Chronic Kidney Disease Flashcards
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Defined as a progressive, irreversible kidney injury & function does NOT recover
Chronic Kidney Disease
When kidney fxn becomes too poor to sustain life, it becomes end stage renal/kidney disease (ESRD or ESKD)
Described in 5 stages (stage 1 is @ risk & has normal kidney function as opposed to stage 2 where actual CKD begins & GFR is worse)
GFR
Kidney Failure: 0-15
Kidney Disease: 15-60
Normal: 60-120
Stage ?
<15 mL/min
- End-stage kidney disease (ESKD)
Implement RRT or kidney transplantation
Stage 5
Stage ?
30-59 mL/min
- Moderate CKD
Implement strategies to slow disease progression
Stage 3
Stage ?
60-89 mL/min
- Mild CKD; reduced kidney function; lab values and other findings (e.g., structural change) point to kidney disease
Focus on reduction of risk factors
Stage 2
Stage ?
15-29 mL/min
- Severe CKD
Manage complications
Discuss patient preferences & values
Educate about options & prepare for RRT
Stage 4
Stage ?
> 90 mL/min
- @ risk; normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease
Screen for risk factors & manage care to reduce risk
> Uncontrolled HTN
> DM
> Chronic kidney or UTI
> Fhx of genetic kidney dz
> Exposure to nephrotoxic substances
Stage 1
CKD
- Up to 80% of GFR may be lost w/few changes in functioning of body
- Remaining nephrons hypertrophy to compensate
- End result is a systemic dz involving every organ
What are 2 of the leading causes of ESRD?
Diabetes (1/2 cases); HTN (1/3)
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Is azotemia w/clinical sx’s
- GFR </= to 10 mL/min
Uremia
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Is the buildup of nitrogen-based wastes in the blood
Azotemia
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Is a condition that incorporates all s/s seen in various systems throughout the body
Uremic syndrome
Urinary System
- Oliguria (occurs as CKD worsens)
? (urine output <40 mL over 24 hrs)
Anuria
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Results from inability of kidneys to concentrate urine
- Occurs most often at night
- SG fixed around 1.010
Polyuria
Metabolic Disturbances
- Waste product accumulation
As GFR ↓, BUN ↑ & serum creatinine lvls ↑
> BUN ↑
- Not only by kidney failure but by protein intake, fever, corticosteroids, & catabolism
- N/V, lethargy, fatigue, impaired thought processes, & headache may occur
- Altered carbohydrate metabolism
> Caused by impaired glucose use
> From cellular insensitivity to the normal action of insulin
- Defective carbohydrate metabolism
> Pts w/diabetes who become uremic may require less insulin than before onset of CKD
> Insulin dependent on kidneys for excretion
> HYPOglycemia becomes a concern
- Elevated triglycerides
> Hyperinsulinemia stimulates hepatic production of triglycerides
> Altered lipid metabolism
- ↓ lvls of enzyme lipoprotein lipase
- Important in breakdown of lipoproteins
! Most pts w/CKD die from cardiovascular disease
Acid-Base Imbalances
- Potassium
> Hyperkalemia - Most serious electrolyte disorder in kidney dz
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Fatal dysrhythmias = K levels 7-8 or >
! Tall, tented/peaked T waves
- Hyperkalemia d/t
> Dec excretion of K by kidneys
> Breakdown of cellular protein
> Bleeding
> Metabolic acidosis
Sodium
> May be normal or low
B/c of impaired excretion, sodium is retained = water is retained
Edema, HTN, CHF
! Sodium intake restricted indiv but ~2 g/day
- Calcium & phosphate alterations
- Mg alterations
> Absence of reflexes
> Dec mental status
> Cardiac dysrhythmias
> Hypotension
> Resp failure
- P is excreted by the kidneys; RF leads to retention
- Rx’s are given PO to combine w/P in GI tract for excretion through intestines
- aluminum hydroxide
- calcium carbonate (Tums)
- calcium acetate (Phos-Ex) [give w/food to promote P binding to rx]
