Transcript Chronic Kidney Disease

Chronic Kidney Disease
(Chapter 47,
“Nursing Management:
Cronic Kidney Disease,” in the Lewis textbookModified by L. Copenhaver)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease (CKD)
• Involves progressive, irreversible
loss of kidney function
• Defined as either presence of
• Kidney damage
• Pathological abnormalities
• Glomerular filtration rate (GFR)
• <60 ml/min for 3 months or longer
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
• Disease staging based on
decrease in GFR
• What is the normal GFR?
• What diagnostic test reflects GFR?
• Last stage of kidney failure
• End-stage renal disease (ESRD)
occurs when GFR <15 ml/min
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
• Leading causes of ESRD
• Diabetes
• Hypertension
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
•Uremia
• Syndrome that incorporates
all signs and symptoms seen in
various systems throughout
the body
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Manifestations of Chronic Uremia
Fig. 47-5
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Urinary system
• Polyuria
• Results from inability of kidneys
to concentrate urine
• Occurs most often at night
• Specific gravity fixed around
1.010
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Urinary system
• Oliguria
• Occurs as CKD worsens
• Anuria
• Urine output <40 ml per 24
hours
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Metabolic disturbances
• Waste product accumulation
• As GFR ↓, BUN ↑ and serum
creatinine levels ↑
• BUN ↑
• Not only by kidney failure but by protein
intake, fever, corticosteroids, and
catabolism
• N/V, lethargy, fatigue, impaired thought
processes, and headaches occur
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Electrolyte/acid–base imbalances
• Potassium
• Hyperkalemia
• Most serious electrolyte disorder in
kidney disease
• Fatal dysrhythmias
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Electrolyte/acid–base imbalances
• Sodium
• May be normal or low
• Because of impaired excretion,
sodium is retained
• Water is retained
• Edema
• Hypertension
• CHF
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Electrolyte/acid–base imbalances
• Calcium and phosphate alterations
• Magnesium alterations
• Metabolic acidosis
• Results from
• Inability of kidneys to excrete acid load
(primary ammonia)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Hematologic system
• Anemia
• Due to ↓ production of
erythropoietin
• From ↓ of functioning renal tubular
cells
• Bleeding tendencies
• Defect in platelet function
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Hematologic system
• Infection
• Changes in leukocyte function
• Altered immune response and
function
• Diminished inflammatory
response
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Cardiovascular system
• Hypertension
• Heart failure
• Left ventricular hypertrophy
• Peripheral edema
• Dysrhythmias
• Uremic pericarditis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Respiratory system
• Kussmaul respiration-Why?
• Dyspnea-Why?
• Pulmonary edema-Why?
• Uremic pleuritis-Why?
• Pleural effusion
• Predisposition to respiratory infections
• Depressed cough reflex
• “Uremic lung”
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Gastrointestinal system
• Every part of GI is affected
• Due to excessive urea
• Mucosal ulcerations
• Stomatitis
• Uremic fetor (urinous odor of the
breath)
• GI bleeding
• Anorexia
• N/V
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Neurologic system
• Expected as renal failure progresses
• Attributed to
•
•
•
•
•
•
•
•
Increased nitrogenous waste products
Electrolyte imbalances
Metabolic acidosis
Demyelination of nerve fibers
Altered mental ability
Seizures and Coma
Dialysis encephalopathy
Peripheral neuropathy
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Neurologic system
• Restless leg syndrome
• Muscle twitching
• Irritability
• Decreased ability to concentrate
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Musculoskeletal system
• Renal osteodystrophy
• Syndrome of skeletal changes
• Result of alterations in calcium and
phosphate metabolism
• Weaken bones, increase fracture risk
• Two types associated with ESRD:
• Osteomalacia
• Osteitis fibrosa
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Renal Osteodystrophy
Fig. 47-6
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Integumentary system
• Most noticeable change
• Yellow-gray discoloration of the skin
• Due to absorption/retention of urinary
pigments
• Pruritus
• Uremic frost
• Dry, pale skin
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Integumentary system
• Dry, brittle hair
• Thin nails
• Petechiae
• Ecchymoses
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Clinical Manifestations
Reproductive system
• Infertility
• Experienced by both sexes
• Decreased libido
• Low sperm counts
• Sexual dysfunction
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
QuickTime™ and a
YUV420 codec decompressor
are needed to see this picture.
