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.

Avoid medications that contain magnesium, such as antacids. Also some laxatives and enemas may also contain magnesium.

Hyperphosphatemia

As the phosphorus levels increase, the calcium level decreases. This leads to the stimulation of parathyroid hormone, causing bone demineralization making bones weak.

To help the patient recover, the goal is focused on lowering serum phosphorus levels. This is done with certain medications such as phosphate binders. Now, because phosphate binders have a constipating effect, stool softeners and laxatives may be given.

Educate the patient about limiting the intake of foods high in phosphorus such as chicken, turkey and nuts. There is a list of foods on our website if you like to have a more complete list.

Hypertension

Now because the kidneys are failing, they can no longer maintain the blood pressure. So monitoring vital signs for an elevated BP is vital. To avoid a high blood pressure, fluid and sodium restrictions are placed by the doctor.

Medications that lower blood pressure are diuretics and antihypertensives.

Hypervolemia

When fluid volume excess occurs, it is important to monitor vital signs for an elevated BP.

Also monitor the patients fluid intake and output along with their daily weight. Assess for periorbital, sacral, and peripheral edema. Monitor the serum electrolyte levels.

When there is too much fluid in the body, it is vital to monitor for signs of heart failure and pulmonary edema, such as restlessness, heightened anxiety, tachycardia, dyspnea, lung crackles, and blood-tinged sputum; If any of these signs occurs, notify the provider immediately

Fluid restrictions will be placed along with a low sodium diet because sodium retains fluid in the body.

Hypocalcemia

There are two causes of hypocalcemia. High phosphorus levels and the inability to activate vitamin D.

Interventions include monitoring the serum calcium level and administering medications.

Medications include calcium supplements and activated vitamin D.

Hypovolemia

When a patient is having fluid volume deficit, they are at risk of hypotension and tachycardia. Interventions include monitoring for a decrease in intake and output as well as daily weight. Monitor for dehydration and electrolyte levels.

Infection

Due to a suppressed immune system, the patient is at risk for infection, especially at the dialysis access site.

Interventions include monitoring for signs of infection and avoiding urinary catheters when possible because any open site going to the body will create a higher risk of bacteria entering their system.

Instruct the patient to avoid fatigue and avoid anyone with an infection.

Administer antibiotics as prescribed while also monitoring for nephrotoxic effects.

Metabolic Acidosis

Since the kidneys are unable to excrete hydrogen ions or make bicarbonate, this causes acidosis.

Medications to help the patient with this are alkalizers such as sodium bicarbonate.

Muscle Cramps

Electrolyte imbalances and the effects of uremia on peripheral nerves will cause muscle cramps.

Interventions include monitoring serum electrolyte levels.

Medications to administer are electrolyte replacements and medications to control muscle cramps which will be discussed in another video. A non pharmacological way to help with muscle cramps include heat and massages.

Neurological Changes

Confusion and impairment in decision making is caused from the build up of wastes and fluids. Another sign from a neurological change is peripheral neuropathy which is numbness, weakness and pain due to the uremia building on the peripheral nerves. During the neurological assessment, monitor the level of consciousness or confusion.

The most important teaching is to educate the patient to examine areas where they have decreased sensation and numbness. Why? Because if the patient can’t feel their feet for example and unknowingly injures it, this leads to infection as it gets left untreated. Remember that patients with CKD have a weak immune system so infections can be life threatening.

Ocular Irritation

The main cause of ocular irritation is due to calcium deposits which cause burning and watering of the eyes. There are medications that will help alleviate this problem which will be listed on another video. Lubricating eye drops help with this issue.

Potential for injury

Since the kidneys are responsible for absorption of calcium and excretion of phosphate, a healthy normal person would not have any fractures. However for a patient with chronic kidney disease, they are at risk for fractures. So preventing injuries is vital. Injuries could occur with falls so also always check the environment for potential hazards such as cords and clutter on the floor.

Pruritus

Why would kidney disease cause itching? Because urate crystals are excreted through the skin since the kidneys cannot excrete them.

When urate crystals sit on the skin, this causes itching which is also known as pruritus. As the disease progresses, uremic frost becomes visible on the skin.

To help alleviate the patient from this complication, you want to monitor for skin breakdown, rash and uremic frost. Educate the patient to take care of their skin and personal hygiene. For example, they should keep their nails trimmed to prevent local infection from scratching. They will also need to avoid harsh soaps that could break down their skin. If itching occurs, antihistamine medications can be administered.

Psychosocial Problems

Remember that this is a life changing disease so take the time to listen to the patient's concerns. Allow the patient time to mourn the loss of kidney function as each person is different.

Educate about treatment options and support the patients decision.

Okay so here's what we learned in this video. We went over chronic kidney disease and the primary causes. Complications with signs and symptoms of each. Interventions which include diet, skin care, fluid restrictions and medications.

Remember, if you can focus on causes and complications then nursing interventions will make sense. The NCLEX will always ask questions about initial actions as a nurse.

As always, thanks for reading!

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