Care Of Patients With Kidney Disease PDF

Care of Clients with problems in Kidney Problems Marlon A. Allecer, RN Objectives At the end of the class, the students will be able to; describe the key factors associated with the 01 development of kidney disorders; explain the pathophysiology, clinical manifestations, 02 m...

Care of Clients with problems in Kidney Problems Marlon A. Allecer, RN Objectives At the end of the class, the students will be able to; describe the key factors associated with the 01 development of kidney disorders; explain the pathophysiology, clinical manifestations, 02 medical management, and nursing management for patients with kidney disorders; 03 differentiate between causes and understand the nursing management of patients with chronic kidney disease and acute kidney injury; Objectives At the end of the class, the students will be able to; compare and contrast the renal replacement therapies, including hemodialysis, peritoneal dialysis, continuous 04 renal replacement therapies, and kidney transplantation; identify the nursing management of the hospitalized 05 patient who is undergoing dialysis; develop a postoperative plan of nursing care for the 06 patient undergoing kidney surgery and transplantation.  PRIMARY GLOMERULAR DISEASES  Diseases that destroy the glomerulus of the kidney. Glomerular capillaries are primarily involved. Antigen-antibody complexes form in the blood & become trapped in the glomerular capillaries (filtering portion of the kidney), inducing an inflammatory response.>Immunoglobulin ( major antibody) found in the blood-can be detected in the glomerular capillary walls. S/S of glomerular injury proteinuria, hematuria, decreased GFR, decreased excretion of Na, edema & hypertension. Acute Nephritic syndrome/AGN Chronic Glomerulonephritis Nephrotic Syndrome Acute Nephritic syndrome/AGN Acute Nephritis Syndrome A type of renal failure w/ glomerular inflammation. Glomerulonephritis is an inflammation of the glomerular capillaries that can occur in acute & chronic forms. Acute Nephritis Syndrome Caused by: - Post infection (Grp A beta-hemolytic streptococcal infection of the throat) - It may also follow impetigo(infection of the skin); & acute viral infections( URTI, mumps, varicella zoster virus, Epstein- Barr virus, hep B, &HIV infection). Acute Nephritis Syndrome Antigens outside the body(meds, foreign serum) initiate the process> antigen-antibody complexes being deposited in the glomeruli Acute Nephritis Syndrome CLINICAL MANIFESTATIONS: Hematuria(microscopic or macroscopic); cola-colored urine (because of rbc’s- indicates glomerular injury & protein plugs); proteinuria primarily albumin- due to increased permeability of the glomerular membrane. Acute Nephritis Syndrome BUN & serum creatinine levels may rise as urine output drops. Anemia Edema & hypertension Severe form- headache, malaise, flank pain Tenderness over CVA Acute Nephritis Syndrome Elderly-circulatory overload w/ dyspnea, engorged neck veins, cardiomegaly, & pulmonary edema. Confusion, somnolence/sleepiness, seizures In ANS, kidneys becomes large, edematous & congested. All renal tissues are affected Acute Nephritis Syndrome Diagnostic Procedure – Electron microscopy & immunofluorescent analysis help identify the nature of the lesion. – Kidney biopsy is needed for definitive diagnosis. Acute Nephritis Syndrome Complications Hypertensive encephalopathy - sudden elevation of arterial pressure usually preceded by severe headache & followed by convulsions, coma heart failure Pulmonary edema ESKD Acute Nephritis Syndrome Medical Management symptomatic treatment, attempting to preserve kidney function, & treating complications promptly. Acute Nephritis Syndrome Medical Management Pharmacologic treatment depends on the cause of AGN. residual streptococcal infection- penicillin rapidly progressive AGN- corticosteroids Acute Nephritis Syndrome Medical Management Dietary protein