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4. Clinical Manifestations
All body systems are affected
A result of retained substances
o Urea
o Creatinine
o Phenols
o Hormones
o Electrolytes
o Water
Typically occurs when the GFR is 10ml/min or less
Respiratory System
o Kussmaul Respirations to compensate for acidosis
o Dyspnea related to fluid volume overload
Gastrointestinal System
o Uremic fetor: ruinous odor of breath
o Nausea, Anorexia, stomatitis
o Delayed gastric empting and constipation
o GI bleeding
Neurologic System
o Changes related to increased nitrogenous waste,
electrolyte imbalances, metabolic acidosis and nerve
fiber damage
o Peripheral neuropathy
Musculoskeletal System
o Mineral and bone disorders
(insert table 47-3)
Integumentary System
o Puritis (more prevalent in dialysis patients)
Reproductive System
o Infertility
o Sexual dysfunction
May return after dialysis/transplantation
Psychologic Changes
o Body changes
o Lifestyle changes
o Fatigue/lethargy due to illness
7. Diagnostic Studies
Laboratory Studies
o Urinalysis
Protein (proteinuria is usually first indication of
kidney damage)
Two or more positive tests over 3 month
period indicates need for further work up
Micro albuminuria (additional test for diabetics)
Albumin-to creatinine ratio
o Serum
Serum
GFR
Cockcroft-Gault formula
MDRD equation
Ultrasound
o Looks for obstructions
Biopsy
o May provide definitive diagnosis
8. Collaborative Care
Early diagnosis and treatment of risk factors is key
All patients with CV disease should be assessed for CKD
9. Drug Therapy
Hyperkalemia (noted by labs or EKG changes)
o Daily management with restrictions of high
potassium foods and medications
o Acute Hyperkalemia
Dialysis (if dialysis patient)
IV Glucose/Insulin
IV Calcium Gluconate 10%
Sodium polystyrene sulfonate (Kayexalate)
Used in stage 4
Can be used as out-patient
Hypertension
o HTN control can delay progression of CKD
o Target BP is <130/80 for all CKD patients and
<125/75 for those with significant protein urea.
o Non-Pharmacological Treatment:
Weight loss (if obese or overweight)
Therapeutic Lifestyle Changes
Exercise
Avoidance of Alcohol Consumption
Smoking cessation
Self monitoring of BP
Diet recommendations
DASH diet
Protein restrictions (?)
Fluid restrictions (dialysis patients with
anuria)
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Nursing Management
Assessment:
History
o Existing or family history of
Alport syndrome and polycystic kidney disease
Diabetes
Hypertension
Lupus erythematous
o Current and past use of medications (prescription,
OTC, herbals)
Decongestants (pseudoephedrine,
phenylephrine)
Use of anti-acids
NSAID use
Analgesics
o Dietary habits
Height and weight
Nursing Diagnoses:
Risk for fluid volume excess
Risk for electrolyte imbalances
Imbalanced nutrition
Planning:
Goals:
Demonstrate knowledge and ability to comply with
therapeutic regimen
o Do they have what they need to facilitate this?
Participate in decision making for the plan of care and future
treatment
o Must be patient centered and not just nurse/doctor
pleasing
Implementation:
Health Promotion
o Identification of CKD
Acute Intervention
Ambulatory and home care
(see table 47-12)
Facilitating behavioral change and management of CKD:
The role of nurses:
According to Dean and Low (2012), Psychological models can help us
to understand how to support behavior change in renal patients.
