Week 13: Chp 62: Chronic Kidney Disease Flashcards
Most common causes of Chronic Kidney Disease?
diabetes and hypertension
Risk factors for CKD
- diabetes and hypertension
- hyperlipidemia, smoking, use of recreational drugs, NSAIDs, obesity, glomerulonephritis, disorders such as PKD, lupus, and atherosclerosis
What id CKD
progressive, irreversible loss of kidney function
- slow increases in BUN and creatinine
- longer, more insidious onset than AKI
- usually caused by long-term disease or medical comorbidities such as hypertension, diabetes, lupus, PKD, and pyelonephritis
What is the difference between AKI and CKD?
AKI is usually caused by an event that leads to kidney injury (dehydration, hypovolemia, surgery, infection, medications, injury or trauma); usually reversible
-CDK is usually caused by a long-term disease that leads to decreased renal function over time (uncontrolled diabetes, uncontrolled hypertension, malnutrition, polycystic kidney disease (PKD)); irreversible
The risk factor or factors most often associated with CKD include which of the following? A. Hypertension B. Diabetes mellitus C. Malnutrition D. Peripheral vascular disease E. Smoking
A. Hypertension
B. Diabetes Mellitus
Clinical features
- anemia
- calcium and vitamin D deficiencies
- Oliguria
- Azotemia
- hypertension
- decreased GFR
- fluid retention
- uremia
Alterations in sodium and fluid balance result in what?
hypertension, heart failure, and pulmonary edema
Altered potassium excretion can result in?
lethal arrhythmias
Impaired metabolic waste elimination results in?
uremia and GI symptoms such as nausea, vomiting, and anorexia
- neurological symptoms such as headache, lethargy, fatigue, confusion
- without treatment, seizures and coma
Altered calcium and phosphorus levels result in?
bone breakdown and osteodystrophies or defective bone development
Decreased acid clearance and bicarbonate production result in?
metabolic acidosis
What endocrine and reproductive dysfunctions occur in CKD?
infertility, amenorrhea, hyperparathyroidism, and thyroid abnormalities
Decreased production of erythropoietin results in?
chronic anemia
Diagnosis of CKD
based on consistently elevated serum creatinine levels and decreased creatinine clearance, both of which are impacted by the GFR
- persistent presence of protein/albumin in the urine
- Urinalysis can detect RBCs, WBCs, protein, casts, and glucose
- Imaging studies such as renal ultrasound, CT scans, and renal biopsy can provide status on kidney function and structure
Chronic kidney disease can be staged based on what?
GFR and protein in the urine
-6 stages delineated by GFR and 3 stages delineated by albuminuria or the albumin-to-creatinine ratio (ACR)
The nurse understands that CKD is characterized by which of the following?
A. a rapid decrease in urine output with a CKD-elevated BUN
B. progressive, irreversible destruction to the kidneys
C. abrupt increasing creatinine clearance with a decrease in urinary output
D. confusion and somnolence leading to coma and death
B. progressive, irreversible destruction to the kidneys
Treatment for CKD
- measures to remove the waste products should be immediately implemented; managed through renal replacement therapies (RRTs)
- support the remaining function of the kidneys, treat the patients clinical manifestations, and prevent any complications
- medication and nutrition management
Preventative and maintenance therapies focus on maintaining and controlling what?
- hyperkalemia
- hypertension
- anemia
- dyslipidemia
- renal osteodystrophies which involves managing phosphate levels, hyperparathyroidism, and hypocalcemia
Hyperkalemia: how to treat it
can be cleared via dialysis or by managing diet; restricting foods high in potassium
-when acutely elevated, medication therapy may be necessary to reduce the serum potassium level
For acute hyperkalemia, what are medication therpaies available?