is restricted when renal insufficiency & elevated BUN develop. Na is restricted- if the pt. has hypertension, edema & heart failure. Acute Nephritis Syndrome Medical Management Loop diuretics & antihypertensive agents- to control hypertension. LOOP DIURETICS TO KIDNEY PATIENTS Diuretics can help slow the progression of kidney disease and reduce the risk of cardiovascular events because they lower blood pressure and reduce the amount of fluid in the body: Lower blood pressure  LOOP DIURETICS TO KIDNEY PATIENTS Diuretics, also known as water pills, help the kidneys remove excess salt and water from the body through urine. This reduces the amount of fluid in the blood vessels, which lowers blood pressure. Reduce fluid in the body Diuretics help the body get rid of excess fluid, which makes it easier for the heart to pump. Reduce risk of cardiovascular events LOOP DIURETICS TO KIDNEY PATIENTS Diuretics can reduce the risk of cardiovascular events in patients with chronic kidney disease (CKD). Most patients with CKD should be treated with a diuretic. However, patients with kidney disease can develop diuretic resistance, which means they need larger doses of diuretics to achieve the same effect Acute Nephritis Syndrome Nursing Management Strict I and O Fluids are given according to the patient’s fluid loss (insensible fluid loss is considered) & daily body weight. STRICT I&O FOR PATIENTS Limiting fluids: Damaged kidneys can't get rid of extra fluid as well as they should, which can lead to high blood pressure, swelling, and heart failure. However, the amount of fluid a patient needs depends on their kidney function and treatment. For example, patients on hemodialysis may need to limit fluids to reduce the risk of low blood pressure and cramping during dialysis.  *If treatment is effective, diuresis will begin resulting in decrease edema & blood pressure. *Proteinuria and microscopic hematuria persist for many months.  *If treatment is effective, diuresis will begin resulting in decrease edema & blood pressure. *Proteinuria and microscopic hematuria persist for many months.  Focus primarily on patient education about the disease process, explanation of laboratory & other diagnostic tests, & preparation for safe effective self-care at home  CHRONIC GLOMERULONEPHRITIS Chronic Glomerulonephritis Due to repeated episodes of AGN, hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitial injury, glomerular sclerosis. Chronic Glomerulonephritis Pathophysiology Kidneys are reduced to 1/5th their normal size , cortex shrinks to 1-2 mm in thickness or less Chronic Glomerulonephritis Pathophysiology bands of scar tissue distort the remaining cortex, making the surface of the kidney rough and irregular Chronic Glomerulonephritis Pathophysiology Numerous glomeruli & their tubules become scarred & branches of renal artery thickens Chronic Glomerulonephritis Pathophysiology RESULT: severe glomerular damage>>>ESRD>>>renal replacement therapy Chronic Glomerulonephritis CLINICAL MANIFESTATIONS RESULT: severe glomerular damage>>>ESRD>>>renal replacement therapy Chronic Glomerulonephritis CLINICAL MANIFESTATIONS Some are asymptomatic for many years Signs and symptoms of renal insufficiency and CRF Chronic Glomerulonephritis CLINICAL MANIFESTATIONS 1. Poorly nourished w/ yellow-gray pigmentation of the skin 2. Peri orbital and peripheral edema 3. Blood pressure- normal or severely elevated 4. Retinal findings: hemorrhage, exudate and papilledema Chronic Glomerulonephritis CLINICAL MANIFESTATIONS 5. Pale mucous membrane because of anemia 6. Signs of heart failure such cardiomegaly, distended neck veins, crackles 7. Peripheral neuropathy(a result of nerve damage, causing weakness, numbness and pain in hands and feet) w/ diminished deep tendon reflexes & neurosensory changes 8. Confusion & limited attention span Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS 5. Pale mucous membrane because of