Focus on Acute and
Chronic Kidney Disease
S. Buckley, N246,
(Adapted from Mosby pp)
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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.
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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
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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)
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ATN-Acute tubular necrosis
• Hypovolemia, decreased renal blood
flow
• Ischemia alters glomerular
permeability, decreased GFR,
tubular dysfunction
• damaged tubules=Interstitial
edema=leaking glomerular filtrate.
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postrenal
• Mechanical obstruction of urinary
outflow (calculi, trauma, BPH, ca)
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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.
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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.
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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
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Chronic Kidney Disease (CKD)
• Involves progressive, irreversible
loss of kidney function
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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
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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
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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
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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
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Chronic Kidney Disease (Cont’d)
• Leading causes of ESRD
 Diabetes
 Hypertension
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Clinical Manifestations
• Result of retained substances
 Urea
 Creatinine
 Phenols
 Hormones
 Electrolytes
 Water
 Other substances
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Clinical Manifestations (Cont’d)
• Uremia
 Syndrome that incorporates all signs
and symptoms seen in various systems
throughout the body
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Manifestations of Chronic Uremia
Fig. 47-5
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Clinical Manifestations
Urinary System
• Polyuria
 Results from inability of kidneys to
concentrate urine
 Occurs most often at night
 Specific gravity fixed around 1.010
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Clinical Manifestations
Urinary System (Cont’d)
• Oliguria
 Occurs as CKD worsens
• Anuria
 Urine output <40 ml per 24 hours
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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
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Clinical Manifestations
Metabolic Disturbances
• Waste product accumulation
(cont’d)
• Serum creatinine and creatinine
clearance are more accurate
indicators of kidney function than
BUN
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Clinical Manifestations
Metabolic Disturbances (Cont’d)
• Defective carbohydrate metabolism
 Caused by impaired glucose use
• From cellular insensitivity to the
normal action of insulin
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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
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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
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Clinical Manifestations
Electrolyte/Acid–Base Imbalances
• Potassium
 Hyperkalemia
• Most serious electrolyte disorder in
kidney disease
• Fatal dysrhythmias
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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
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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
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Clinical Manifestations
Electrolyte/Acid–Base Imbalances (Cont’d)
• Calcium and phosphate alterations
• Magnesium alterations
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Clinical Manifestations
Electrolyte/Acid–Base Imbalances (Cont’d)
• Metabolic acidosis
 Results from
• Inability of kidneys to excrete acid
load (primary ammonia)
• Defective reabsorption/regeneration
of bicarbonate
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Clinical Manifestations
Hematologic System
• Anemia
 Due to ↓ production of erythropoietin
• From ↓ of functioning renal tubular
cells
• Bleeding tendencies
 Defect in platelet function
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Clinical Manifestations
Hematologic System (cont’d)
• Infection
 Changes in leukocyte function
 Altered immune response and function
 Diminished inflammatory response
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Clinical Manifestations
Hematologic System (cont’d)
• Increased incidence of cancer
 Lung
 Breast
 Uterus
 Colon
 Prostate
 Skin
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Clinical Manifestations (Cont’d)
Cardiovascular System
• Hypertension
• Heart failure
• Left ventricular hypertrophy
• Peripheral edema
• Dysrhythmias
• Uremic pericarditis
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Clinical Manifestations (Cont’d)
Respiratory System
• Kussmaul respiration
• Dyspnea
• Pulmonary edema
• Uremic pleuritis
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Clinical Manifestations
Respiratory System (cont’d)
• Pleural effusion
• Predisposition to respiratory
infections
• Depressed cough reflex
• “Uremic lung”
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Clinical Manifestations (Cont’d)
Gastrointestinal System
• Every part of GI is affected
 Due to excessive urea
• Mucosal ulcerations
• Stomatitis
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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
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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
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Clinical Manifestations
Neurologic System (cont’d)
• Altered mental ability
• Seizures
• Coma
• Dialysis encephalopathy
• Peripheral neuropathy
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Clinical Manifestations
Neurologic System (cont’d)
• Restless leg syndrome
• Muscle twitching
• Irritability
• Decreased ability to concentrate
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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
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Clinical Manifestations
Musculoskeletal System (cont’d)
• Metastatic calcifications
 Muscles, lungs, skin, GI tract, eyes
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Renal Osteodystrophy
Fig. 47-6
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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
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Clinical Manifestations
Integumentary System (cont’d)
• Dry, brittle hair
• Thin nails
• Petechiae
• Ecchymoses
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Clinical Manifestations (Cont’d)
Reproductive System
• Infertility
 Experienced by both sexes
• Decreased libido
• Low sperm counts
• Sexual dysfunction
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Clinical Manifestations (Cont’d)
Endocrine System
• Manifestations of hypothyroidism
• Thyroid function may yield low to
low-normal levels of T3 and T4
