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Chronic Kidney Disease

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Noelle Sedgwick

on 6 February 2012

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Transcript of Chronic Kidney Disease

Juanita Chronic Kidney Disease Involves progressive, irreversible destruction of the nephrons in both kidneys. The stages are based on kidney function. Stage 1: There is Kidney Damage with normal or increased GFR. Treatment of co-mirbid conditions, controlling BP, diagnosing and treament of underlying cause, control blood glucose and proteinuria Stage 2: Kidney damage with mild decrease GFR . Estimation of progression. Treatments and procedures will be similar as stage 1. Stages of Chronic Kidney Failure Stage 3: Moderate decreased GFR. Further measures are taken to prevent and treat complications. Stage 4: Severed decreased GFR. Patient will start to prepare for renal replacement therapy, which can be dialysis or transplantation. Stage 5: Kidney Failure. Start renal replacement therapy. The leading Causes of end-stage Renal disease in Canada are diebetes mellitus and hypertension Uremia: is a syndrom that incorporates all the signs and symptoms seen in the various systems througout the body in chronic kidney disease. Dialysis Most patients are treated with dialysis because:
1) There is a lack of donated organs
2) Some patients are mentally and physically unsuitable for a transplant
3) Some patients do not want a transplant
4) Some patients are not eligible because of their medical condition(s)

Clinical Manifestations:

Atherosclerotic Heart Disease
Pericardial Effusion

Uremic Factor
GI Bleeding
Peptic Ulcer
Thyroid Abnormalities
Sexual Dysfunction
Carbohydrate Intolerance
Nutritional Deficiencies
Uremic Lung
Pulmonary Edema
Uremic pleuritis
Depressed Cough Reflex
Sleep Disturbances
Muscular Irratibility
Pigmentation Changes
Uremic Frost
Dry, Scaly Skin Juanita, a 46 year old Native American school teacher, has been treated for type 2 diabetes mellitus since the age of 25. She has been observed by her nephrologist for the past several years for manifestations of progressive chronic kidney disease. Eight weeks ago, she had an ateriovenous fistula created in preperation for starting hemodialysis. Over the past week she has experienced anorexia, nausea, vomiting, problems with concentration, and puritis. Nursing Management Further Details:
Psychological Changes Personality changes such as depression and withdrawl are commonly observed.
Fatigue and lethargy can contribute to the feeling of "being ill".
A decrease in the ability to concentrate, individuals may appear dull and disinterested in their environment. Metabolic Changes As the BUN increases, common signs and symptoms such as headaches, lethargy, nausea, vomiting and impaired thought processes appear.
This is due because of the accumulated wastes in the CNS and GI tissues. Urinary System Initially, the patient will experience polyuria. This is because the kidneys are unable to concentrate the urine. Nocturia can also be present.
As the disease progresses, oliguria eventually develops. Generally, the patient will experience an output of <40mL/ 24 hours. Assessments A thorough family history should be obtained. Information such as previous family history of chronic kidney disease should be evaluated.
Important information obtained from a personal health history includes: hypertension, diabetes, frequent urinary tract infections (UTI's) and lupus erythematosus.
Gathering a past and present medication history is essential. Many drugs can be potentially or are nephrotoxic.
Early signs and symptoms of chronic kidney disease includes puritis, fatigue, lethargy, hypertension and changes in urine characteristics.
Chronic kidney disease affects all aspects of one's life, including work and social life, relationships, and self image. Support systems should also be assessed. Planning Health Promotion Having regular check up's that include serum creatinine levels, BUN testing, and a urinalysis.
The patient must be advise to report any changes in urine characteristics. Characteristics inlude colour and odour.
Good glycemic control is essential for Juanita in delaying and slowing the progression of chronic kidney disease.
Acute interventions Teaching includes:
Explaination of fluid and dietary restrictions (protein, sodium and phosphates).
Encouraging discussion in any concerns in dietary changes.
Explaination of early signs and symptoms of electrolye imbalance.
Education in alternative ways of managing thirst. For example, sucking on ice cubes.
Explain the drug regimen, the rationale for these drugs, and how to take the medications properly.
Explain the importance of reporting the following signs and symptoms: a weight gain >2kg, increased BP, shortness of breath, edema, increasing in fatigue, weakness, confusion or lethargy.