anemia 6. Signs of heart failure such cardiomegaly, distended neck veins, crackles 7. Peripheral neuropathy(a result of nerve damage, causing weakness, numbness and pain in hands and feet) w/ diminished deep tendon reflexes & neurosensory changes 8. Confusion & limited attention span Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS Urinalysis- specific gravity about 1.010, variable proteinuria, & urinary cast. As renal failure progresses, GFR falls below 50 ml/min, the ff. changes occur: Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS > Hyperkalemia- due to decreased K excretion, catabolism & excessive K intake from food & meds > Metabolic acidosis from decreased acid secretion by kidneys & inability to regenerate bicarbonate Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS > Hypoalbuminemia w/ edema > Increased serum Phosphorus - 2.5 - 4.5 mg/dL(Nl) > Decreased serum Ca level(8.5 - 10.3 mg/dL)-Ca binds to phosphorus to compensate for Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS > Hypoalbuminemia w/ edema > Increased serum Phosphorus - 2.5 - 4.5 mg/dL(Nl) > Decreased serum Ca level(8.5 - 10.3 mg/dL)-Ca binds to phosphorus to compensate for elevated serum phosphorus Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS > Mental status changes > Impaired nerve conduction due to electrolyte abnormalities & uremia Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS Chest x-ray- cardiac enlargement & pulmonary edema ECG- normal or left ventricular hypertrophy associated w/ HPN & signs of electrolyte disturbances, such as tall, peaked T waves associated w/ hyperkalemia. Chronic Glomerulonephritis ASSESMENT & DIAGNOSTIC FINDINGS CT & magnetic resonance imaging(MRI) scans show a decrease in the size of the renal cortex. Chronic Glomerulonephritis MEDICAL MANAGEMENT 1.Antihypertensives for HPN; Na & H2O restriction 2.Diuretics- to treat fluid overload; weight is monitored daily 3.Antibiotics for UTI( treated promptly to prevent further kidney damage) 4.Dialysis- prevent F&E imbalance, minimize risk of complications of renal failure. Chronic Glomerulonephritis NURSING MANAGEMENT 1. Sodium (2000mg) and water restriction (1 to 1.5L/day). 2. Daily monitoring of weight. 3. Intake of proteins( dairy products, eggs meat) to promote good nutritional status. Chronic Glomerulonephritis NURSING MANAGEMENT 4. Adequate calories are also important to spare protein for tissue growth & repair 5. Changes in F & E status, cardiac & neurologic status are reported promptly to the physician. 6. Provide emotional support NEPHROTIC SYNDROME Nephrotic Syndrome Is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria. Nephrotic Syndrome Primary cause: kidney diseases Secondary causes: systemic diseases such as diabetes mellitus Nephrotic Syndrome CLNICAL MANIFESTATIONS Soft and pitting edema which commonly occurs: - around the eyes (periorbital edema), - in independent areas( sacrum, ankles and hands), - in the abdomen(ascites) Nephrotic Syndrome CLNICAL MANIFESTATIONS Pt may also exhibit irritability, headache & malaise Nephrotic Syndrome ASSESSMENT & DIAGNOSTIC FINDINGS Proteinuria (albumin) exceeding 3.5 g/day Protein electrophoresis and immunoelectrophoresis - categorize the type of proteinuria Nephrotic Syndrome ASSESSMENT & DIAGNOSTIC FINDINGS Urine may also contain increased WBC’s as well as granular & epithelial cast Needle biopsy of the kidney - to confirm the diagnosis Nephrotic Syndrome COMPLICATIONS Infection (Due to deficient immune response) Thromboembolism ( especially the renal vein) Pulmonary emboli Acute kidney injury ( due to hypovolemia) Accelerated atherosclerosis(due to hyperlipidemia) Nephrotic Syndrome MEDICAL MANAGEMENT Treatment is focused on: a. addressing the underlying disease state causing the proteinuria b. slowing the progression of CKD c. relieving symptoms Nephrotic Syndrome MEDICAL MANAGEMENT Typical treatment includes: > diuretic agents( for