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o Dwell (equilibration)
May take 20-30min or up to 8+ hours
Diffusion and osmosis occurs between patients
blood and the peritoneal cavity
o Drain
15-30 min. gentle massage may facilitate
Dialysis solutions
o Glucose
Hyperglycemia
Hypertriglyceridemia
Long-term peritoneal membrane dysfunction
o Icodextrin
o Amino acid
Dialysis Systems
o Automated Peritoneal Dialysis (APD)
Most popular form (done during sleep)
Four or more cycles (1-2 hours/cycle)
Usually need 1-2 additional daytime cycles
o Continuous Ambulatory Peritoneal Dialysis (CAPD)
Done during the day
Four cycles (5ish hours/cycle)
Connected during inflow and drain but
disconnected during dwell
Complications
o Infection
Catheter exit (Staphylococcus aureus or
Staphylococcus epidermidid)
Redness at site
Tenderness
Drainage
Treatment is ABX therapy
o Peritonitis
o Hernias
o Low Back Problems
o Bleeding
o Pulmonary Complications
o Protein Loss
Effectiveness
o Mortality rates are same for PD and HD for first two
years
o Higher than HD after two years
o Indicated for patients
Who prefer and OP setting
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Hemodialysis
Vascular Access: Rapid blood flow is required
o Arteriovenous Fistulas (anastomosis)
Allows arterial blood flow through a vein
Not compatible with PVD, IV drug use, obese
women
Placed at least 3 months prior to HD
Thrill-felt
Bruit-heard
o Arteriovenous Grafts (synthetic anastomosis)
2-4 weeks till use
may impede distal circulation
Do not perform BP measurement, IV access or
venipuncture in extremity with VA
o Temporary Vascular Access
Catheterization of internal jugular or femoral
vein.
For Acute Hemodialysis
o Dialyzers
Long plastic cartridge that contains thousands
of parallel hollow tubes or fibers.
Fibers are semipermeable membranes
Procedure for Hemodialysis:
(see 47-12)
o Prior to dialysis fluid status assessment is needed
Weight
BP
Peripheral edema
Lung/heart sounds
o Compare last post dialysis weight with pre-dialysis
weight
Settings and schedules
o 3 days/wk (3-4 hrs)
Complications
o Hypotension
o Muscle cramps
o Loss of blood
o Hepatitis
o Infection (second leading cause of death by HD)
Effectiveness
o 19-24% of deaths per year
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CV disease
Stroke and MI
Continuous Renal Replacement Therapy (CRRT): To dialyze patients in
a more physiologic way over 24 hours, like kidneys.
(see 47-14)
May be used alone or in conjunction with HD
Used for AKI
Typically done in ICU by trained nurse
Kidney Transplantation
Best treatment option for ESKD (fewer than 4% receive)
o Supply/demand
93,000 currently on list
Cadaveric kidney wait is usually 2-5 years
o 90% success rate after 1 year
Recipient Selection
o Varies by transplant center
o CV disease patients are high risk
o May be excluded for health factors such as obesity
and smoking
o Must be histocompatable
Donor Sources
o Live Donors
Extensive evaluation to ensure minimized risks
Physical
Emotional
Better patient and graft survival rates
Immediate availability
Minimized out of body time
o Deceased Donors
Donor Networks may be used
Usually Head Trauma Death
Permission from legal next of kin
May be preserved up to 72 hours
Less is better to avoid ATN.
Surgical Procedure
o Live Donor
27% of all transplants in US.
Usually removed via laparoscopic technique
Open nephrectomy may require removal of 11th
rib
o Kidney Transplant Recipient
Transplanted kidney placed in right iliac fossa
12
(insert 47-15)
Nursing Management
Transplant Recipient
Pre-op care:
o EKG, CXR, labs
o Label vascular access no procedures
May be needed post op
Post-op care
o ICU care for close monitoring of fluid and electrolyte
balance
o Large volumes of urine expected
New kidneys ability to filter BUN which acts as
a diuretic
Abundance of fluids received during surgery
Initial renal tubular dysfunction which inhibits
normal concentration of urine
o Sudden decrease in u/o is concerning in early post-op
period
Dehydration
Rejection
Leak
Obstruction (blood clot or catheter)
Maintain catheter patency and
Gentle irrigation to remove clots
Immunosuppressive Therapy
o Prevent rejection
o Maintain immunity
Complications of Transplantation
o Rejection
o Infection
o CV disease
o Malignancies
o Recurrence of Original Kidney Disease
o Corticosteroid-Related Complications
Aseptic necrosis of joints
PUD
13
Glucose intolerance
Diabetes
Cataracts
Dyslipidemia
Malignancies
Infections
Decrease or eliminate use
Monitor for side effects
Gerontologic Considerations
o Increased incidence
o Diabetes/hypertension
o Increased number of comorbidities
o May have increased issues with assistance or
transportation
o May choose to withdraw from treatment
o Raises Ethical concerns
Reference:
Lewis, S., Dirksen, S., Heikemper, M., & Bucher, L. (2014) Medical-surgical
nursing: Clinical management for positive outcomes (9th ed.) St. Louis, Mosby.
ISBN 978-0-323-08678-3
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