexplained weight loss. In addition to these,
other symptoms may occur, such as excessive hunger, fatigue and wounds that do not heal, where the
diabetic foot can be listed. In many cases, the symptoms manifest gradually and slowly, causing the
patient not to realize that he is aected by the disease, where he starts to develop other diseases as a
result of DM, such as chronic renal failure (SILVA et al. 2015).
In addition to type 1 and 2 diabetes, there is also gestational diabetes. In gestational DM,
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it leads to dysfunction of β cells because of hyperglycemic hormones and placental enzymes that
degrade insulin, causing resistance to this hormone (SBD, 2019).
According to Nascimento et al. (2020) and Silva et al. (2015), the growth in the incidence
of chronic diseases associated with diabetes mellitus is a reality known by public managers and
has provoked many discussions among health professionals, and is currently treated as an important
public health problem. Regarding renal disease, according to Silva et al. (2015, p. 149):
[...] consists of kidney damage and progressive and irreversible loss of kidney
function Chronic kidney disease (CKD) is the presence of kidney damage or
reduced level of kidney function for 3 months or more, regardless of the diag-
nosis. In its most advanced stage, it is called end-stage chronic kidney disease
(ESRD), or end-stage kidney disease (ETDR), when there is progressive and
irreversible loss of kidney function.
Kidney diseases in diabetics, understood as diabetic nephropathy (DN) are conceptualized,
according to Bouças et al. (2021), Azevedo et al. (2022) and Mascarenhas et al. (2011) as a syndrome
characterized by specic glomerular lesions added to the gradual increase in urinary albumin. In
addition, it is associated with the presence of arterial hypertension and cooling of the glomerular
ltration rate. The syndrome, according to Azevedo et al. (2022, p. 3615) “it is one of the main
complications that aects patients with type 2 Diabetes Mellitus”.
According to Bouças et al. (2021, p. 81): “Although DN is a pathological process exclusive
to DM, 25 to 50% of patients do not have increased renal albumin excretion, thus contradicting the
classic denition of kidney disease attributed to this pathology”.
According to Viana and Rodriguez (2011), diabetic nephropathy is a “chronic alteration
characterized by albuminuria, arterial hypertension and progressive decline in renal function”. The
authors also state that this disease “aects about 10 to 40% of patients, and is currently the pathology
most associated with new cases of patients with kidney problems who undergo hemodialysis, that is,
in patients with end-stage renal failure” (VIANA; RODRIGUEZ, 2011, p. 292).
Corroborating the above-mentioned acrimony, Azevedo et al. (2022, p. 3616) explain that
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diabetic nephropathy “is the leading cause of chronic kidney disease (CKD) and end-stage renal
disease (ESRD) worldwide”. Thus, it is understood that chronic renal failure in diabetic patients may
be directly linked to diabetes mellitus.
Because it is progressive and irreversible, Amorim et al. (2019, p. 577) explain that:
[...] The pathogenesis of DKD is associated with functional and structural
changes of dierent types of renal cells as a response to metabolic stress indu-
ced by excessive inux of cellular glucose, through the activation of specic
metabolic pathways interconnected with redox imbalance and inammation.
According to Carneiro, Santos and Silva (2021, p. 12773) “the kidneys are vital organs in the
control of the homeostasis of the human body. Therefore, a kidney complication compromises other
important organs”. When kidney complications are associated with diabetes mellitus, the damage to
the body can be more serious. “Epidemiological data show that, in about 63% of CKD cases, SAH and
DM are present” (CARNEIRO; SAINTS; SILVA, 2021, p. 12773).
Regarding the most serious phases of kidney failure, two stand out:
• Clinical or severe renal failure: the patient already suers from renal dysfunction, presents
marked signs and symptoms of uremia, among which anemia, arterial hypertension,
edema, weakness, malaise and digestive symptoms are the earliest and most common. It
corresponds to the glomerular ltration rate range between 15 and 29 mL/min/1.73 m2.
(SILVA et al., 2015, p. 150).
• Chronic renal failure: corresponds to the range of renal function in which the kidneys
have lost control of the internal environment, which has become suciently altered to be
compatible with life. At this stage, the patient is intensely symptomatic. Its therapeutic
options are methods of articial blood clearance (peritoneal dialysis or hemodialysis)
or kidney transplantation. It comprises a glomerular ltration rate of less than 15 mL/
min/1.73 m2. (SILVA et al., 2015, p. 150).
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With these data and descriptions, both of diabetes mellitus and of chronic renal failure, he
begins to understand the role of nursing in the care of patients with these types of diseases.
