Chronic Kidney Disease Exemplar Table Medical Diagnosis/Concept (List the concept) Concept: Elimination Chronic Kidney Disease – progressive, irreversible loss of kidney function (Define the diagnosis/exemplar in your own words) Clinical Manifestations Finding: (List the display or disclosure of characteristic signs or symptoms of the diagnosis and include prioritized Nursing Interventions for each manifestation or group of findings) Often asymptomatic Leading causes: diabetes, hypertension Less common causes: glomerulonephritis, cystic disease, and urologic disease Kidney damage or decreased GFR < 60 for longer than 3 months End-stage renal disease – last stage of kidney disease 1. GFR < 15. Need RRT (dialysis or transplantation) Uremia – kidney function declines and damages other organs 1. Often occurs when GFR <15 Diabetes is primary cause of CKD 1. Waste Product Accumulation – GFR decreases and BUN and creatinine increase Creatinine is more accurate indicator of kidney dysfunction Increased BUN can cause nausea, vomiting, lethargy, fatigue, impaired thought process, and headaches 2. Altered Carbohydrate Metabolism – impaired glucose metabolism, resulting from cellular insensitivity to insulin Mild to moderate hyperglycemia and hyperinsulinemia may occur 3. Elevated Triglycerides – hyperinsulinemia stimulates hepatic production of triglycerides Patients with uremia will develop dyslipidemia, increased VLDLs, increased LDLs, der=creased HDLs Acid-Base Imbalances Potassium – hyperkalemia Most serious electrolyte disorder in kidney disease Fatal dysthymias a. When potassium level reaches 7 to 8 Sodium – may be high, normal, or low Because of impaired excretion, sodium and water are retained Dilutional hyponatremia may occur a. Can cause edema, hypertension, and heart failure. b. Sodium restricted to 2g/day Calcium and Phosphate and Magnesium Hypermagnesemia related to ingestion of magnesium a. Can result in absence of reflexes, decreased mental status, cardiac dysthymias, hypotension, respiratory failure Metabolic Acidosis kidneys impaired ability to excrete excess acid defective reabsorption and regeneration of bicarbonate plasma bicarbonate usually falls to 16 to 20 mEq/L Hematologic System Anemia Due to decreased production of erythropoietin Contributing factors – nutritional deficiencies, decreased RBC life span, increased hemolysis of RBCs, frequent blood sampling, and GI bleeding Iron deficient and need supplements GI side effects can cause adherence difficulties Need supplemental folic acid due to loss from dialysis Bleeding Tendencies Defective platelet function Caused by impaired platelet aggregation and impaired release of platelet factor III Infection Increased susceptibility to infection Changes in WBC function and altered immune response and function Cellular and humoral immune suppression Cardiovascular System – susceptible to dysrhythmias from hyperkalemia and decreased coronary artery perfusion Most common death in CKD is CVD Traditional risk factors are hypertension and increased lipids CVD may be related to vascular calcification and arterial stiffness Calcium deposits stiffen blood vessels Vascular smooth muscle cells change 1. Into chondrocytes or osteoblasts 2. High calcium and phosphate result from abnormal bone metabolism 3. Impaired renal excretion 4. Drug therapies to treat bone disease Hypertension – both a cause and consequence of CKD Worsened by sodium retention and increased ECF Increased renin production can contribute Can develop into left ventricular hypertrophy, cardiomyopathy, and HF Can cause retinopathy, encephalopathy, nephropathy Respiratory System Kussmaul breathing Dyspnea occurs because of fluid overload, pulmonary edema, uremic pleuritis, pleural effusions, and respiratory infections Gastrointestinal System Stomatitis with exudates and ulcerations Metallic taste in mouth and uremic fetor (urinous odor of the breath) Anorexia, nausea, vomiting develops if CKD progresses to ERSD and not treated with dialysis Weight loss and malnutrition Diabetic gastroparesis (delayed gastric emptying) GI bleeding due to mucosal irritation and platelet defect Constipation due to ingesting iron salts or calcium containing phosphate binders Neurologic System Changes are expected as disease progresses Result of increased nitrogenous waste products electrolyte imbalances, metabolic acidosis, and atrophy and demyelination of nerve fibers CNS becomes depressed resulting in: lethargy, apathy, decreased concentration, fatigue, irritability, altered