- As P lvls inc, body tries to keep normal P:Ca ratio by taking Ca from bones
> bone demineralization & path fx’s - Hypocalcemia d/t inability of dz’d kidney to convert Vit D to active form
- Treatment: active forms of Vit D = calcitrol & DHT
Metabolic Acidosis
- From
> Inability of kidneys to excrete acid load (primary ammonia)
> Defective reabsorption/regeneration of bicarbonate
S&S
> Anorexia, weakness, lethargy, may become stuporus or comatose
> Kussmaul’s respirations, severe CNS depression causing shock, death
Treatment
- Promote output
- Maintain pulmonary function to allow some excretion (carbonic acid) via lungs (C&DB, avoid URI’s)
- Na bicarbonate given PO/IV to buffer acids
- Bistro (alkalinizing agent; chemicals in med convert to bicarbonate)
Hematologic System
- Anemia
> D/t ↓ production of erythropoietin (from ↓ in functioning of renal tubular cells)
- Bleeding tendencies
> Defect in platelet function (Factor III)
- Infection
> Changes in leukocyte function
> Altered immune response & function
> Diminished inflammatory response
Uremic pneumonia
- In uremia have thick, sticky secretions plus high susceptibility to infection; have them turn, C&DB
Cardiovascular System
- HTN (may be cause or result)
- HF & LVH (r/t inc work load)
- Peripheral edema
- Dysrhythmias
- Uremic pericarditis
> Inflamed pericardial sac r/t toxins/infection; leads to tamponade (dec PP & bradycardia) which requires removal of pericardial fluid w/needle, cath, drainage tube into pericardium
Respiratory System
- Kussmaul’s respirations (r/t acidosis; when too much is blown off, resp alkalosis can happen)
- Dyspnea (r/t HF)
- Pulmonary edema (r/t heart being overworked)
- Uremic pericarditis
- Pleural effusion
- Predisposition to resp infection
Gastrointestinal System
! Every part of GI is affected (d/t excessive urea)
> Mucosal alterations
> Stomatitis
> Uremic feitor (urinous odor of breath)
> GI bleeding
> Anorexia (lack of appetite), N/V
Neurological System
- ↑ nitrogenous waste products
- Electrolyte imbalance; metabolic acidosis
- Axonal atrophy
- Demyelination of nerve fibers
- RLS
- Muscle twitching
- Irritability
- Decreased ability to concentrate
- Peripheral neuropathy
- AMS
- Seizures
- Coma
- Dialysis encephalopathy
Musculoskeletal System
- CKD mineral & bone disorder
> Systemic disorder of mineral & bone metabolism
> Results in skeletal complications (osteomalacia, osteitis fibrosa) & extra-skeletal (vascular) calcifications
Integumentary System
- Pruritus
- Uremic frost (rare)
Reproductive System
- Infertility (experienced by both sexes)
- Dec libido
- Low sperm counts
- Sexual dysfunction
Psychological Changes
- Personality & behavioral changes
- Emotional lability (laughter/crying extremes @ inopportune times)
- Withdrawal
- Depression
CRF: Take Action - Drug Therapies
! Diuretic therapy cautiously (Lasix [ototoxic], Mannitol)
> Used to inc u/o
- Cardiac glycosides (digoxin)
> Improves ventricular contraction & inc SV & CO
- Bicarbonate for metabolic acidosis
- Cation exchange resins (Kayexalate for ↑ K)
- Abx if infection
- Vitamins, minerals (folic acid, FeSO4)
> Iron replacements taken w/food; dialysis removes essential V&M’s
- Synthetic erythropoietin (Epogen/Procrit; Aranesp)
> Prevent anemia by stimulating blood cell growth & maturation in bone marrow - Phosphate binders
> High phosphate causes hypocalcemia; (rx’s bind w/P in food & excrete) [separate Dig & P binders by 2 hrs]
Conservative Therapy
- Correction of ECF volume overload or deficit
- Nutritional therapy
Drug Therapy
- Hyperkalemia
- IV insulin
> IV glucose to manage hypoglycemia - IV 10% calcium gluconate
- Sodium polystyrene sulfate (Kayexalate) [! diarrhea]
> Cation-exchange resin
> Resin in bowel exchanges P for Na
- HTN
- Weight loss
- Lifestyle changes
- Diet recommendations
- Na & fluid restriction
- Antihypertensive rx’s (diabetic or not?)