edema) > ACE inhibitors ( to reduce proteinuria) > lipid-lowering agents (for hyperlipidemia) Nephrotic Syndrome NURSING MANAGEMENT Early stages- same with AGN Disease worsens- same with CRF Pts. need adequate instruction about the importance of ff all medication & dietary regimens so that their condition can remain stable. Nephrotic Syndrome NURSING MANAGEMENT Pts should communicate any health- related change to their health care providers so that appropriate medication & dietary changes be made before further changes occur w/in the glomeruli. RENAL FAILURE Renal Failure Results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions. Renal Failure Substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion. Renal Failure Is a systemic disease & a final common pathway of many different kidney & UT diseases. ACUTE KIDNEY INJURY Acute Kidney Injury Is a rapid loss of renal function due to damage to the kidneys Criteria: 50% or greater increased in serum creatinine Acute Kidney Injury Urine may be normal, or changes may occur such as oliguria(less than 0.5 ml/kg/h), nonoliguria (greater than 800 ml/day) or anuria(less than 50 ml/day) Increased serum creatinine & BUN levels Azotemia- retention of other metabolic products. Acute Kidney Injury Pathophysiology Conditions that reduce blood flow to the kidney& impair renal function: a. Hypovolemia b. Hypotension c. Reduced cardiac output & heart failure Acute Kidney Injury Pathophysiology d.Obstruction of the kidney or lower UT by tumor, blood clot or kidney stone e.Bilateral obstruction of the renal arteries or veins *If these conditions are treated & corrected before the kidneys are permanently damaged, including BUN & creatinine levels, oliguria & other signs maybe reversed. Acute Kidney Injury Pathophysiology f. Some hereditary stone disease & infection related urolithiasis Acute Kidney Injury Category 1.Prerenal (hypoperfusion of kidney) 2.Intrarenal (actual damage to kidney tissue) 3.Postrenal(obstruction to urine flow) Acute Kidney Injury Category: Pre-Renal Occurs in 60-70% of cases, is the result of impaired blood flow that leads to hypoperfusion of the kidney commonly caused by: – Volume depletion (burns, hemorrhage or gastrointestinal losses, renal losses) Acute Kidney Injury Category: Pre-Renal – Impaired cardiac efficiency ( myocardial infarction, heart failure, dysrhythmias or cardiogenic shock) – Vasodilation( sepsis or anaphylaxis, antihypertensive medications or other meds that causes vasodilation) Acute Kidney Injury Category: Intra-Renal Result of actual parenchymal damage to the glomeruli or kidney tubules a) Prolonged renal ischemia resulting from: Pigment Nephropathy(associated w/ the breakdown of blood cells containing pigments that in turn occlude kidney structures) Acute Kidney Injury Category: Intra-Renal Myoglobinuria (trauma, crash injuries, burns) Hemoglobinuria (Transfusion reaction, hemolytic anemia) Acute Kidney Injury Category: Intra-Renal b) Nephrotoxic Agent such as: Aminoglycoside antibiotics (gentamycin, tobramycin) Radiopaque contrast agents; NSAID Heavy metals (lead, mercury); ACE inhibitors Acute Kidney Injury Category: Intra-Renal c) Infectious process such as: Acute pyelonephritis Acute glomerulonephritis Acute Kidney Injury Category: Post-Renal Results from obstruction distal to the kidney by conditions such as: a) Urinary tract obstruction, including: Calculi Tumors BPH Blood clots Strictures Acute Kidney Injury Category: Post-Renal *pressure rises in the kidney tubules and eventually, the GFR decreases. Acute Kidney Injury Category: Post-Renal 2.Oliguria Period- Accompanied by an increase in serum concentration of substances usually excreted by kidneys (urea, creatinine, uric acid, organic acids & the intracellular cations- K & Mg) Acute Kidney Injury Category: Post-Renal Uremic symptoms first appear life threatening conditions such as hyperkalemia develops Acute Kidney Injury Category: 