mental status Seizures and coma may result from increased BUN and hypertensive encephalopathy Slowing of nerve conduction leads to peripheral neuropathy and paresthesias Motor involvement includes foot drop, muscle weakness, atrophy, loss of deep tendon reflexes, muscle twitching, jerking, asterixis, nocturnal leg cramps Advanced stage 5 CKD may develop restless leg syndrome Musculoskeletal System CKD mineral and bone disorder 1. Caused by deterioration in kidney function Skeletal complications include: osteomalacia and osteitis fibrosa Soft tissue complications result from vascular calcifications Irritation from calcium deposits cause uremic red eye Intracardiac calcifications can cause cardiac arrest Integumentary System Pruritus 1. Dry skin, calcium-phosphate deposition in skin and sensory neuropathy 2. Intense itching can lead to bleeding and infection Uremic frost – urea crystallizes on the skin (rare) BUN over 200 Reproductive System Women - Decreased libido and infertility - Low estrogen, progesterone, luteinizing hormone, causes anovulation and menstrual changes Men - Loss of testicular consistency, decreased testosterone, and low sperm counts Pregnancy carries a significant risk to mother and infant Changes in sexual function include psychologic problems, physical stress, and medication side effects Psychologic Changes Personality and behavioral changes, emotional liability, withdrawal, and depression occurs Fatigue and lethargy Changes in body image like edema, integumentary changes, and access devices can cause anxiety and depression Decreased ability to concentrate, slowed mental activity give the appearance of disinterest Long term survival depends on medications, dietary restrictions, dialysis, and transplantation Nursing Interventions: preserve existing kidney function, reduce risks of CV disease, prevent complications, and provide comfort for the patient Diagnostic Studies (List and prioritize the studies required to diagnose this condition and define in your own words each one and why study is necessary) (List panel or panels and state which lab would be most significant and include prioritized Nursing Interventions/responsibility for each) Collaborative Care 1. 2. 3. 4. 5. 6. 7. Renal ultrasound, renal scan, CT scan – to detect obstructions and determine size of the kidneys Renal biopsy – to provide definitive diagnosis BUN, creatinine, and creatinine clearance levels Lipid profile Urinalysis – to detect RBCs, WBCs, protein, casts, and glucose Hematocrit and hemoglobin levels Dipstick evaluation of protein - Nursing Interventions: Conservative Therapy: correction of ECF volume overload or deficit, nutritional therapy, erythropoietin therapy, calcium supplementation, phosphate binders, antihypertensive therapy, measures to lower potassium, adjustment of drug dosages to degree of renal function 1. Nephrologist – to detect and treat potentially reversible causes of kidney failure 2. Therapist – to help them cope with their disease 3. Health care provider – to maintain other health issues that can lead to CKD (List other healthcare professionals and describe in your own words how they would assist your patient and any prioritized Nursing intercollaborative care) Pharmacologic Interventions (List priority medications required with mechanism of action, adverse effects, and what diagnostics if any should be reviewed before and after medication is administered/Nursing intervention) 4. Social worker – to help find support groups or other help if they live alone 5. Dietician – to help make a healthy meal plan 1. Hyperkalemia – treat with IV glucose and insulin a. Or IV calcium gluconate b. Sodium polystyrene sulfonate – cation exchange resin - Given to lower potassium levels - Has osmotic laxative action and ensures evacuation of potassium from the bowels c. Patiromer (veltessa) – binds potassium in the GI tract - Used to treat hyperkalemia - Can bind oral medications, take 6 hrs. before or after other medications 2. Hypertension – treatment includes: a. Weight loss, therapeutic lifestyle changes, diet recommendations, and antihypertensive drugs b. ACE inhibitors and ARBs are given to diabetic patients 3. CKD-MBD a. Gold standard is bone biopsy b. Interventions include limiting dietary phosphorus, giving phosphate binders, supplementing vitamin D, controlling hyperparathyroidism c. Phosphate not restricted until patient needs RRT - Phosphate usually limited to 1 g/day d. Calcium acetate and calcium carbonate - Bind in the bowel and excrete in stool - Giving calcium may increase calcium load and increase risk for vascular calcifications - Non calcium-based phosphate binders: lanthanum carbonate (fosrenol), sevelamer carbonate (renvela), velphoro, auryxia e. Avoid aluminum preparations - Don’t use magnesium antacids, magnesium depends on the kidneys for excretion - Can cause constipation f. Hypocalcemia – due to inability of the GI tract to absorb calcium in absence of vitamin D 4. 