Chronic Kidney Disease (CKD) - created from Mind Map

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Implementation (American Kidney Fund, 2019;Bonner, et al., 2014, Lewis et al., 2014)

Diagnosis (Lewis et al., 2014)

Outcome/Planning

Assessment

Evaluation (Lewis, 2014)

Renal Replacement Therapies including

Medications (NHS Foundation, 2019)

Patient teaching consists of (Ormandy, 2008)

Treat Reversible Causes; cardiac failure, nephrotoxins, infections, renal stenosis, urinary tract obstruction, dehydration

Dialysis; hemodialysis, peritoneal dialysis, this will remove artically remove waste products and excess fluid from bloodstream

Transplant; a surgical procedure to put a donor kidney into the recipient, the kidney can from a living or deceased donor

Iron supplements will be used due to the risk of anemia with dialysis, these are given via injection for easy absorption

Diuretics are used to Increases rate of excretion of fluids from the body, flushing system of harmful substances. A primary example being Furosemide.

Anti-hypertensives will be used as hypertension can damage the blood vessels supplying the kidneys, therefore lowering it will provide increased flow. Some common antihypertensives include Atenolol, Rampiril, Doxazosin, and Irbesartan.

Erythropoietin will be administered to stimulate bone marrow to healthy red blood cells, as kidney failure will inhibit this process

Phosphate binders are given to both prevent itchiness as well as reducing the risk of heart problems associated with chronic kidney disease

Sodium bicarbonate is used to counteract acids to prevent acid buildup in body as a result of decreased kidney excretion

Statins will be used to lower cholesterol levels in order to decrease the risk of congestive heart failure. Some common examples include Atorvastin, Simvastatin, and Pravastatin.

How kidneys work and what happens when they fail

what can be done to protect the remaining healthy kidney or slow the progression

Life expectancy with or without treatment and possibility of death if treatment is refused. Patients with a GF of 60 aged 30-50 years have anywhere between 12 and 24 years (Landry, 2017)

Education on the impact this disease will have on their lifestyle

Encourage leisure activities such as; walking, swimming, bicycling, skiing, aerobic dancing or other activities that allow the movement of large muscle groups. No heavy lifting. (National Kidney Foundation, 2019)

How to cope or treat their symptoms at home that may result from their treatment

Financial implications & information on any additional support available

What are their medications purpose, how they will work, and possible side effects

inofrmation on why the different test's are being performed

How to adapt and cope with dialysis; could allow patient to visit the dialysis ward if applicable, to meet health care team and talk with other patients. Give information on community support groups.

Lifestyle Changes such as; no smoking or using tobacco, limit alcohol, will have to stick to treatment schedule, and will need to start or continue to exercise

Diet/Nutrition changes

Protein restriction because BUN is the end product of protein metabolism & CKD already causes BUN levels to be increased. Proten intake must have all essential amino acids; milk, poultry, meat or eggs

Sodium & Fluid Restriction

Potassium Restriction (2-4g/day) avoid potassium-rich food such as oranges, tomatoes, bananas

Phosphate Restrictions (1000mg/day), avoid phosphate rich foods such as dairy products

Fluid intake depends on the daily output & fluid balance. If patient is not on dialysis there is no fluid restriction , if patient is on hemodialysis fluid allowance is 600ml + amount equal to previous days's urine output

2-4g of sodium allowed depending on if the patient is presenting with hypertension and/or edema. Avoid sodium rish foods such as curred meats, pickled foods or canned soups

Avoidance of salt substitutes because they contain potassium chloride and contribute to hyperkalemia

Routine laboratory measurements to look for proteinuria (earliest marker for kidney damage)

Urinalysis to look for presence of WBCs, RBCs, glucose, casts, and protein

Ultrasound to determine the size of the kidneys, any obstructions, and image of kidneys

eGFR will be taken to determine stage of CKD

Renal biopsy

Patients with diabetes, hypertension, autoimmune disease, vascular disease, or eGFR <60mL/min are at high risk for CKD and should be screened routineley