3. Diuresis Period Post-Renal Is marked by a gradual increase in urine output w/c signals that glomerular filtration has started to recover. Laboratory values stabilize & eventually decrease. Urinary output=normal or including, renal function may still be abnormal Uremic symptoms may still be present Observe closely for dehydration w/c can increase uremic symptoms Acute Kidney Injury Category: Post-Renal 4.Recovery Period Signals the improvement of renal function May take 3-12 months Laboratory values return to normal level Permanent reduction of GFR 1% to 3% may occur. Acute Kidney Injury Clinical Manifestation Patient may appear critically ill & lethargic(lacking energy). Skin & mucous membranes are dry from dehydration. CNS s/s include drowsiness, headache, muscle twitching, & seizures. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS In AKI, urine output varies fr. scanty to a normal volume, hematuria maybe present,& urine has low sp. Gravity (normal=1.010-1.025) Earliest manifestation of tubular damage: inability to concentrate urine. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Prerenal azotemia pts- decreased amount of Na in urine (less than 20 mEq/L) & normal urinary sediment. Intrarenal azotemia- urinary Na levels greater than 40 mEq/L w/ urinary casts (wbc, rbc, kidney cells, CHON, fat) & other cellular debris. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Renal sonogram or CT or MRI scan may show anatomic changes BUN level increases steadily depending on the degree of catabolism, renal perfusion & protein intake. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS w/ decline GFR> oliguria & anuria, pts are at risk for hyperkalemia( protein catabolism results in the release of cellular K into the body fluids)>lead to dysrhythmias such as ventricular tachycardia & cardiac arrest. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Progressive metabolic acidosis occur bec. pts cannot eliminate daily metabolic load of acid- type substances produced by the normal metabolic process & normal buffering mechanisms fail. Increase in blood phosphate concentrations. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Low Ca levels due to decreased absorption of Ca from the intestine & as a compensatory mechanism for the elevated blood phosphate level Anemia as a result of reduced erythropoietin production, uremic GI lesions, reduced RBC lifespan, & blood loss from the GI tract.. Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS LABORATORY TEST IN AKI: 1.Urinalysis 2.Serum creatinine levels 3.BUN level 4.Serum electrolytes 5.CBC(complete blood count) Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS 6. Renal Ultrasonography 7. Renal sonogram or CT or MRI scan 8. IVP (Intravenous Pyelography) 9. Renal Biopsy Ultrasound-guided kidney biopsy CT-guided kidney biopsy Surgical biopsy Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS MEDICAL MANAGEMENT: Objectives of treatment for AKI: Restore normal chemical balance Prevent complications until repair of renal tissue Restoration of renal function Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Management includes: Eliminating the underlying cause -prerenal azotemia- treated by optimizing renal perfusion -postrenal failure- treated by relieving the obstruction - inrarenal azotemia- treated w/ supportive therapy  Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Maintaining fluid balance- based on daily body weight, serial measurements of CVP, serum & urine concentrations, fluid losses, BP, clinical status of the pt. - basis for fluid replacement: parenteral & oral intake, output of urine, gastric drainage, stools, wound drainage & perspiration, insensible fluid losses Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS Avoiding fluid excesses - fluid excess can be detected by the clinical findings- dyspnea, tachycardia, distended neck veins- lungs are auscultated for crackles. - Pulmonary edema maybe caused by excessive administration of parenteral fluids - generalized edema- assessed by examining the presacral & pretibial areas. Diuretics are given for diuresis Acute Kidney Injury ASSESSMENT & DIAGNOSTIC FINDINGS When needed, providing renal replacement therapy. - prerenal causes-adequate blood flow can be restored by IV fluids or BT. Acute Kidney Injury PHARMACOLOGIC TREATMENT 1. Diuretics – to control fluid volume 2. ACE(angiotensin-converting enzyme) inhibitors-used mainly in the treatment of hypertension (high blood pressure) and heart failure. 