5. 6. 7. 8. - Supplemental calcium and vitamin D should be given - Vitamin D given in the form of cholecalciferol g. Treat secondary hyperparathyroidism - Requires activated vitamin D - IV calcitriol, IV paricalcitol, oral or IV doxercalciferol - Can reduce high PTH levels - Cinacalcet used to control secondary hyperparathyroidism h. Hypercalcemia – occurs with calcium and vitamin D supplementation Anemia - Decreased production of erythropoietin a. Epoetin alfa IV or subcutaneously 2 or3 times a week b. Darbepoetin alfa can be given weekly or biweekly - Hemoglobin and hematocrit increase in 2 to 3 weeks - Higher hemoglobin increases thromboembolic events and risk for CV events - Reduce need for blood transfusions a. Increase antibodies b. May lead to iron overload - Iron supplements is plasma ferritin is <100 a. Iron supplements cause dark stool b. Decreased patient adherence due to GI side effects - Folic acid 1 mg/day needed for RBC formation, removed by dialysis Dyslipidemia - Atorvastatin – used to lower LDLs - Fibrates like gemfibrozil (Lopid) used to lower triglyceride levels and increase HDLs Complications of Drug Therapy - Drug toxicity due to accumulation of drugs - Drugs of concern: digoxin, diabetic agents, antibiotics, opioid drugs Nutritional Therapy - PD – protein intake must be high a. 1.2 g/kg Fluid Restriction - Reduce fluid retention, diuretics often used - HD patients urine output decreases, fluids restricted 9. Sodium and Potassium Restrictions - Avoid high sodium foods a. 2 to 4 g/day - Potassium restriction depends on kidneys a. PD doesn’t need potassium restriction b. May need oral potassium because of dialysis 10. Phosphate Restriction - Can develop hyperphosphatemia a. Limit to 1 g/day b. Foods high in phosphate: meat and dairy products, they are also high in protein c. Phosphate binders control phosphate levels Nursing Interventions: 1. Hyperkalemia – restrict high potassium foods and drugs 2. Sodium polystyrene sulfonate can cause diarrhea a. Never give to hypoactive bowel patient because fluid shifts can lead to bowel necrosis b. Observe for sodium and water retention c. Peaked T waves and widened ORS complexes – dialysis may be needed to remove potassium 3. Patiromer – has a delayed onset of action – don’t give in emergency situations 4. ACE inhibitors and ARBs can decrease GFR and increase serum potassium levels 5. EPO can increase BP and is contraindicated in hypertension 6. Avoid high protein diets, low in sodium and potassium Nursing Diagnosis (List 3 priority nursing diagnosis based on clinical findings and define in your own words the rationale) 1. Fluid imbalance – fluid can build up due to the heart not working well and the kidneys cant compensate 2. Electrolyte imbalance – kidneys can’t process electrolytes properly and get rid of them or retain them 3. Impaired nutritional status – risk for malnutrition due to protein energy wasting and micronutrient deficiency Patient Education 1. Do not add to salt to food and eat a low sodium diet 2. Teach the signs and symptoms of electrolyte imbalance especially high potassium (List 3 priority education points you would discuss with patient and defend in your own words your selection of the points) Interrelated Concepts (List ALL interrelated concepts and describe in your own words how it interrelates with exemplar) 3. Teach them different ways to reduce their thirst such as sucking on ice cubes, lemons or hard candy to help with dry mouth 1. 2. 3. 4. 5. Nutrition – body can’t properly filter and use the nutrients it is getting Cognition – can lead to a buildup of toxins in the body and cause altered mental status Mobility – causes muscle weakness and bone loss Fluid and Electrolytes – kidneys cant balance fluids and electrolytes Acid-Base Imbalance – kidneys can’t remove enough acid and can lead to metabolic acidosis References Kwong, Mariann Harding, Dottie Roberts, Courtney Reinisch, Debra Hagler, J. Lewis's Medical-Surgical Nursing. Available from: Pageburstls, (11th Edition). Elsevier Health Sciences (US), [Insert Year of Publication].
