Medical Surgical Nursing: Chronic Kidney Disease
This post will cover Chronic Kidney Disease.
Before we start, be sure to download the free PDF study guide with this post to enhance your learning. The link is listed here!
Chronic Kidney Disease, which is also known as CKD, is a slow, progressive, irreversible loss in kidney function.
The GFR will be less than or equal to 60 mL/minute for 3 months or longer.
This disease occurs in stages. With a loss of 75% of functioning nephrons, the client becomes symptomatic. This eventually results in uremia or end-stage kidney disease. End stage kidney disease is diagnosed when there is a loss of 90% to 95% of functioning nephrons.
Okay so from our previous videos, let's think back to why certain symptoms happen because of the kidneys inability to excrete sodium and water. We remember hypervolemia right? This will always be the number one sign and symptom for CKD. CKD affects all major body systems and requires dialysis or kidney transplantation to maintain life.
Primary Causes of CKD
Let's go over the primary causes of CKD. The list of causes include:
Acute Kidney Injury
Diabetes mellitus
Metabolic disorders
Hypertension
Chronic urinary obstruction
Recurrent infections
Autoimmune disorders
Assessment of Chronic Kidney Disease
With Chronic Kidney Disease, many systems will be affected. This includes neurological, cardiovascular, respiratory, gastrointestinal, urinary, integumentary and musculoskeletal manifestations. We are going to go over each system and their manifestations. The key to remembering these is simply to realize that the patient builds up fluids and electrolytes which negatively affect each system.
Neurological Manifestations
Signs and symptoms include asterixis which is a tremor of the hand, ataxia which is an alteration in gait, inability to concentrate, lethargy, seizures and coma.
Cardiovascular Manifestations
Signs and symptoms include hypertension, heart failure, peripheral edema, cardiomyopathy and pericardial effusion.
Respiratory Manifestations
Signs and symptoms include crackles, yawning, depressed cough reflex and shortness of breath.
Gastrointestinal Manifestations
Signs and symptoms include nausea, vomiting, changes in taste acuity, constipation, diarrhea and stomatitis.
Urinary Manifestations
Signs and symptoms include polyuria, proteinuria, diluted appearance, hematuria and oliguria
Integumentary Manifestations
Signs and symptoms include decreased skin turgor, dry skin, ecchymosis, uremic frost.
Musculoskeletal Manifestations
Signs and symptoms include bone pain, muscle weakness, cramping and pathological fractures.
Now that we have an idea of how each system will be affected, let's talk about what actions we take as a nurse that will help the patient improve and maintain their life.
Interventions for Chronic Kidney Disease
Administer a diet prescribed by the provider. The diet ordered consists of a moderate protein, high carbohydrate, low potassium and low phosphorus diet.
In order to prevent stomatitis and mouth sores, oral care is important to teach or provide.
Educate proper skin care to prevent pruritus which is itching of the skin.
Teach the patient about fluid restrictions and that it is vital that they weigh themselves daily. They should weigh themselves at the same time, with the same clothes and same scale for accurate measurements.
If the patient is newly diagnosed, support the patient because this is a difficult time for them. Imagine being told you have a chronic illness that requires complete lifestyle changes. The patient will have a long life treatment of dialysis and the possibility of kidney transplantation.
Since we now understand the importance of our kidneys as it regulates the entire body as a system, can you think of long term issues CKD will cause? Take a moment to think about possible answers and pause the video here.
Alright let's go over long term issues with kidney disease and interventions
Long term issues with CKD include the following:
Activity intolerance
Insomnia
Anemia
Gastrointestinal Bleeding
Hyperkalemia
hypermagnesemia
hyperphosphatemia
hypertension
hypervolemia
hypocalcemia
hypovolemia
infection
metabolic acidosis
muscle cramps
neurological changes
ocular changes,
potential for injury,
pruritus
psychological issues.
Let’s learn about each complication and along with the nursing actions.
As we go through each focus on what causes each complication, the signs of the complication, how we can avoid making the complication worse and how to improve the patient's condition.
Activity intolerance and Insomnia
Now why would a patient feel fatigued? Well because of the anemia and the buildup of wastes from the diseased kidneys. We instruct adequate rest and to plan activities in order to avoid fatigue. Mild central nervous system depressant medications may also be given.
Anemia
Now anemia occurs because of the decreased secretion of erythropoietin by damaged nephrons, which causes decreased production of red blood cells.
What may be an important lab to monitor when there's a decrease of red blood cells? Can you think of it?
It's the hemoglobin and hematocrit levels. These labs determine if a person is receiving an adequate amount of oxygen. It is important to monitor for decreased hemoglobin and hematocrit levels.
Administering hematopoietics such as epoetin alfa or darbepoetin alfa, will promote the maturity of the red blood cells.
Other medications include folic acid, iron and stool softeners. Stool softeners are used because iron causes constipation.
Depending on hemoglobin and hematocrit levels, a blood transfusion may be ordered. However, most providers try to avoid blood transfusions because it causes the development of antibodies against human tissues, which can make matching for kidney transplantation difficult.
Gastrointestinal Bleeding
What causes Gastrointestinal bleeding? Well G.I. bleeding is caused by the irritation of ammonia as it stays in the G.I. mucosa. This happens because urea can no longer break down effectively due to kidney dysfunction.
Decreased hemoglobin and hematocrit levels may also indicate bleeding. So it is also important to monitor stool with a stool sample for occult blood.
Hyperkalemia
Hyperkalemia is when potassium levels are increased. This is life threatening. What would be the first action as a nurse? The first important action is to place the patient on continuous telemetry to monitor their heart rhythm.
Hyperkalemia may cause dysrhythmias.
An elevated serum potassium level can cause decreased cardiac output, heart blocks, fibrillation, or asystole. Signs and symptoms may include hypertension or hypotension.
With hyperkalemia, a low-potassium diet will be ordered.
To lower the serum potassium level, you may administer electrolyte-binding and electrolyte-excretion medications such as oral or rectal sodium polystyrene sulfonate.
Other five medications include:
50% dextrose
regular insulin IV, which shift potassium into the cells;
calcium gluconate IV to reduce myocardial irritability from hyperkalemia,
sodium bicarbonate IV to correct acidosis and
loop diuretics excrete potassium
There are also important medications to avoid which are potassium-retaining medications such as spironolactone
and triamterene because these medications will increase the potassium levels.
If potassium levels are very high then the patient will need to be prepared for peritoneal dialysis or hemodialysis.
Hypermagnesemia
With Chronic kidney disease, magnesium cannot be excreted, resulting in hypermagnesemia.
You will want to monitor for cardiac manifestations such as bradycardia, peripheral vasodilation, hypotension. CNS changes, such as drowsiness lethargy and neuromuscular manifestations, such as reduced or absent deep tendon reflexes.
Medications will include loop diuretics to excrete magnesium and calcium for cardiac problems.