According to Oliveira et al. (2019), Silva et al. (2015) and Veira et al. (2017), the purpose of
diabetes treatment is to maintain good control of metabolism and keep blood glucose levels at adequate
values, to promote health and improve the patient’s quality of life. For these authors, adherence to
treatment for this disease has been a challenge for health professionals, and in the case of this study,
it refers to the nurse who participates in the education of patients with diabetes mellitus and chronic
renal failure. Also because it is important that the education of the patient, family and other health
agents takes place, respectively, and it is up to the nurse to provide this guidance.
At the time of dietary guidance, the Brazilian Diabetes Society (SBD, 2019) informs that
the consumption of adequate amounts of carbohydrates, proteins, fats, vitamins and minerals should
be emphasized that it is essential for the proper functioning of the body. It is worth remembering
that the consumption of proteins such as meat, eggs and cheeses do not contain sugar, but in excess
they also alter glycemic values. Fiber intake is essential, as they are components of foods that do not
have calories, but fulll gastrointestinal functions and act in the treatment and prevention of diabetes
(SBD, 2019).
Nascimento et al. (2020) understand that another guideline that should be given to patients
with DM is to put a physical activity program into their routine, as this results in numerous varieties
of physiological and metabolic adaptations. Physical activity is highly recommended by the Brazilian
Diabetes Society (SBD, 2019) where they state in their guidelines that patients who maintain an active
lifestyle develop glucose tolerance less frequently than in people with a sedentary lifestyle. Hence the
importance of this guidance for all patients with diabetes mellitus.
It is important to remember that the role of the nurse is beyond health guidelines. The
professional needs to know the patient well to be successful in the orientation. On this, it can be read
that:
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It is the nurse’s responsibility to provide guidance on lifestyle changes and
assessment of the potential for self-care, in addition to addressing other risk
factors, such as socioeconomic status and level of education [...] (CARLES-
SO; GATES; MORESCHI JÚNIOR, 2017, p. 117).
Regarding the competencies and functions of nursing with renal patients and patients with
diabetes mellitus, Silva et al. (2015, p. 151), state that:
Nursing care has seven dierent functions: to help; educate; diagnose, follow
up and monitor the patient; solve rapidly evolving situations; administer and
monitor therapeutic protocols; ensure and monitor the quality of health care
and ensure and monitor skills in the organization of health services.
In order to act eectively by nurses to avoid the worsening of renal diseases in patients with
diabetes mellitus, Nascimento et al. (2020, p. 5) observe that “planned actions must be based on health
education, providing guidance on the risks of serious evolutions”. These actions developed by nurses
should start right away in Primary Health Care, with the objective of providing guidance on how to
prevent and reduce the progression of chronic renal failure, “considering that interventions carried
out correctly and in a timely manner contribute to improving care and consequently improving the
clinical prognosis of patients” (NASCIMENTO et al., 2020, p. 5).
According to Silva et al. (2015, p. 150) “The nurse’s work is related to health promotion
according to the needs of the population, since it is necessary to detect risk groups and guide and point
out ways for them to face and adapt to the new lifestyle and their health condition”. Also according
to these authors:
[...] it is necessary to develop health promotion activities in an educational
way, to reduce the incidence of CKD and improve the quality of life of the po-
pulation. Nurses play an important role as caregivers and educators, responsi-
ble for systematizing and encouraging self-care (SILVA et al., 2015, p. 150).
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All the authors cited in this study understand that the care and performance of nurses are
directly linked to the education that the professional should pass on to the patient. As can be read in
the words of Oliveira et al. (2019): “[...] nurses are essential professionals in health education and can
contribute to the prevention of CKD, using their knowledge in the care of diabetic patients [...]”. It is
understood, therefore, that health care, care and guidance are also educational practices.
For these actions to eectively happen, it is necessary to have good communication between
all team members, which can range from the exchange of reports and opinions, which can be written
manually or lled out electronically, in ready-made spreadsheets or using other ways of typing
documents (BRASIL, 2013). The Ministry of Health also says that even direct communication with
telephone calls to discuss the case can be carried out.
CONCLUSION
The research showed that nurses are professionals who play a relevant role in raising awareness
and educating patients with chronic renal failure and diabetes mellitus. The nursing team must act in
the promotion of health and/or prevention of diseases such as diabetes and its comorbidities.
In addition, it was observed in this review that continuing education actions and orientation
of patients towards self-care should be intensely promoted by nurses. These actions should occur
among the population that, because they have diabetes mellitus, are predisposed to risk factors for the
development of chronic renal failure.
It is also concluded that educational prevention actions end up reecting on the improvement
of the quality of life of patients with diabetes mellitus and chronic kidney disease. Finally, it is
understood that, within Primary Health Care, places of rst contact with the patient and the nursing
professional, training and improvement courses are necessary, which are oered by government
ocials or health managers aimed at the technical and scientic improvement of nursing professionals.
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