3. Avoid nephrotoxic drugs: antibiotics, Acute Kidney Injury PHARMACOLOGIC TREATMENT 3.Avoid nephrotoxic drugs: antibiotics, 4.Na polystyrene sulfonate(Kayexalate)- cation- exchange resins - works by exchanging Na ions for K ions in the intestinal tract. 5. Phosphate binding agents( calcium or lanthanum carbonate) Acute Kidney Injury PHARMACOLOGIC TREATMENT 6. Insulin and glucose 7. Erythropoietin Alfa (Synthetic erythropoietin)- treat anemia Acute Kidney Injury NURSING INTERVENTION 1. Monitor and maintain fluid and electrolyte balance. Measure I & O every hour. Note excessive losses in diuretic phase Administer IV fluids and electrolyte supplements as ordered. Weigh daily and report gains. Monitor lab values; assess/treat fluid & electrolyte and acid-base imbalances as needed Acute Kidney Injury NURSING INTERVENTION 2. Reducing metabolic rate Bed rest may be indicated to reduce exertion & the metabolic rate during the most acute stage of the disorder. Fever & infection w/c could increase metabolic rate & catabolism are prevented or treated promptly Acute Kidney Injury NURSING INTERVENTION 3.Promoting pulmonary function Patient is assisted to turn, cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection. Drowsiness & lethargy may prevent the patient from moving & turning w/o encouragement & assistance. Acute Kidney Injury NURSING INTERVENTION 4. Preventing infection Asepsis is essential w/ invasive lines & catheters to minimize the risk of infection & increased metabolism IFC is avoided due to the high risk of UTI Acute Kidney Injury NURSING INTERVENTION 5. Providing skin care Meticulous skin care is important due to dry or susceptible to breakdown as a result of edema. Bathing the patient w/ cool water, frequent turning, & keeping the skin clean & well moisturized & fingernails trimmed to avoid excoriation are often comforting & prevent skin breakdown. Acute Kidney Injury NURSING INTERVENTION 6. Providing psychological support Pt & family needs assistance, explanation & support during this period. Acute Kidney Injury NUTRITIONAL THERAPY Replacement of dietary proteins is individualized to provide maximum benefit & minimize uremic symptoms. High carbohydrate meals are encouraged to spare protein from meeting energy requirement. – Foods & fluids containing K or P(bananas, citrus fruits & juices, coffee) are restricted. Acute Kidney Injury NUTRITIONAL THERAPY Diuresis period- results of blood chemistry test are used to determine the amount of Na, K & H2O needed for replacement, along w/ assessment for over or under hydration Recovery period- client is placed on a high- protein, high calorie diet & is encouraged to resume activities gradually. CHRONIC KIDNEY DISEASE Chronic Kidney Disease Is an umbrella term that describes kidney damage or a decrease in the GFR lasting for 3 or more months. Untreated CKD can result in ESKD, w/c is the final stage of renal failure. Chronic Kidney Disease RISK FACTOR In the early stages of CKD, there can be significant changes to the kidneys w/o signs or symptoms. The pathophysiology of CKD is not clearly understood, but the damaged to the kidneys is thought to be caused by prolonged inflammation that is not organ specific & thus, has subtle systemic manifestations. Chronic Kidney Disease STAGES OF CKD Stages are based on the GFR. Normal GFR= 125 ml/min/1.73 m2 Stage 1 GFR>=90 ml/min/1.73 m2 Kidney damage w/ normal or increased GFR Stage 2 GFR= 60-89 ml/min/1.73 m2 Mild decreased in GFR Chronic Kidney Disease Stage 3 STAGES OF CKD GFR= 30-59 ml/min/1.73 m2 Moderate decreased in GFR Stage 4 GFR=15-29 ml/min/1.73 m2 Severe decreased in GFR Stage 5 GFR< 15 ml/min/1.73 m2 ESKD/CRF Chronic Kidney Disease CLINICAL MANIFESTATION 1.Elevated serum creatinine levels - as creatinine level increases symptoms of CKD begin. 