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Clinical Manifestations (Cont’d)
•
•
•
•
•
Psychologic changes
Personality and behavioral changes
Emotional ability
Withdrawal
Depression
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Diagnostic Studies
• History and physical examination
• Laboratory tests
 BUN
 Serum creatinine
 Creatinine clearance
 Serum electrolytes
 Protein-creatinine ratio (first morning
void)
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Diagnostic Studies
• Laboratory tests (cont’d)
 Urinalysis
 Urine culture
 Hematocrit
 Hemoglobin
• Renal ultrasound
• Renal scan
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Diagnostic Studies (Cont’d)
• Renal scan
• CT scan
• Renal biopsy
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Collaborative Care
• Conservative therapy
• Correction of extracellular fluid
volume overload or deficit
• Nutritional therapy
• Erythropoietin therapy
• Calcium supplementation,
phosphate binders
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Collaborative Care (Cont’d)
• Antihypertensive therapy
• Measures to lower potassium
• Adjustment of drug dosages to
degree of renal function
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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
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Collaborative Care
Drug Therapy (cont’d)
• Hyperkalemia (cont’d)
 Sodium polystyrene sulfonate
(Kayexalate)
• Cation-exchange resin
• Resin in bowel exchanges potassium
for sodium
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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
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Collaborative Care (Cont’d)
Drug Therapy
• Hypertension
 Weight loss
 Lifestyle changes
 Diet recommendations
 Sodium and fluid restriction
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Collaborative Care
Drug Therapy (cont’d)
• Hypertension (cont’d)
 Antihypertensive drugs
• Diuretics
• β-Adrenergic blockers
• Calcium channel blockers
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Collaborative Care
Drug Therapy (cont’d)
• Hypertension (cont’d)
 Antihypertensive drugs (cont’d)
• Angiotensin-converting enzyme
(ACE) inhibitors
• Angiotensin receptor blocker agents
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Collaborative Care
Drug Therapy (cont’d)
• Renal osteodystrophy
 Phosphate intake restricted to
<1000 mg/day
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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
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Collaborative Care
Drug Therapy (cont’d)
• Renal osteodystrophy (cont’d)
 Phosphate binders (cont’d)
• Should be administered with each
meal
• Side effect: Constipation
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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
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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
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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
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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
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Collaborative Care
Drug Therapy (cont’d)
• Anemia (cont’d)
 Folic acid supplements
• Needed for RBC formation
• Removed by dialysis
 Avoid blood transfusions
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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
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Collaborative Care
Drug Therapy (cont’d)
• Dyslipidemia (cont’d)
 Fibrates
• Fibric acid derivatives
• Most effective for lowering
triglycerides
• Can also decrease HDLs
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Collaborative Care (Cont’d)
Drug Therapy
• Complications
 Drug toxicity
• Digitalis
• Antibiotics
• Pain medication (Demerol, NSAIDs)
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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
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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
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Collaborative Care
Nutritional Therapy (cont’d)
• Potassium restriction
 2 to 4 g
 High-potassium foods should be
avoided
• Oranges
• Bananas
• Tomatoes
• Green vegetables
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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
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Nursing Management
Nursing Assessment
• Complete history of any existing
renal disease, family history
• Long-term health problems
• Dietary habits
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Nursing Management
Nursing Diagnoses
• Excess fluid volume
• Risk for injury
• Imbalanced nutrition: Less than
body requirements
• Grieving
• Risk for infection
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Nursing Management
Planning
• Overall goals
 Demonstrate knowledge and ability to
comply with therapeutic regimen
 Participate in decision making
 Demonstrate effective coping
strategies
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Nursing Management
Planning
• Overall goals (cont’d)
 Continue with activities of daily living
within psychologic limitations
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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
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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
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Nursing Management
Nursing Implementation (Cont’d)
• Acute intervention (cont’d)
 Medication education
 Motivate patients in management of
their disease
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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
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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
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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
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Gerontologic Considerations (Cont’d)
• Diminished cardiopulmonary
function
• Bone loss
• Immunodeficiency
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Gerontologic Considerations (Cont’d)
• Altered protein synthesis
• Impaired cognition
• Altered drug metabolism
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Gerontologic Considerations (Cont’d)
• Most common cause of death in the
elderly ESRD patient
 Cardiovascular disease (MI, stroke)
 Withdrawal from dialysis
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Case Study
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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
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Case Study (Cont’d)
• Symptoms progressed over 4
months, with 10 pounds of weight
lost with no decline in appetite
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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
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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
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
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
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
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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?
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?
Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.