Download Chronic Kidney Disease

Chronic Kidney Disease
Chronic Kidney Disease (CKD)
• Involves progressive, irreversible destruction
of the nephrons in both kidneys
• Can lose up to 80% of kidney function
without overt body changes
• Creatinine clearance: an indicator of GFR
(amount of creatinine voided out in 24
hours)
• Creatinine clearance falls below
1 mL/sec
Chronic Kidney Disease (CKD)
• Stages defined based on level of kidney function
 Diminished renal reserve: normal BUN,
creatinine, and creatinine clearance
 Renal insufficiency: GFR 25% of normal; BUN
and creatinine elevated
 End-stage renal disease (ESRD)
• Last stage
• GFR <1 mL/sec
Chronic Kidney Disease (CKD)
• End result is a systemic disease
involving every organ
• Each year 70,000 people die from
causes related to renal failure
Chronic Kidney Disease (CKD)
Leading causes of ESRD
Diabetes
Hypertension
Clinical Manifestations
Retained substances
Urea
Creatinine
Phenols
Hormones
Electrolytes
Water
Manifestations of Chronic Uremia
Fig. 45-3
Clinical Manifestations
Uremia
Incorporates all the signs and
symptoms seen in the various
systems throughout the body
Clinical Manifestations
Urinary System
Polyuria
Results from inability of the kidneys to
concentrate urine
Oliguria and anuria develop
Casts, protein, WBCs, RBCs in urine
Occurs most often at night
Clinical Manifestations
Urinary System
Oliguria
Occurs as CKD worsens
Anuria
<40 ml per 24 hours
Clinical Manifestations
Urinary System
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Proteinuria
Casts
Pyuria
Hematuria
Clinical Manifestations
Metabolic Disturbances
Waste product accumulation
 BUN; creatinine
Nausea
Vomiting
Lethargy
Fatigue
Clinical Manifestations
Metabolic Disturbances
• Altered carbohydrate metabolism
Results from cellular insensitivity to
the normal action of insulin
• Elevated triglycerides
Clinical Manifestations
Electrolyte and Acid-Base
Imbalances
Potassium
Hyperkalemia
• Most serious electrolyte disorder
• Fatal arrhythmias
• Results from  excretion by kidneys
Clinical Manifestations
Electrolyte and Acid-Base
Imbalances
Sodium
May be normal or low
Edema
Hypertension
CHF
Clinical Manifestations
Electrolyte and Acid-Base
Imbalances
• Calcium and phosphate
• Magnesium
• Metabolic acidosis
Results from inability of kidneys to
excrete acid load (primarily ammonia)
Clinical Manifestations
Hematologic System
• Anemia
 Due to  production of erythropoietin
• Bleeding tendencies
 Defect in platelet function
• Infection
 Changes in leukocyte function
 Altered immune response and function
 Diminished inflammatory response
Clinical Manifestations
Hematologic System
Increased incidence of cancer
Lung
Breast
Uterus
Colon
Prostate
Skin
Clinical Manifestations
Cardiovascular System
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Hypertension
CHF
Pulmonary edema
Peripheral edema
Arrhythmias
Atherosclerosis
Uremic pericarditis
Clinical Manifestations
Respiratory System
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Kussmaul respiration
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Dyspnea
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Pulmonary edema
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Uremic pleuritis
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Pleural effusion
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Predisposition to respiratory infections
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Depressed cough reflex
Clinical Manifestations
Gastrointestinal System
• Mucosal ulcerations: Anorexia, Nausea,
Vomiting
• Ulceration and bleeding
• Uremic fetor (urinous odor of the breath)
Clinical Manifestations
Neurologic System
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Altered mental ability
Seizures
Coma
Dialysis encephalopathy
Peripheral neuropathy
Lethargy
Apathy
Fatigue
Irritability
Clinical Manifestations
Musculoskeletal System
Renal osteodystrophy
Syndrome of skeletal changes
Result of alterations in calcium and
phosphate metabolism
Clinical Manifestations
Musculoskeletal System
Renal osteodystrophy
Two types associated with ESRD:
• Osteomalacia
• Osteitis fibrosa
Clinical Manifestations
Integumentary System
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Yellow-gray discoloration of the skin
Pruritus
Uremic frost
Dry, pale skin
Dry, brittle hair
Thin nails
Petechiae
Clinical Manifestations
Reproductive System
• Infertility
Experienced by both sexes
• Decreased libido
• Low sperm counts
• Sexual dysfunction
Clinical Manifestations
Endocrine System
• Manifestations of hypothyroidism
• Thyroid function may yield low to lownormal levels of T3 and T4 levels
Clinical Manifestations
Psychologic Changes
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Personality and behavioral changes
Emotional lability
Withdrawal
Depression
Life style changes
Collaborative Care
Conservative Therapy
Goals:
Preserve existing renal function
Treat clinical manifestations
Prevent complications
Provide for the patient’s comfort
Collaborative Care
Drug Therapy
Hyperkalemia
IV glucose and insulin
IV 10% calcium gluconate
Sodium polystyrene sulfonate
(Kayexalate)
Collaborative Care
Drug Therapy
Hypertension
Sodium and fluid restriction
Antihypertensive drugs
Collaborative Care
Drug Therapy
Renal osteodystrophy
Phosphate intake restricted to <1000
mg/day
Calcium-based phosphate binders
Collaborative Care
Drug Therapy
Anemia
Erythropoietin
• Epogen
• Procrit
Collaborative Care
Drug Therapy
Complications of drug therapy
Drug toxicity
• Digitalis
• Antibiotics
• Pain medication
Collaborative Care
Nutritional Therapy
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Protein restriction
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Fluid restriction
 Intake depends on daily output
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Sodium and potassium restriction
 Diets vary from 2 to 4 g depending on degree of edema and HTN
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Phosphate restriction
 1000 mg/day
 Foods high in phosphate
• Dairy products
Nursing Management
Nursing Assessment
• Complete history of any existing renal
disease
• Long-term health problems
• Dietary habits
Nursing Management
Nursing Diagnoses
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Excess fluid volume
Impaired skin integrity
Risk for injury
Activity intolerance
Imbalanced nutrition: less than body
requirements
• Anticipatory grieving
• Risk for infection
Nursing Management
Planning
Overall goals:
Demonstrate knowledge and ability to
comply with therapeutic regimen
Participate in decision making
Demonstrate effective coping strategies
Continue with activities of daily living
within psychologic limitations
Nursing Management
Nursing Implementation
Health Promotion
Identify individuals at risk for CKD
• History of renal disease
• Hypertension
• Diabetes mellitus
• Repeated urinary tract infection
Nursing Management
Nursing Implementation
Acute Intervention
Daily weight
Daily BPs
Identify signs and symptoms of fluid
overload
Strict dietary adherence
Nursing Management
Nursing Implementation
Ambulatory and Home Care
When conservative therapy is no
longer effective, HD, PD, and
transplantation are treatment options
Nursing Management
Evaluation
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Maintenance of ideal body weight
Acceptance of chronic disease
No infections
No edema
No itching or skin dryness
Slowing of bone disease
Hematocrit and hemoglobin levels in
acceptable range