2. Anemia- due to dec erythropoietin production by the kidney, metabolic acidosis, & abnormalities in Ca & Phosphorus Chronic Kidney Disease CLINICAL MANIFESTATION 3. Fluid retention- evidenced by both edema & congestive heart failure 4. As the disease progresses, abnormalities in electrolytes occur, heart failure worsens, & HPN becomes difficult to control. Chronic Kidney Disease ASSESSMENT AND DIAGNOSTIC FINDINGS 1. Glomerular filtration rate (GFR) - amount of plasma filtered through the glomeruli per unit of time. 2. Creatinine clearance - measure of the amount of creatinine the kidneys are able to clear in a 24 hr. period. Normal values differ in men & women. Chronic Kidney Disease MEDICAL MANAGEMENT 1. Treatment of the underlying cause. 2. Regular clinical & lab assessment is important to keep BP below 130/80 mmHg. 3. Early referral for initiation of RRT as indicated by patient’s renal status. Chronic Kidney Disease MEDICAL MANAGEMENT 4. Prevention of complications is accomplished by controlling cardiovascular risk factors; treating hyperglycema; managing anemia; smoking cessation; weight loss; & exercise programs as needed; & reduction in salt & alcohol intake. CHRONIC RENAL FAILURE/ ESKD: CHRONIC RENAL FAILURE/ESKD: When a patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis, the patient has moved into the fifth or final stage of Chronic kidney disease, also referred to as ESKD or chronic renal failure Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Neurologic- weakness & fatigue; confusion; inability to concentrate; disorientation; tremors; seizures; asterixis; restlessness of legs; burning of soles of feet; behavior changes Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Integumentary- gray-bronze skin color; dry, flaky skin; pruritus; ecchymosis; purpura; thin, brittle nails; coarse, thinning hair Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Cardiovascular- HPN, pitting edema(feet, hands, sacrum); periorbital edema; pericardial friction rub; engorged neck veins; pericarditis; pericardial effusion; pericardial tamponade; hyperkalemia; hyperlipidemia Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Pulmonary- crackles; thick, tenacious sputum; depressed cough reflex; pleuritic pain; SOB, tachypnea; kussmaul-type repirations; uremic pneumonitis Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Gastrointestinal- ammonia odor to breath( uremic fetor); metallic taste; mouth ulcerations & bleeding; anorexia, nausea & vomiting; hiccups; constipation or diarrhea; bleeding from gastrointestinal tract. Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Hematologic- anemia; thrombocytopenia Reproductive- amenorrhea; testicular atrophy; infertility; decreased libido Chronic Renal Failure/ESKD CLINICAL MANIFESTATION Musculoskeletal- muscle cramps; loss of muscle strength; renal osteodystrophy; bone pain; bone fractures; footdrop Chronic Renal Failure/ESKD ASSESSMENT AND DIAGNOSTIC FINDINGS Glomerular filtration rate - as the GFR dec(due to nonfunctioning glomeruli)> creatinine clearance dec> serum crea & BUN inc. Chronic Renal Failure/ESKD ASSESSMENT AND DIAGNOSTIC FINDINGS Na & H2O retention - kidney cannot concentrate or dilute urine normally in ESKD. - some retain Na & H2O- edema, heart failure; hpn - HPN- results in activation of RAAS. - others lose Na resulting to hypovolemia, hypotension - vomiting & diarrhea-cause Na & H2O depletion w/c worsens the uremic state. Chronic Renal Failure/ESKD ASSESSMENT AND DIAGNOSTIC