5 stages of CKD (American Kidney Fund, 2019)

Stage 2 chronic kidney disease will be mild with little to no symptoms and a eGFR of 60-89

Stage 1 chronic Kidney disease will be very mild with no symptoms and a eGFR>90

Stage 3a chronic kidney disease will be of moderate severity with symptoms of polyuriam, swelling, back pain, and a eGFR of 45-54

Stage 4 chronic kidney disease with be severe with complications of gout, heart disease, and hyperkalemia as well as the symptoms present in stage 3a/b. It will maintain a eGFR of 15-30

Stage 5 chronic kidney disease will result in total kidney failure leading to death without dialysis or treatment. Alongside all other complications there will be excessive nausea/vomitting, dicciculty breathing, and abdominal cramping. It will maintain a eGFR<15.

Stage 3b chronic kidney disease will possess the same symptoms as stage 3a with added complications of anemia, hypternsion, and bonedisease. It will have a eGFR of 30-44

Goals for Patients with CKD (Prasad-Reddy et al., 2017, Lewis et al., 2014)

Prevention of further CKD progression (CDC, 2017)

Diabetics with CKD may require less insulin because insulin will remain in the body longer due to impaired excretion; patient's insulin dose may be lowered or hyperinsulinemia may occur

Diabetic patients should maintain their HGBA1C <7%

Hypertensive patients should maintain their BP <140/90mmhg, and may require ACE inhibitors or ARBs to do so

Patients with hyperlipidemia should reduce the occurrence of atherosclerosis and cardiovascular events

Preserve existing renal function

Treat clinical manifestations

Educate patient and family

Keep your kidneys healthy by taking meds as prescribed, reduce salt intake, eat more fruit, keep cholesterol levels in a healthy range, stay active and have a targeted blood pressure range recommended by the doctor

If you have Diabetes; Get your urine and blood tests for CKD done yearly, Try and meet blood sugar targets, Get your A1C test done up to 4 times a a year with a minimum of 2 times a year, Check your blood pressure regularly and talk to your doctor about ways to combat high blood pressure and discuss medications that are harmful to your kidneys with your doctors

Be proactive; quit smoking, if you are an at-risk patient be sure to have test's done regularly, try to lose excess weight, find it early treat it early with urine and blood tests; visit family doctor for annual check-ups

What Can Cause Kidney Damage? (National Kidney Foundation, 2010, Prasad-Reddy et al., 2017)

Manifestations of CKD (Lewis et al., 2014)

Risk Factors include: obesity, High blood pressure, being of African American, Hispanic, Asian pacific islander or American Indian decent, diabetes, and having a family history

Diabetes (#1 cause); increased sugar in the blood damages the glomeruli in the kidney's

High blood pressure (2nd most common cause) it makes the kidney's worker hard leading to injury

Kidney conditions

Certain medication; bowel cleaners, NSAIDs, and contrast dyes in x-rays and scans

Viral infections including hepatitis C and HIV

Injuries such as trauma and accidents

Other causes; environmental exposure such as toxic chemicals, birth defects, smoking, tumors, lupus, ureter or bladder disease, obesity

Glomerulonephritis: an infection that affects the glomeruli of the kidneys

Polycystic kidney disease: many cysts on the kidneys that tale over its tissue and decreases its function; inherited

Obstructions; ex. kidney stones

Urinary System manifestations; anuria, oliguria and polyuria ussually occuring at night due to kidney's inability to concentrate urine

Metabolic manifestations

Electrolyte and Acid-Base Imbalances include; possible hypermagnesemia causing absence of reflexes, hypotension, respiratory failure, and cardiac dysrhythmias; hypernatremia dues to sodium retention or hyponatremia due to water retention; metabolic acidosis due to impaired kidney excretion of acids; hyperkalemia due to drugs, dietary supplements, metabolic acidosis, cellular protein breakdown and decreased kidney excretion