Regular meetings with a dietician should be established to discuss alterations in diet and adresse any questions or concerns In addition with drug therapy education, writting down all the drugs and their times to take them can enhance drug regimen compliance and avoid any confusion. Home care The length of time for conservative therapy lasts vary with each individual. Variables such as co-morbid conditions and how quickly the disease progresses will determine when conservative therapy is no longer effective, and other therapies and treatments such as hemodialysis and transplantation should be considered.
Decisions regarding future treatments should be made during the conservative therapy stage, before complications such as bleeding, a decline in mental health status, and fluid overload occur. Arteriovenous Fistula What is it? It is done by connecting an artery directly to a vein. It is commonly done in the forearm.
Requires advanced planning, an account that a fistula takes awhile after surgery to develop.
It allows the person to be connected to a dialysis machine.
A fistula provides a long-lasting site through which blood can be removed and returned during hemodialysis.
Procedure It is done under local anesthesia, by a general surgeon.
Performed in a hospital or day surgery center or an outpatient basis.
A small incision in the forearm, blood vessels will be appropriately blocked to stop blood flow for the procedure and incisions will be made to join them, silk sutures will be used to close incised areas as needed after the vein and artery have been joined.
Care Vascular access problems can occur and lead to treatment failure.
The AV fistula requires regular care to make dialysis easier and to help avoid clots, infection, and other complications. Dialysis is performed as critical life support when someone suffers acute or chronic kidney failure.
There are two types of dialysis: hemodialysis and peritoneal dialysis.
Hemodialysis: circulates blood through a dialysis machine that contains a filter membrane.
Peritoneal: blood is filtered within the body by a filter that has been placed in the abdomen. Risks The most frequent complications in hemodialysis relate to the vascular access site where needles are inserted.
Other complications that can occur during and after hemodialysis include things such as: low blood pressure, nausea, muscle cramps, headache, clotting, bloating or fluid overload. Medications Medications used for hemodialysis and kidney disease:
Vitamins and minerals
Phosphate binders
Hemodialysis What is it? It is a mechanical way to cleanse the blood and balance body fluids and chemicals when the kidneys are not able to perform these essential functions.
Dialysis is performed as critical life support when someone suffers acute or chronic kidney failure.
Dialysis may also be used in irreversible or chronic kidney shutdown when transplantation is the medical goal and the patient is waiting for donated kidneys. But!.... Some critically ill patients, with life-threatening illnesses, such as cancer or severe heart disease, and are not candidates for transplantation, dialysis may be the only option for treating what is called end-stage renal disease (ESRD).
There are two types of dialysis: hemodialysis and peritoneal dialysis In hemodialysis, the blood circulates through a machine outside the body and is filtered as it circulates. The blood is slowly pumped out of the body and into the machine for filtering. After being filtered, the blood is returned to the body through the same vascular access. About one cup of blood is outside the body at any given moment during the continuous circulation process. Peritoneal dialysis, blood is filtered within the body by a filter that has been placed within the abdomen and exits via a port. Hemodialysis is usually done three times a week, taking between three and five hours each time. Kidney dialysis diet:

Limiting fluids
Eating a low-protein diet (this may be recommended)
Restricting salt, potassium, phosphorous, and other electrolytes
Getting enough calories if you are losing weight
Labs Measures rate at which kidneys are clearing creatinine from the blood.
Reflects glomerular filtration rate.
Based on estimate of body surface area.
Determines extent of nephron damage in renal disease.
Minimum 50% of functioning nephrons must be lost before values are decreased.
Evaluates glomerular function and can monitor effectiveness of treatment
Therefore, decreased in conditions of impaired kidney function, reduced renal blood flow, or decreased glomerular filtration rate.
Juanita's Value: 8.2 ml/min.
Normal range: 87-107 ml/min.
Creatinine Clearance: Serum Creatinine: Ideal substance to test renal clearance because a fairly constant quantity is produced in the body.
Is elevated in renal disease, acute and chronic renal failure, CHF, and dehydration.
Usually, BUN is ordered with creatinine for comparison. BUN:creatinine ratio can indicate disease. The ratio should be between 10:1 and 20:1.
Juanita's value: 12.8 ml/dL or 1132 micromol/L.
Normal range: 0.5-1.1 mg/dL or 44-97 micromol/L. BUN: Reflects balance between production and excretion of urea.
Is elevated in chronic glomerulonephritis, decreased renal perfusion, diabetes, ketoacidosis, pyelonephritis, and use of nephrotoxic agents.
May be used to evaluate hemodialysis therapy.
Juanita's value: 125 mg/dL or 45 mml/L (critically high).
Normal value: 10-20 mg/dL or 3.6-7.1 mmol/L.
Critical value adverse effects: acidemia, agitation, confusion, fatigue, nausea, vomiting, coma.

