1. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Acute and Chronic Kidney Disease S. Buckley, N246, (Adapted from Mosby pp)

2. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Renal failure Partial or complete impairment of Kidney function resulting in an inability to excrete metabolic waste products and water Results in functional disturbances of all body systems Acute renal failure (ARF) has rapid onset, reversible, mortality rate~50%. Chronic kidney disease (CKD) develops slowly, requires dialysis or transplant.

3. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Renal Failure ARF-rapid loss of renal function with progressive azotemia ( accumulation of nitrogenous waste products; urea nitrogen, creatinine in blood ), few symptoms initially. Uremia -renal function declines to point of symptom development; oliguria

4. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology Prerenal -causes leading to ARF are due to factors external to the kidneys that reduce renal blood flow and lead to decreased glomerular perfusion and filtration (oliguria, na and water conservation, azotemia) Intrarenal-conditions that cause direct damage to the renal tissue resulting in impaired nephron function (ATN, nephrotoxins, glomerulonephritis)

5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. ATN-Acute tubular necrosis Hypovolemia, decreased renal blood flow Ischemia alters glomerular permeability, decreased GFR, tubular dysfunction damaged tubules=Interstitial edema=leaking glomerular filtrate.

6. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. postrenal Mechanical obstruction of urinary outflow (calculi, trauma, BPH, ca)

7. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

8. Clinical course of ARF Initiating phase-hours to days, begins at time of insult and continues until symptoms become apparent. Oliguric phase- most common, reduction of GFR, begins 1-7 days after event, lasts 10-14 days (or months),urine sp. Gr (1.010), RBC, WBC in urine. Other changes: fluid volume excess, metabolic acidosis, hyponatremia, hyperkalemia, amenia, ca deficit, phosphate excess, waste accumulation (increase BUN, creatinine,neuro disorders.

9. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. ARF (continued) Diuretic phase-increase in u/o of 1-3 L/day, may result hypovolemia, hypotension, hyponatremia, hypokalemia, dehydration. Lasts 1-3 wks. Recovery phase-begins when GFR increases, allowing BUN and serum creatinine levels to decrease, up to 12 months to stabilize. Outcome influenced by overall health.

10. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

11. Nursing interventions (ARF) Assessment of systemic complications (p. 1201) Monitor; vs, u/o, labs, skin color, edema, mental status, emotional state, educate pt, monitor diet, potential dialysis, medications, treat infections, manage fluid and electrolytes

12. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD) Involves progressive, irreversible loss of kidney function

13. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (Cont’d) Defined as either presence of  Kidney damage Pathologic abnormalities Markers of damage Blood, urine, imaging tests  Glomerular filtration rate (GFR) <60 ml/min for 3 months or longer

14. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (Cont’d) Disease staging based on decrease in GFR  Normal GFR 125 ml/min, which is reflected by urine creatinine clearance  Last stage of kidney failure End-stage renal disease (ESRD) occurs when GFR <15 ml/min

15. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (Cont’d) Up to 80% of GFR may be lost with few changes in functioning of body Remaining nephrons hypertrophy to compensate Result is a systemic disease involving every organ

16. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (Cont’d) Each year 70,000 people die from causes related to renal failure 40 million Americans are at risk for CKD Number of patients with ESRD is expected to reach 660,000 by 2010

17. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (Cont’d) Leading causes of ESRD  Diabetes  Hypertension

18. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Result of retained substances  Urea  Creatinine  Phenols  Hormones  Electrolytes  Water  Other substances

19. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Uremia  Syndrome that incorporates all signs and symptoms seen in various systems throughout the body

20. Manifestations of Chronic Uremia Fig. 47-5 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

21. Clinical Manifestations Urinary System Polyuria  Results from inability of kidneys to concentrate urine  Occurs most often at night  Specific gravity fixed around 1.010

22. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Urinary System (Cont’d) Oliguria  Occurs as CKD worsens Anuria  Urine output <40 ml per 24 hours

23. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

24. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Metabolic Disturbances Waste product accumulation (cont’d) Serum creatinine and creatinine clearance are more accurate indicators of kidney function than BUN

25. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Metabolic Disturbances (Cont’d) Defective carbohydrate metabolism  Caused by impaired glucose use From cellular insensitivity to the normal action of insulin

26. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Metabolic Disturbances Defective carbohydrate metabolism (cont’d)  Patients with diabetes who become uremic may require less insulin than before onset of CKD  Insulin dependent on kidneys for excretion

27. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Metabolic Disturbances (Cont’d) Elevated triglycerides  Hyperinsulinemia stimulates hepatic production of triglycerides  Altered lipid metabolism ↓ Levels of enzyme lipoprotein lipase Important in breakdown of lipoproteins

28. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Electrolyte/Acid–Base Imbalances Potassium  Hyperkalemia Most serious electrolyte disorder in kidney disease Fatal dysrhythmias

29. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Electrolyte/Acid–Base Imbalances Potassium  Hyperkalemia (cont’d) Results from decreased excretion by kidneys, breakdown of cellular protein, bleeding metabolic acidosis, food intake, medications

30. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Electrolyte/Acid–Base Imbalances (Cont’d) Sodium  May be normal or low  Because of impaired excretion, sodium is retained Water is retained Edema Hypertension CHF

31. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium and phosphate alterations Magnesium alterations Clinical Manifestations Electrolyte/Acid–Base Imbalances (Cont’d)

32. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Metabolic acidosis  Results from Inability of kidneys to excrete acid load (primary ammonia) Defective reabsorption/regeneration of bicarbonate Clinical Manifestations Electrolyte/Acid–Base Imbalances (Cont’d)

33. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Hematologic System Anemia  Due to ↓ production of erythropoietin From ↓ of functioning renal tubular cells Bleeding tendencies  Defect in platelet function

34. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Hematologic System (cont’d) Infection  Changes in leukocyte function  Altered immune response and function  Diminished inflammatory response

35. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Hematologic System (cont’d) Increased incidence of cancer  Lung  Breast  Uterus  Colon  Prostate  Skin

36. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis

37. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Uremic pleuritis

38. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Respiratory System (cont’d) Pleural effusion Predisposition to respiratory infections Depressed cough reflex “Uremic lung”

39. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Gastrointestinal System Every part of GI is affected  Due to excessive urea Mucosal ulcerations Stomatitis

40. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Gastrointestinal System (cont’d) Every part of GI is affected (cont’d)  Due to excessive urea (cont’d) Uremic fetor (urinous odor of breath) GI bleeding Anorexia N/V

41. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Neurologic System Expected as renal failure progresses  Attributed to ↑ nitrogenous waste products Electrolyte imbalances Metabolic acidosis Axonal atrophy Demyelination of nerve fibers

42. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Neurologic System (cont’d) Altered mental ability Seizures Coma Dialysis encephalopathy Peripheral neuropathy

43. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Neurologic System (cont’d) Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate

44. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) 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

45. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Musculoskeletal System (cont’d) Metastatic calcifications  Muscles, lungs, skin, GI tract, eyes

46. Renal Osteodystrophy Fig. 47-6 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

47. Clinical Manifestations (Cont’d) Integumentary System Most noticeable change  Yellow-gray discoloration of the skin Due to absorption/retention of urinary pigments Pruritus Uremic frost Dry, pale skin

48. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Integumentary System (cont’d) Dry, brittle hair Thin nails Petechiae Ecchymoses

49. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Reproductive System Infertility  Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction

50. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Endocrine System Manifestations of hypothyroidism Thyroid function may yield low to low-normal levels of T 3 and T 4

51. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations (Cont’d) Psychologic changes Personality and behavioral changes Emotional ability Withdrawal Depression

52. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies History and physical examination Laboratory tests  BUN  Serum creatinine  Creatinine clearance  Serum electrolytes  Protein-creatinine ratio (first morning void)

53. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

54. Diagnostic Studies Laboratory tests (cont’d)  Urinalysis  Urine culture  Hematocrit  Hemoglobin Renal ultrasound Renal scan

55. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies (Cont’d) Renal scan CT scan Renal biopsy

56. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Conservative therapy Correction of extracellular fluid volume overload or deficit Nutritional therapy Erythropoietin therapy Calcium supplementation, phosphate binders

57. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Antihypertensive therapy Measures to lower potassium Adjustment of drug dosages to degree of renal function

58. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Drug Therapy Hyperkalemia  IV insulin IV glucose to manage hypoglycemia  IV 10% calcium gluconate  Sodium bicarbonate Shift potassium into cells Correct acidosis

59. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Hyperkalemia (cont’d)  Sodium polystyrene sulfonate (Kayexalate) Cation-exchange resin Resin in bowel exchanges potassium for sodium

60. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Hyperkalemia (cont’d)  Sodium polystyrene sulfonate (Kayexalate) (cont’d) Evacuates potassium-rich stool from body Educate patient that diarrhea may occur due to laxative in preparation

61. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Drug Therapy Hypertension  Weight loss  Lifestyle changes  Diet recommendations  Sodium and fluid restriction

62. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Hypertension (cont’d)  Antihypertensive drugs Diuretics β-Adrenergic blockers Calcium channel blockers

63. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Hypertension (cont’d)  Antihypertensive drugs (cont’d) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blocker agents

64. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Renal osteodystrophy  Phosphate intake restricted to <1000 mg/day

65. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Renal osteodystrophy (cont’d)  Phosphate binders Calcium carbonate (Tums) Bind phosphate in bowel and excreted Sevelamer hydrochloride (Renagel) Lowers cholesterol and LDLs

66. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Renal osteodystrophy (cont’d)  Phosphate binders (cont’d) Should be administered with each meal Side effect: Constipation

67. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Renal osteodystrophy (cont’d)  Supplementing vitamin D Calcitriol (Rocaltrol) Serum phosphate level must be lowered before administering calcium or vitamin D

68. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Renal osteodystrophy (cont’d)  Controlling secondary hyperparathyroidism Calcimimetic agents Cinacalcet (Sensipar) ↑ Sensitivity of calcium receptors in parathyroid glands Subtotal parathyroidectomy

69. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Drug Therapy Anemia  Erythropoietin Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks Side effect: Hypertension

70. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Anemia (cont’d)  Iron supplements If plasma ferritin <100 ng/ml Side effect: Gastric irritation, constipation May make stool dark in color

71. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Anemia (cont’d)  Folic acid supplements Needed for RBC formation Removed by dialysis  Avoid blood transfusions

72. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Drug Therapy Dyslipidemia  Goal Lowering LDL below 100 mg/dl Triglyceride level below 200 mg/dl  Statins HMG-CoA reductase inhibitors Most effective for lowering LDL

73. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Drug Therapy (cont’d) Dyslipidemia (cont’d)  Fibrates Fibric acid derivatives Most effective for lowering triglycerides Can also decrease HDLs

74. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Drug Therapy Complications  Drug toxicity Digitalis Antibiotics Pain medication (Demerol, NSAIDs)

75. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) Nutritional Therapy Protein restriction  0.6 to 0.8 g/kg body weight/day Water restriction  Intake depends on daily urine output

76. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care (Cont’d) 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

77. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Nutritional Therapy (cont’d) Potassium restriction  2 to 4 g  High-potassium foods should be avoided Oranges Bananas Tomatoes Green vegetables

78. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Nutritional Therapy (cont’d) Phosphate restriction  1000 mg/day  Foods high in phosphate Dairy products  Most foods high in phosphate are also high in calcium

79. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment Complete history of any existing renal disease, family history Long-term health problems Dietary habits

80. Copyright © 2010, 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

81. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Planning Overall goals  Demonstrate knowledge and ability to comply with therapeutic regimen  Participate in decision making  Demonstrate effective coping strategies

82. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Planning Overall goals (cont’d)  Continue with activities of daily living within psychologic limitations

83. Copyright © 2010, 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

84. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Acute intervention  Daily weight  Daily BPs  Identify signs and symptoms of fluid overload  Identify signs and symptoms of hyperkalemia  Strict dietary adherence

85. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Acute intervention (cont’d)  Medication education  Motivate patients in management of their disease

86. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Ambulatory and home care  When conservative therapy is no longer effective, HD, PD, and transplantation are treatment options  Patient/family need clear explanation of dialysis and transplantation

87. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation Maintenance of ideal body weight Acceptance of chronic disease No infections No edema Hematocrit, hemoglobin, and serum albumin levels in acceptable range

88. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations About 35% of ESRD patients are 65 years of age or older Most common diseases leading to renal failure in the older adult  Hypertension  Diabetes

89. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations (Cont’d) Diminished cardiopulmonary function Bone loss Immunodeficiency

90. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations (Cont’d) Altered protein synthesis Impaired cognition Altered drug metabolism

91. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations (Cont’d) Most common cause of death in the elderly ESRD patient  Cardiovascular disease (MI, stroke)  Withdrawal from dialysis

92. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study

93. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study 35-year-old male began to notice weakness with activities such as walking distances or running Also began experiencing tingling all over his body, particularly in his hands and feet

94. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Symptoms progressed over 4 months, with 10 pounds of weight lost with no decline in appetite

95. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Increased urinary output with normal frequency Strong thirst at night Sought medical help because he was afraid he was getting diabetes

96. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study - History History reveals grandmother and aunt have diabetes with no family history of renal disease At 5 years of age, he was admitted to the hospital for hematuria  Urinary protein 4+  BUN 31 mg/dl  Hb 11.6  Was diagnosed with acute glomerulonephritis

97. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study - History At 11 years of age, he was admitted to the same hospital with gross hematuria  Albuminuria 4+  BUN 10.5  Hb 15.7  Diagnosed with recurring acute glomerulonephritis

98. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study He has had no follow-up medical care after that hospitalization until being admitted to the hospital currently

99. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Current lab values  Potassium 6.0 mEq/L  BUN 110 mg/dl  Creatinine 12 mg/dl  Hct 20%  Hb 6 gm/dl

100. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions 1.Why would his symptoms seem similar to diabetes? 2.Why is he developing chronic renal failure so many years after his primary diagnosis?

101. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions (Cont’d) 3.What is the priority of care for him? 4.What patient teaching should be done with him?