FINDINGS Anemia - develops as a result of inadequate erythropoietin production, shortened lifespan of RBCs & pts tendency to bleed. - in ESKD- erythropoietin production decreases, & anemia results> fatigue, angina, & SOB Chronic Renal Failure/ESKD ASSESSMENT AND DIAGNOSTIC FINDINGS Ca and Phosphorus imbalance - in renal failure, the body does not respond to parathormone> Ca leaves the bone causing bone changes & bone disease. Uremic bone changes( renal osteodystrophy) Chronic Renal Failure/ESKD COMPLICATIONS OF ESKD Hyperkalemia due to dec excretion, metabolic acidosis, catabolism, & excessive intake(diet, medications, fluid) Pericarditis, pericardial effusion, & pericardial tamponade due to retention of uremic waste products & inadequate dialysis Chronic Renal Failure/ESKD COMPLICATIONS OF ESKD HPN- due to Na & H2O retention & malfunction of the RAAS. Anemia- due to dec erythropoietin production, dec RBC lifespan, bleeding in the GI tract from irritating toxins & ulcer formation, & blood loss during hemodialysis. Chronic Renal Failure/ESKD COMPLICATIONS OF ESKD Bone disease & metastatic & vascular calcifications due to retention of P, low serum Ca levels, abnormal vit. D metabolism & elevated aluminum levels Chronic Renal Failure/ESKD MEDICAL MANAGEMENT Goal of management: maintain kidney function & homeostasis for as long as possible. - All contributing & reversible factors are identified & treated. - Management use of meds & diet therapy, dialysis may also be needed. To dec uremic waste products in the blood & control electrolyte balance. Chronic Renal Failure/ESKD PHARMACOLOGIC THERAPY 1. Calcium & Phosphorus binders 2. Antihypertensive & Cardiovascular agents 3. Antiseizure agents- IV diazepam(valium) or phenytoin 4. Erythropoietin Chronic Renal Failure/ESKD NUTRITIONAL THERAPY 1.Careful regulation of protein intake - chon must be of high biologic value( dairy products, egg, meat) 2. Fluid intake to balance fluid losses - 500-600 ml more than the previous day’s 24-hr urine output. Chronic Renal Failure/ESKD NUTRITIONAL THERAPY 3. Na intake to balance Na losses 4. Restriction of K 5. Adequate caloric intake & vitamin supplementation must be ensured - calories are supplied by CHO & fat to prevent wasting. Vit supplementation is necessary because a CHON restricted diet does not contain necessary vits. Pt on dialysis may lose water soluble vitamins. during the treatment Chronic Renal Failure/ESKD NURSING MANAGEMENT 1.Assess fluid status & identifying potential sources of imbalance 2.Implementing a dietary program to ensure proper nutritional intake w/in the limits of tx regimen. 3.Promoting positive feelings by encouraging increased self-care & greater independence Chronic Renal Failure/ESKD NURSING MANAGEMENT 4. Emotional support - provide explanations & info to the pt & family concerning ESKD, treatment options, & potential complications. Chronic Renal Failure/ESKD NURSING DIAGNOSIS 1. Excess fluid volume related to decreased urine output, dietary excesses, & retention of sodium and water. 2. Imbalance nutrition: less than body requirements related to anorexia, nausea, vomiting, dietary restrictions, & altered oral mucous membranes. Chronic Renal Failure/ESKD NURSING DIAGNOSIS 3. Deficient knowledge regarding condition & treatment. 4. Activity intolerance related to fatigue, anemia, retention of waste products & dialysis procedure. 5. Risk for situational low self-esteem related to dependency, role changes, change in body image, & change in sexual function. Chronic Renal Failure/ESKD RENAL REPLACEMENT THERAPIES use of RRT becomes necessary when the kidneys can no longer remove wastes, maintain electrolytes, & regulate fluid balance. The need for RRT can be acute or chronic. The main RRT include various types of dialysis & kidney transplantation. Chronic Renal Failure/ESKD RENAL REPLACEMENT THERAPIES DIALYSIS: Types of dialysis: 1.Hemodialysis 2.CRRT 3.Peritoneal dialysis