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Chronic Kidney Disease

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Tamara Povey

on 25 March 2013

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Transcript of Chronic Kidney Disease

Diabetes is the leading cause of kidney disease worldwide.
occurs in 30–40% of diabetics after 25–40 years
preventable occurrence
prevalent in certain ethnic group

(Evans & Capell, 2000) Juanita
46 years old
Native American
Type 2 Diabetes Mellitus for 21 years
Developing Chronic Kidney Disease
Introduce client scenario
Explain diabetic nephropathy & it's clinical manifestations
Discuss diagnostic studies
Identify indications and process of dialysis
Provide related nursing diagnoses and interventions
Summary of presentation Juanita
Chronic Kidney Disease Client Scenario Pathophysiologic mechanisms are not completely understood

Primary event is glomurus basement membrane (GBM) damage
progressive thickening of the GBM due to formation of advanced glycosylation end products (AGEs)
passage of macromolecules through the GBM may activate inflammatory pathways
(Evans & Capell, 2000) (cross section) Objectives Pathophysiology Diabetic Nephropathy Juanita has been observed by her nephrologist for the past several years for manifestations of progressive chronic kidney disease. Assess kidney function
glomerular filtration rate
blood creatinine

(Evans & Capell, 2000) Diagnosis All of Juanita’s subjective and objective data indicate her need for dialysis. As her kidneys cannot filter her blood, the excess accumulation of fluid and waste products has reached toxic levels. Juanita’s symptoms and signs are getting progressively worse; starting her on hemodialysis is vital to her overall wellness, and life.

Eight weeks ago she had an arteriovenous fistula created in preparation for starting hemodialysis. Treatment to replace the work of her non-functioning kidneys Blood is removed from the body to remove waste and excess fluid. The clean blood is then returned into the body via an arteriovenous fistula.
Done by connecting an artery directly to a vein. Due to the increased blood flow, the vein grows larger and stronger, making repeated needle insertions for hemodialysis treatments easier. Two needles will then be inserted into the fistula to cycle the blood.

(National Kidney and Urologic Diseases Information Clearinghouse, 2011) Interventions
Monitor daily weights (Weight reflects changes in fluid volume)
Monitor Input and Output (Important with patients with fluid overload)
Sodium Restricted Diet (2.3g/day-favors renal excretion of excess fluid)
Implement fluid restriction (decreases intravascular volume and myocardial workload)
Teach dietary restrictions : electrolytes, protein, fluid (Shown to decrease weight gain between dialysis treatments)

(Ackley & Ladwig, 2011). pump the blood safely
clean the wastes from the blood
monitor blood pressure and the rate of fluid removal from the patient’s body

The hemodialysis machine will pump your blood through a canister called a ‘dialyzer’, which acts as a kidney by filtering the body’s waste products and fluids.

(National Kidney and Urologic Diseases Information Clearinghouse, 2011) Nursing Diagnosis

Monitor hemoglobin levels as an indicator of the client's oxygen-carrying capacity
Monitor response of hemoglobin to ESA's (erythropoiesis-stimulating agents)
Administer oral iron between meals, IV iron and ESA's to maintain erythropoiesis and stimulate production of RBC's
Administer folic acid after hemodialysis because it is removed with dialysis
Provide adequate periods of rest to enable client to recuperate from past activities and participate in future activities
Teach client to plan activities to avoid fatigue

Listen to the concerns of the client to convey a caring attitude and foster a relationship to determine how client is handling the situation
Allow client time to mourn loss of body function so that client can deal with feelings and identify ways of coping with losses more effectively
Include family members in discussions of client's concerns to enable them to assist the client and foster their support and understanding
(Lewis et al, 2010). Prophylactic infusion of normal saline. If the patient loses too much blood volume, they can suffer from extreme hypotension.

Hemodialysis patients must follow a strict diet and are only allowed approximately 250-500 mL of fluid per day, as too much fluid and waste problems can accumulate in the blood and cause serious wellness issues. Most renal failure patients undergo hemodialysis treatment 3-4 times a week. The session takes approximately 4-5 hours

(National Kidney and Urologic Diseases Information Clearinghouse, 2011) Dialysis Machine Hemodialysis Summary Clinical Manifestations Lab and Diagnostic Tests Collaborative Problems Hypertension: r/t sodium and H2O retention and alterations of renin-angiotensin system
Hyperkalemia: r/t decreased renal function, increased tissue catabolism, and shift of potassium into extracellular fluid secondary to metabolic acidosis
Peripheral neuropathy r/t effects of uremia on peripheral nerves
(Lewis et al, 2010). Activity intolerance r/t anemia and neuropathy AEB fatigue, shortness of breath, pallor, dyspnea, and tachycardia Anticipatory grieving r/t loss of kidney function AEB expression of feelings of sadness, anger, inadequacy, and hopelessness Ackley, B. J. & Ladwig, J. B. (2011). Nursing diagnosis handbook. An evidence based guide to planning care (9th ed.). St. Louis, MO: Mosby.