Potassium: Elevated in chronic interstitial nephritis and dialysis, insulin deficiency, ketoacidosis, and ARF.
Symptoms of high potassium: irritability, diarrhea, cramps, oliguria, difficulty speaking, cardiac arrhythmias
Juanita's value: 6 mEq/L or 6 mmol/L.
Normal range: 3.5-5.0 mEq/L or 3.5-5.0 mmol/L.
Hematocrit: Lowered in: anemia, blood loss, chronic disease, hemolytic disorders, hemorrhage, fluid retention, nutritional deficit, splenomegaly.
Symptoms of anemia: anxiety, dyspnea, edema, hypertension, hypotension, hypoxia, jugular venous distention, fatigue, pallor, rales, restless, weakness.
Juanita's value: 20%.
Normal range: 37-47%. Obectives:
1. To understand what the lab values indicate about renal disease.
2. To understand nursing strategies and the nursing role in the care of a patient diagnosed with chronic kidney disease.
3. Be able to identify and understand the pathophysiology and impact type 2 diabetes mellitus has on chronic kidney disease.
4. Be able to differentiate between the two types of dialysis, and to understand the general process of dialysis. References:

Pathophysiology Diabetic nephropathy is a result from the change in how the blood flows through the vessels of the glomerular capsule. This is the part of the kidney that filters the blood.
There are many changes in the vessels that cause diabetic nephropathy. There can be decreased flow of oxygenated blood, loss of vasodilator tone, and impairment of vascular wall integrity. All of these factors can cause irreversible damage to glomerular capillaries, which can lead to kidney failure.

High glucose levels in the blood can have irreversible effects on the glomerulus and the capillaries. Studies show that glucose reacts with proteins in the blood, forming permanent protein complexes.
As high levels of glucose remain in the blood, the body continues to form these protein complexes. What happens is that the endothelium of the cell walls slowly thickens, loses permeability to nitric oxide and become subject to increased platelet and white blood cell adhesion.
As this layer of adhesive material thickens, the pores become stiff and are left open. These pores, which once were able to control what was filtered and what wasn’t, now are stiffly open and leakage of serum proteins from the blood start to happen (Stam et al., as quoted by Sego, 2007). So this just turns into a vicious cycle of high blood glucose levels to the forming of these protein chains, which then are deposited in the blood cells, which cause vascular injury and dysfunction, which leads to poor kidney filtration and excretion, which then leads to the body keeping a lot of toxic products.
These symptoms are increases with the diabetic co-morbidities of hypertension and hyperlipidemia.
Nitric oxide is a vasodilator. It is a natural occurring substance in the body that helps regulate blood pressure. Nursing Care Plan for Juanita Diagnosis: Outcomes: Interventions Rationale Evaluation Anticipatory grieving r/t loss of kidney function and change in health status. Acceptance of additional chronic disease. Listen to the concerns of Juanita. Conveying a caring attitude and foster a relationship to determine how Juanita is handling the situation. Allow Juanita time to mourn loss of body function. Allows Juanita to deal with feelings and identify ways of coping with losses more effectively. Juanita will display appropriate and effective grieving. Juanita will be able to voice different coping mechanisms. Peripheral neuropathy r/t effects of uremia on peripheral nerves and type 2 diabetes mellitus. Juanita will monitor peripheral neruropathies. Teach Juanita to examine areas of decreased sensation. To observe for any injuries, sores or any altered state of the skin. Prevent trauma and excess stimulation to extremities. Areas, such as the feet, are extremely prone to skin breakdown with diminished sensation. Juanita will report any deviations from acceptable parameters.
Assess Juanita for decreased sensation in feet, numbness and burning of feet, muscle cramps, restlessness of legs, loss of muscle strength, and footdrop. Identifies the presence of peripheral neuropathies. Explain to Juanita the reason for neuropathy assessment. Increases understanding and decreases anxiety. Juanita will promptly report any changes to peripheral sensation in part of managing two chronic illnesses. Holecheck, M.J.(2006). Nursing Management Acute Renal Failure and Chronic Kidney Disease. In S. Goldsworthy & M. A. Barry.(Eds.), Medical-Surgical Nursing in Canada. (pp.1217-1253). Toronto,ON: Mosby.
Sego, S. (2007). Pathophysiology of diabetic nephropathy. Nephrology Nursing Journal, 34(6),
631-633. Retrieved from EBSCOhost on March 1, 2011.
Shaw, S.M. (2007). Responding appropriately to patients with chronic illness. Nursing Standard
21(24): 35-39.
Van Leeuwen, A.M., & Poelhuis-Leth, D.J. (2009). Davis’s comprehensive handbook of
laboratory and diagnostic tests with nursing implications (3rd ed.). Philadelphia, PA: F.A.Davis Company. (cc) image by rocketboom on Flickr (cc) image by quoimedia on Flickr
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