- IV calcium gluconate to stabilize the cardiac membrane
- Intravenous glucose and insulin, Albuterol, or bicarbonate may be administered to stimulate the movement of potassium into the cell
- Intravenous furosemide is administered to improve clearance through the kidneys
- sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin, used to lower elevated serum potassium levels; it binds with potassium in the GI tract to allow excretion in the stool, diarrhea is expected with this treatment because it contains sorbitol, a sugar alcohol that exerts an osmotic laxative action that causes evacuation of the potassium from the bowel
How to manage hypertension
- target BP 130/80
- weight loss for obese
- lifestyle changes such as exercise, avoidance of alcohol, smoking cessation, and diet modification and prescribed medication compliance
- Medication therapy: diuretics, beta-adrenergic blockers, calcium channel blockers, ACE inhibitors, Angiotensin-receptor blocker agents
Management of Anemia
Hemoglobin should be 11 to 12 g/dL and Hematocrit should be 33 to 36% for patients with CKD
- erythropoietin can be produced and administered intravenously or subcutaneously
- oral iron supplements if ferritin concentrations fall below 100 ng/mL; constipation is a side effect of oral iron supplements, requiring stool softeners; parenteral oral injection may be used if oral supplements do not increase levels
- Supplemental oral folic acid is also given because folic acid is removed with dialysis (folic acid enhances formation of RBCs)
- -blood transfusions are an option but should be used only if the patient is actively bleeding and is symptomatic with dyspnea, excess fatigue, tachycardia, palpitations, or chest pains
Undesirable effects of blood transfusions
the suppression of erythropoiesis, which is stimulated in the face of hypoxia
-because each unit of blood contains about 250 mg of iron, there is a possibility of iron overload
How to manage dyslipidemia
this is because of lipoprotein metabolism alterations in patient with CKD
-goal of lowering low-density lipoproteins (LDLs) below 100 mg/dL and maintaining a triglyceride level below 200 mg/dL
>statins are most effective for lowering LDL cholesterol levels
>fibrates (fibric acid derivatives) are most effective for lowering triglyceride levels and increase HDLs
Treatment options for Osteodystrophies
include managing phosphate and calcium levels
>phosphate management= limiting dietary phosphorus, administering phosphate binders, and controlling hyperparathyroidism; phosphorus intake is restricted to less than 1000 mg/day
Treatment for Osteodystrophies: Phosphate binders
are used to bind phosphate in the GI tract, which allows it to be excreted in the stool
- must be administered with each meal to be effective because most phosphorus is absorbed within 1 hour after eating
- constipation is a complaint with phosphate binders, so stool softeners may be added
- some contain aluminum; excessive aluminum have been associated with dementia and bone disease so use in precaution
- magnesium-containing antacids that can be used as phosphate binders should be avoided because magnesium is solely excreted via the kidneys
Managing hyperparathyroidism
occurs because of excessive parathyroid stimulus due to decreased calcium levels in CKD
-calcimimetic agents are used to control hyperparathyroidism by increasing the sensitivity of the calcium receptors in the parathyroid glands
-as a result, the parathyroid glands detect calcium at lower serum levels and decrease PTH secretion
>PTH hormone and alkaline phosphate levels should be monitored
Managing Hypocalcemia
this is present because of the inability of the GI tract to absorb calcium in absence of activated vitamin D
-management includes vitamin D and calcium supplementation
>regular monitoring is essential because hypercalcemia may occur if hyperparathyroidism and the release of calcium from bone are not controlled
-hypercalcemia can cause increased cardiac irritability and mortality in end-stage renal disease
Managing Medications
CKD can cause delayed and decreased elimination of medications, leading to potentially toxic accumulation of medications in the circulatory system
- Demerol (pain med to be avoided)
- NSAIDs avoided
- Aminoglycosides, penicillin, and tetracyclines can be nephrotoxic, thus requiring adjustments to the frequency or dose
- medication administration times may need to be changed on patients on dialysis; water-soluble medications are filtered out in dialysis, resulting in decreased therapeutic benefit; many meds prescribed in the morning may need to be given after dialysis, anti-hypertensives and cardiac medications may need to be given after dialysis to avoid the hypotensive events that may occur because of fluid shifts during dialysis
Nutrition
- dietician should be consulted
- diet is individualized
- dietary proteins are restricted in patients with CKD because urea nitrogen and creatinine are end products of protein metabolism; if starting dialysis an increase in protein may be allowed
- diet low in protein, and low in phosphorus that is supplemented with amino acids can slow the progression of renal failure
- sufficient calories
- water restrictions
- sodium and potassium restrictions
- phosphate limitations
Nutrition: Sufficient calories
sufficient calories from carbohydrates and fats are needed to minimize the catabolism of body protein and to maintain body weight
- required intake of carbs and fats should be 30 to 35 kcal/kg of body weight/day
- with malnutrition or inadequate caloric intake, prepared products are available that are high in calories and low in protein, sodium and potassium; Nepro, Microlipid, Sumacal, Suplena, and Polycose
- amino acids may also be supplemented
Nutrition: Water restrictions
based on urine output and insensible water loss
- careful monitoring of all liquid intake is important, including gelatin and ice cream that are liquid at room temperature
- the fluid replacement must be distributed throughout the day to lessen the patients feelings of thirst