Casey, G. (2011). The sugar disease -- understanding type 2 diabetes mellitus. Kai Tiaki Nursing New Zealand, 17(2), 16-21.

Evans, T., & Capell, P. (2000). Diabetic nephropathy. Clinical Diabetes, 18(1). Retrieved on March 6, 2013 from http://journal.diabetes.org/clinicaldiabetes/v18n12000/Pg7.htm

Headley, C., & Wall, B. (2007). Flash pulmonary edema in patients with chronic kidney disease and end stage renal disease. Nephrology Nursing Journal, 34(1), 15.

Hill, J. (2009). Reducing the risk of complications associated with diabetes. Nursing Standard, 23(25), 49-55. [Table]

Lewis, S.M., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., & Bucher, L. (2010). Medical-surgical nursing in Canada: Assessment and management of clinical . problems. (2nd ed.). Toronto, ON: Elsevier Canada.

National Kidney and Urologic Diseases Information Clearinghouse. (2011). Treatment Methods for Kidney Failure: Hemodialysis - National Kidney and Urologic Diseases Information Clearinghouse. National Kidney and Urologic Diseases Information Clearinghouse. Retrieved March 10, 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/hemodialysis

Nazarko, L. (2011). Health risks in undiagnosed or poorly-controlled diabetes. British Journal Of Healthcare Assistants, 5(10), 479-482.

Nurko, S. (2006). Anemia, in chronic kidney disease: Causes, diagnosis, treatment. Cleveland Clinical Journal of Medicine, 73(3), 289-297

O’Callagan, C. A. (3rd Ed.). (2009). The renal system at a glance. West Sussex, UK: Blackwell Publishing.

Robins, V. (2010). Managing diabetic nephropathy. Practice Nursing, 21(2), 84.

Van Leeuwen, A.M., Poelhuis-Leth, D.J., & Bladh, M.L. (2011). Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications. (4th ed.). Philadelphia, PA: F.A. Davis. (Van Leeuwen, Poelhuis-Leth, and Bladh, 2011).

Figure 1: Arteriovenous fistula.
(National Kidney and Urologic Diseases Information Clearinghouse, 2011) References: Summary Over the past week, Juanita has experienced anorexia, nausea, vomiting, problems with concentration, and pruritis.
Juanita has also complained of swelling in her hands and feet, weight gain of 10lb (4.5kg) in the past 2 weeks, and dyspnea and weakness when walking. Anorexia, Nausea, and Vomiting: buildup of toxins in the body;
irritation of the GI tract

Concentration Problems: hypermagnesia; neurologic changes; axonal atrophy and demyelination of nerve fibers

Which comes first: the pruritis or the infection?
(Casey, 2011: infection causes pruritis; Lewis et al., 2010: scratching can cause infections).

Edema: retained Na

Weight Gain: direct result of edema

Dyspnea: fluid overload

Weakness: ineffective ATP conversion; inability to utilize glycogen reserves Table 2: Comparison of Juanita's lab values to expected lab values. Juanita’s Chest X-ray revealed pulmonary edema.

Pulmonary edema is increased fluid volume within the lungs and/or alveoli which results from fluid accumulating in the lungs faster than what it can be removed.

Peripheral edema can occur in chronic kidney disease due to increased proteinuria, or deterioration of kidney function
(Headley and Wall, 2007)

Juanita would experience edema due to her kidneys decreased ability to filter and excrete excess fluid within the body. Chest X-ray: Diabetes can lead to kidney disease.
Kidney function can decline due to glomerulus basement membrane damage.
Some common clinical manifestations are edema, weight gain, dyspnea, and weakness.
Juanita's objective data suggests the need for dialysis.
Hemodialysis replaces the work of Juanita's non-functioning kidneys.
Juanita's weight, intake and output, and diet should be assessed daily.
Juanita should receive regular lab work to ensure her body is not reaching toxic levels.
Juanita needs emotional support and comfort on her journey with chronic kidney disease. Table 1: Stages of diabetic nephropathy (Hill, 2009) *clinical manifestations vary
*changes are very gradual (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2010) (Robins, 2010) (Lewis et al., 2010) (Lewis et al., 2010) (Lewis et al., 2010) (Lewis et al., 2010) (Lewis et al., 2010; Robins, 2010). (Nazarko, 2011). Excess Fluid Volume r/t edema resulting from oncotic fluid shift caused by serum protein loss and renal retention of salt and water Post Test By: Bailey Clampitt, Chelsea Brown, Danny Christie, Kristen Cooke, Mieka Twerdoclib, and Tamara Povey
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