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Diagnostic Studies
• Laboratory tests (cont’d)
• Urinalysis
• Urine culture
• Hematocrit
• Hemoglobin
• Renal ultrasound
• Renal scan
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Hyperkalemia
• IV insulin and glucose
• IV 10% calcium gluconate
• Raises threshold for excitation
• Sodium bicarbonate
• Shift potassium into cells
• Correct acidosis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Hyperkalemia (cont’d)
• Sodium polystyrene sulfonate
(Kayexalate)
• Cation-exchange resin
• Resin in bowel exchanges potassium for
sodium
• Evacuates potassium-rich stool from body
• Educate patient that diarrhea may occur due
to laxative in preparation
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Hypertension (cont’d)
• Antihypertensive drugs
•
•
•
•
Diuretics
β-Adrenergic blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE)
inhibitors
• Angiotensin receptor blocker agents
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Renal osteodystrophy
• Phosphate intake restricted to
<1000 mg/day
• Phosphate binders
• Calcium carbonate (Tums)
• Bind phosphate in bowel and excreted
• Sevelamer hydrochloride (Renagel)
• Lowers cholesterol and LDLs
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Renal osteodystrophy (cont’d)
• Phosphate binders (cont’d)
• Should be administered with each meal
• Side effect: Constipation
• Supplementing vitamin D
• Calcitriol (Rocaltrol)
• Serum phosphate level must be lowered before
administering calcium or vitamin D
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Renal osteodystrophy (cont’d)
• Controlling secondary
hyperparathyroidism
• Calcimimetic agents
• Cinacalcet (Sensipar)
• ↑ Sensitivity of calcium receptors in
parathyroid glands
• Subtotal parathyroidectomy
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Anemia
• Erythropoietin
• Epoetin alfa (Epogen, Procrit)
• Administered IV or subcutaneously
• Increased hemoglobin and hematocrit in
2 to 3 weeks
• Side effect: Hypertension
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Anemia (cont’d)
• Iron supplements
• If plasma ferritin <100 ng/ml
• Side effect: Gastric irritation,
constipation
• May make stool dark in color
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Anemia (cont’d)
• Folic acid supplements
• Needed for RBC formation
• Removed by dialysis
• Avoid blood transfusions
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Drug therapy
• Complications
• Drug toxicity
• Digitalis
• Antibiotics
• Pain medication (Demerol, NSAIDs)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Nutritional therapy
• Protein restriction
• 0.6 to 0.8 g/kg body weight/day
• Water restriction
• Intake depends on daily urine output
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Nutritional therapy
• Sodium restriction
• Diets vary from 2 to 4 g depending on
degree of edema and hypertension
• Sodium and salt should not be equated
• Patient should be instructed to avoid
high-sodium foods
• Salt substitutes should not be used because
they contain potassium chloride
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
Nutritional therapy
• Potassium restriction
• 2 to 4 g
• High-potassium foods should be
avoided
•
•
•
•
Oranges
Bananas
Tomatoes
Green vegetables
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Collaborative Care
• Phosphate restriction
• 1000 mg/day
• Foods high in phosphate
• Dairy products
• Most foods high in phosphate are also
high in calcium
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Nursing Diagnoses
• Excess fluid volume
• Risk for injury
• Imbalanced nutrition: Less than
body requirements
• Grieving
• Risk for infection
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Nursing Implementation
• Health promotion
• Identify individuals at risk for CKD
•
•
•
•
History of renal disease
Hypertension
Diabetes mellitus
Repeated urinary tract infection
• Regular checkups and changes in
urinary appearance, frequency and
volume should be reported
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Gerontologic Considerations
• Diminished cardiopulmonary
•
•
•
•
function
Impaired cognition
Altered drug metabolism
Bone loss
Immunodeficiency
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Kidney Disease
Gerontologic Considerations
• Most common cause of death in
the elderly ESRD patient
• Cardiovascular disease (MI, stroke)
• Withdrawal from dialysis
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.