> Diuretics
> Calcium channel blockers
> ACE inhibitors
> ARB agents
Target BP <130/80 mmHg pts w/CKD
125/75 for pts w/significant proteinuria
- Dyslipidemia
- Goal
> Lowering LDL below 100 mg/dL
> TG lvl <200 mg/dL
- Statins
> HMG-CoA reductase inhibitors (most effective for lowering LDL)
- Erythropoietin therapy
- Ca supplement; phos binders
- Sevelamer hydrochloride (Renagel)
> Lowers cholesterol & LDLs - Adjustment of drug dosages to degree of renal function
Drug Therapy - Complications
- Drug toxicity
- Digitalis
- Abx
- Pain medication (Demerol, NSAIDs)
Nutritional Therapy
- Protein restriction (benefits are being studied)
> Protein not usually restricted for pt undergoing dialysis
Calorie-protein malnutrition is a serious problem
Malnutrition b/c depression & complex diets that restrict protein, P, K, & Na
- Water restriction (intake depends on daily u/o)
> Generally 600mL (from insensible loss) plus an amt equal to the prev day’s u/o is allowed for a pt receiving hemodialysis
- Sodium restriction; 2-4g
> Salt substitutes shouldn’t be used b/c they contain KCl
- Potassium restriction
> 2-3g
> High-K foods should be avoided
- Phosphate restriction
> 1000 mg/day
> Foods high in phosphate (dairy products [meat, milk, ice cream, cheese, yogurt, pudding])
> Most foods high in phosphate are also high in protein
Nursing Diagnoses
Deficient Fluid Volume r/t fluid loss from a variety of causes
Excess Fluid Volume r/t inability of the kidneys to produce urine
Outcomes
> Deficient fluid volume will not occur
> Excess fluid volume will be managed
Imbalanced Nutrition: Less Than Body Requirements r/t anorexia & altered metabolic state
Outcome
> Maintain adequate nutrition aeb sufficient intake to prevent protein catabolism & maintain lab values within safe lvls
Risk for Impaired Skin Integrity r/t poor cellular nutrition & edema
Outcomes
> Intact skin
Interventions
> Frequent turning
> Meticulous skin care
> Special mattresses
Risk for Infection
Outcomes
> No infection
Interventions
> Meticulous resp tract, wound, central line, & urinary catheter care
Anxiety r/t unknown outcome of dz process
Outcome(s)
> Demonstrated ability to manage anxiety
Interventions
> Freq & careful explanations
> Provide emotional support
Diagnostic Studies
- HPE
- Dipstick eval
> A person w/persistent proteinuria (1+ protein on standard dipstick testing 2 or more times over a 3-month period) should have further assessment of risk factors & a diagnostic workup w/blood urine tests - Albumin-creatinine ratio (1st am void)
- GFR
- Renal ultrasound
- Renal scan
- CT scan
- Renal bx
Nursing Management: Planning
Overall goals
- Demonstrate knowledge & ability to comply w/therapeutic regimen
- Participate in decision making
- Demonstrate effective coping strategies
- Continue w/ADL’s within psychologic limitations
Nursing Management: Implementation/Taking Action
Health Promotion
* ID individuals @ risk for CKD
- H/o renal dz
- HTN
- DM [check for microalbuminuria]
- Repeated UTI
- Regular checkups & changes in urinary appearance, freq, & volume should be reported
Acute Intervention
- Daily weight & BP’s
- ID s/s of fluid overload & hyperkalemia
- Strict dietary adherence
- Medication education
- Motivate pts in management of their dz
Ambulatory & home care
- When conservative therapy is no longer effective, HD, PD, & transplantation are treatment options
- Pt/family need clear explanation of dialysis & transplantation
Nursing Management: Evaluation
- Maintenance of ideal body weight
- Acceptance of chronic dz
- No infection
- No edema
- Hct, Hgb, & serum albumin lvls in acceptable range