Hematological System manifestations; Infections caused by leukocyte function changes, altered immune response, malnutrition, hypoglycemia, & external trauma (catheters, needles); Normocytic & normochromic anemia result of decreased erythropoietin production by the kidneys causing decreased erythropoiesis in bone marrow, nutritional deficiencies, decreased RBC lifespan, GI bleeds, increased hemolysis of RBCs, frequent blood sampling, blood loss from frequent hemodialysis, iron deficiency, folic acid removal in blood

Cardiovascular System manifestations; Hypertension due to increased renin production, increased ECF volume & sodium retention; Chronic hypertension can lead to atherosclerotic vascular disease, infrarenal arterial spasm, left ventricular hypertrophy, renopathy, congestive heart failure, and encephalopathy; Uremic pericarditis which is manifested by friction rub, chest pain and a low-grade fever.

Respiratory System manifestations; kassmual's respirations, uremic pneumonia, uremic pleuritis, predisposition to respiratory infections,pleural effusion, dyspnea, and pulmonary edema

Gastrointestinal system manifestations include; Constipation due to ingestion of iron salts and/or phosphate binders and fluid restrictions; Inflammation of mucosa due to excessive urea can cause GI bleeding, anorexia, nausea, and vomiting,; stomatitis with exudates and ulcerations; metallic taste in the mouth, and ureic fetor. Patient at risk for weight loss & malnutrition

Neurological System manifestations include peripheral neuropathy occurring as bugs crawling on legs, parathesis, CNS depression and electrolyte imbalances causeing changes consisting of nitrogenous waste build up, demyelination of nerve fibres, and axonal atrophy

Musculoskeletal System manifestations include; Skeletal complications such as; renal osteodystrophy, osteitis fibrosis, osteomalacia, adynamic bone disorder and mixed osteodystrophy. Also, decreased serum Vit.D due to decreased phosphorus elimination, leading to decreased calcium absorptions in the intestine

Integumentary System manifestations include; pruritus from calcium-phosphate deposition in the skin, dry skin, or sensory neuropathy; uremic frost due to high levels of BUN creating urea crystals on the skins surface

Reproductive system manifestations

Psychological manifestations include; depression, personality & behavioural changes, emotional lability, body image changes leading to withdrawal, lifestyle changes

Waste product accumulation such as build up of nitrogenous waste causes vomiting, nausea, fatigue, lethargy, impaired thought processes

Carbohydrate metabolism becomes defective due to impaired glucose use because of cellular insensitivity to normal functions of insulin. This may cause hyperglycaemia, hyperinsulinemia, and abnormal glucose tolerance tests

Elevated triglyceride levels due to hyperinsulinemia which stimulates hepatic production of triglycerides

Due to decline in serum GFR and increased in creatinine and BUN levels

Dyslipidemia may occur due to decreased levels of lipoprotein lipase, and results in elevated levels of VLDLs, low levels of HDLs, and normal or decreased levels of LDLs

Males & females experience sexual dysfunction (possibly due to physical stress, adverse drug effects, physiological problems, and anemia causing fatigue and decreased libido), and infertility,

Females experience an ovulation and menstrual changes, anorgasmy due to peripheral neuropathy, and decreased levels of estrogen, progesterone, and luteinizing hormone

Males experience loss of testicular consistency, impotence due to peripheral neuropathy, low sperm count, and decreased testosterone levels

Patient maintains an acceptable body weight and fluid balance with dietary modifications or with peritoneal dialysis or hemodialysis

Patient will report having a better quality of life, decreased fatigue and improve ability to exercise/lose excess weight

hemoglobin, blood pressure and if applicable blood sugars will be controlled in acceptable ranges

Patient will have effective coping mechanism and or will be engaging in support groups or using any additional service needed

Patient will adhere to medication regimen

Patient's will be knowledgeable about their diagnosis, their chosen treatment and will have collaborated with HCP's to create their careplan