- adjustments must be made to fluid intake to maintain weight gains of no more than 1 to 3 kg between dialysis treatment
Nutrition: Sodium and potassium restriction
- sodium may be restricted to 2 and 4 g depending on degree of edema and hypertension; avoid high-sodium foods such as cured meats, pickled foods, canned soups and stews, frankfurters, cold cuts, soy sauce, and salad dressings; salt substitutes should be avoided because of high potassium chloride content
- potassium restriction of 2 to 4 g; high-potassium foods to avoid are oranges, bananas, melons, tomatoes, prunes, raisins, deep green and yellow vegetables, beans and legumes
Nutrition: Phosphate
be limited to 1000 g/day
- foods high in phosphate include dairy products (milk, ice cream, cheese, and yogurt) and some puddings
- most foods high in phosphate are also high in calcium, so restricting phosphate also restricts calcium
What does the clinical manifestations reflect in CKD
the derangements of all body systems seen with CKD
- include: hypertension, heart failure, and pulmonary edema because of alterations in sodium and fluid balance
- GI symptoms such as nausea, vomiting, and anorexia
- Neurological symptoms such as headache, lethargy, fatigue, and confusion due to impaired metabolic waste elimination
- altered calcium and phosphorous levels result in bone breakdown and osteodystrophies
- endocrine and reproductive dysfunctions occur such as infertility, amenorrhea, hyperparathyroidism, and thyroid abnormalities
- anemia is a result of decreased production of erythropoietin
Nursing Diagnoses
- excess fluid volume r/t renal failure and fluid retention
- disturbed thought processes r/t the effects of uremic toxins in the CNS
- fatigue r/t anemia, metabolic acidosis, and uremic toxins
- potential complications: dysrhythmias arising from electrolyte imbalances
Nursing Assessments
- vital signs
- assess pulmonary, cardiac, and peripheral vascular systems
- monitor lab values
Assessments: Vitals signs/ SpO2
hypertension may indicate fluid overload due to inadequate water removal
-oxygen saturation may be decreased in the presence of fluid overload/ pulmonary edema
Assessments: assess pulmonary, cardiac, and peripheral vascular systems
- rales may be present on auscultation because of fluid retention
- peripheral edema and neck vein distention may be present because of fluid retention
Assessment: Monitor Lab values
- Serum potassium: hyperkalemia may be present in CKD because of decreased glomerular filtration
- Serum sodium: may be increased or decreased depending on volume status
- Serum Calcium and Phosphate: calcium levels are decreased due to the loss of vitamin D activation; phosphate and calcium levels are inversely related; decreases in calcium levels stimulate the parathyroid gland to release PTH, increasing phosphate; phosphate is also increased due to inadequate clearance in the kidneys
- Hemoglobin and Hematocrit: hemoglobin and hematocrit levels are decreased because of decreased production of erythropoietin
- Arterial pH: metabolic acidosis may be present because of decreased hydrogen ion excretion and decreased bicarbonate production
Nursing Actions
- maintain cardiac monitor
- weigh the patient at the same time each day in the morning before dialysis, use the same scale and record and maintain the same clothing with weights
- restrict fluids and sodium
- administer prescribed medications as directed
- skin care
- proper positioning
- renal diet; adequate protein level
Action: maintain cardiac monitor
necessary to assess for ECG changes that might indicate hyperkalemia
Action: weigh the patient at the same time each day in the morning before dialysis; use the same scale and record and maintain the same clothing with weights
provides accurate information regarding fluid status
-weight gain/loss guides the dialysis treatment plan; it helps in identifying the amount of fluid to be removed
Action: restrict sodium and fluids
fluid and sodium restrictions are necessary because of the kidneys inability to remove excess fluid, placing the patient at risk of volume overload
Action: administer the prescribed medications as directed
- Medication to treat hyperkalemia: essential to maintain potassium within normal ranges to avoid potentially lethal cardiac dysrhythmias
- Anti-hypertensives: to control hypertension
- Phosphate Binders: bind phosphate in the GI system, allowing for excretion in the stool
- Calcium supplementation: used when necessary to maintain normal calcium levels
- Calcimimetic Agents: manage secondary hyperparathyroidism by increasing the parathyroid glands sensitivity to calcium, thus decreasing the release of PTH
- Synthetic erythropoietin: replaces reduced erythropoietin levels that occur in CKD, helping maintain adequate hemoglobin and hematocrit levels
- Folic acid and ferrous sulfate: replacement may be necessary to support RBC production; they are water-soluble vitamins that are lost during dialysis
- Stool softeners: constipation is a side effect of many medications used in CKD, and so stool softeners help treat constipation
Actions: skin care
edema decreases tissue perfusion and increases risk of decubitus ulcers
Actions: Proper positioning
maintaining a semi-fowlers position eases work of breathing by facilitating the diaphragm to lower on inspiration
Actions: renal diet; adequate protein levels
adequate caloric intake is necessary to avoid protein breakdown, which worsens the accumulation of nitrogenous wastes
Nursing Teachings
- do not miss dialysis appointments
- dietary restrictions
- clinical manifestations of CKD and complications
- avoid nephrotoxic substances such as NSAIDs, contrast media, nephrotoxic antibiotics, and alcohol
- daily weight
Teaching: do not miss dialysis appointments
may result in acute and lethal fluid and electrolyte complications, especially hyperkalemia
Teaching: dietary restrictions
adequate protein and limited salt and fluid are necessary to support the caloric needs of the body and reduce the occurrence of volume overload
