Chronic Kidney Disease

Chronic Kidney Disease

1. Disease Process

   • Progressive decline in kidney function (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2014)
     • Causes
       • Diabetes
         • Diabetic nephropathy
           • Glucose damaging small vessels in the kidney
           • https://www.davita.com/UploadedImages/Diabetes_CKD_620.jpg
       • Hypertension
         • Atherosclerosis leading to decrease blood to kidneys
       • Untreated Acute Kidney Disease
   • Reduced blood flow to kidneys
     • Nephron loss due to inadequate oxygen (Lewis et al, 2014)
       • Glomerular filtration rate (GFR) less than 60mL/min/1.73m2 for 3 or more months (Enworom & Tabi, 2015)
         • Decreased secretion of electrolytes and waste (Lewis et al, 2014)
           • Acidosis
           • Hyperkalemia
           • Azotemia
           • Uremia
           • Medication may build up in the body
           • http://lettermaster.site/wp-content/uploads/2018/02/trash-clipart-kitchen-pencil-and-in-color-trash-clipart-kitchen-with-regard-to-best-of-smelly-garbage-clipart.jpg
     • Renin-Angiotensin-Aldosteron mechanism activation (Lewis et al, 2014)
       • Increase Blood pressure leading to further nephron loss in a positive feedback loop (Remuzzi, Perico, Macia, & Ruggeneti, 2005)
   • Loss of erythropoietin leading to anemia (Thomas, Kanso, & Sedor, 2008)
     • Angina due to inadequate oxygen to the heart
       • https://comps.canstockphoto.com/sick-red-heart-with-a-thermometer-illustration_csp4326252.jpg
   • Buildup of phosphorus and inability to activate vitamin D (Thomas et al, 2008)
     • Renal Osteodystrophy
   • Altered lipoprotein lipase function (Lewis et al, 2014; Thomas et al, 2008)
     • Dyslipidemia
     • Risk of Myocardial infarction
   • Stages of CKD (Lewis et al, 2014; Copstead & Banasik, 2012)
     • Stage 1
       • Stage 2
         • Asymptomatic
         • Mild decrease in GFR (60-89 mL/min/1.73m2)
         • Stage 3
           • Hypertension
           • Altered blood chemistry
           • moderate GFR decrease (59-30 mL/min/1.73m2)
           • Stage 4
             • Severe GFR decrease ( 15-29 mL/min/1.73m2)
             • Stage 5 (End stage kidney disease)
               • Complete loss of function
               • Kidney replacement required
             • severe symptoms (fatigue, anemia, pruritus, peripheral neuropathy, azotemia, uremia)
       • Asymptomatic
       • Normal to high GFR
       • http://cdn.naturallifeenergy.com/wp-content/uploads/2016/11/kidney-disease-factors.jpg

2. Nursing Care

   • Assessments (Lewis et al, 2014)
     • Cardiovascular
       • Check for arrhythmias
       • Monitor for hypertension
       • Signs of anemia (pale skin, SOB, fatigue, increase HR)
     • Respiratory
       • Lung sounds for pulmonary edema
         • Heart failure
         • Fluid overload
     • Intake and output
       • Note presence of edema
       • Strict input and output monitoring
         • Fluid restriction to prevent overload
           • General rule: 600mL + previous day's output
           • Monitor weight
     • Blood composition
       • Electrolyte levels
         • Potassium
         • Calcium
         • Sodium
       • BUN and Creatinine
     • Pain
       • PQRST assessment
       • Determine cause of pain
         • Myocardial infarction (Gansevoort et al, 2013)
         • Flank pain from kidney
   • Medications (Lewis et al, 2014)
     • Antihypertensive (ACE inhibitors, diuretics, vasodilators)
       • Counter RAA mechanism to prevent further damage to nephron (Remuzzi et al, 2005)
     • Vitamin D and Ca supplement
       • Maintain bone density
     • Kayexalate
       • Excretion of potassium
     • Analgesics
       • Avoid NSAID (Plantinga et al, 2011)
         • Decreased excretion leading to buildup
         • Decreases prostaglandins that promote renal blood flow
     • Statins
       • Control cholesterol levels
         • Reduce cardiovascular disease risk
   • Kidney Failure
     • Kidney Transplant (Lewis et al, 2014)
       • Preoperative
         • Informed consent
       • Postoperative
         • Immunosuppressive therapy
         • Monitor kidney function
           • Urine output
             • Sudden decrease should be reported
           • Fluid therapy to maintain perfusion
         • Short-term dialysis
     • Dialysis (Lewis et al, 2014)
       • Peritoneal Dialysis
       • Hemodialysis
         • Assess for patency before use
           • Anticoagulants
           • Palpate skin for warmth
         • Monitor for infection

3. Patient Centered Care

   • Dietary changes (Lewis et al, 2014; Thomas et al, 2008)
     • Limit protein consumption
       • prevent uric acid buildup
     • Limit potassium, magnesium, and phosphate
       • Requires kidney function to excrete
     • Increase vitamin D and calcium
       • Promote bone health
         • https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRBlEEpt55nJ-ZNl6-qf97frhPwJxJbTAfjQcNIWj4LneMZO__GQw
     • Diet of complex carbohydrates (whole grains, beans, lentils
       • Prevents protein catabolism
   • Lifestyle recommendations (Lewis et al, 2014)
     • Smoking cessation programs
       • Smoking contributes to hypertension and decreased renal blood flow
     • Limit alcohol consumptom
     • Exercise
       • Control weight and diabetes
   • Kidney Transplant education (Lewis et al, 2014)
     • Complications
       • Immunosupressed
         • Infection risk
         • Cancer risk due to compromised immunity
           • Regular screening
           • Reduce exposure to carcinogens
       • Rejection
     • Return to mostly normal lifestyle
       • No more dialysis
       • No strict diet and fluid restrictions
   • Support groups (Lewis et al, 2014; Enworom & Tabi, 2015)
     • Main issues
       • Fear of unknown
       • Loss of autonomy
       • Fear of death
     • Share experience
       • Motivate each other to make lifestyle changes
       • http://innovationforsocialchange.org/wp-content/uploads/2015/03/sharing-is-caring.png

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