Focus on Chronic Kidney Disease Relates to Chapter

Chronic Kidney Disease (CKD) • Involves progressive, irreversible loss of kidney function Copyright ©

Chronic Kidney Disease • Defined as either presence of • Kidney damage • Pathological

Chronic Kidney Disease • Disease staging based on decrease in GFR • Normal GFR

Chronic Kidney Disease • Up to 80% of GFR may be lost with •

Chronic Kidney Disease • Each year 70, 000 people die from • • causes

Chronic Kidney Disease • Leading causes of ESRD • Diabetes • Hypertension Copyright ©

Chronic Kidney Disease Clinical Manifestations • Result of retained substances • • Urea Creatinine

Chronic Kidney Disease Clinical Manifestations • Uremia • Syndrome that incorporates all signs and

Manifestations of Chronic Uremia Fig. 47 -5 Copyright © 2007, 2004, 2000, Mosby, Inc.

Chronic Kidney Disease Clinical Manifestations Urinary system • Polyuria • Results from inability of

Chronic Kidney Disease Clinical Manifestations Urinary system • Oliguria • Occurs as CKD worsens

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances • Waste product accumulation • As GFR

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances • Waste product accumulation (cont’d) • Serum

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances • Defective carbohydrate metabolism • Caused by

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances • Elevated triglycerides • Hyperinsulinemia stimulates hepatic

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances • Potassium • Hyperkalemia • Most serious

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances • Sodium • May be normal or

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances • Calcium and phosphate alterations • Magnesium

Chronic Kidney Disease Clinical Manifestations Hematologic system • Anemia • Due to ↓ production

Chronic Kidney Disease Clinical Manifestations Hematologic system • Infection • • • Changes in

Chronic Kidney Disease Clinical Manifestations Hematologic system • Increased incidence of cancer • •

Chronic Kidney Disease Clinical Manifestations Cardiovascular system • Hypertension • Heart failure • Left

Chronic Kidney Disease Clinical Manifestations Respiratory system • Kussmaul respiration • Dyspnea • Pulmonary

Chronic Kidney Disease Clinical Manifestations Respiratory system • Pleural effusion • Predisposition to respiratory

Chronic Kidney Disease Clinical Manifestations Gastrointestinal system • Every part of GI is affected

Chronic Kidney Disease Clinical Manifestations Neurologic system • Expected as renal failure progresses •

Chronic Kidney Disease Clinical Manifestations Neurologic system • Altered mental ability • Seizures •

Chronic Kidney Disease Clinical Manifestations Neurologic system • Restless leg syndrome • Muscle twitching

Chronic Kidney Disease Clinical Manifestations Musculoskeletal system • Renal osteodystrophy • Syndrome of skeletal

Chronic Kidney Disease Clinical Manifestations Musculoskeletal system • Metastatic calcifications • Muscles, lungs, skin,

Renal Osteodystrophy Fig. 47 -6 Copyright © 2007, 2004, 2000, Mosby, Inc. , an

Chronic Kidney Disease Clinical Manifestations Integumentary system • Most noticeable change • Yellow-gray discoloration

Chronic Kidney Disease Clinical Manifestations Integumentary system • Dry, brittle hair • Thin nails

Chronic Kidney Disease Clinical Manifestations Reproductive system • Infertility • Experienced by both sexes

Chronic Kidney Disease Clinical Manifestations Endocrine system • Manifestations of hypothyroidism • Thyroid function

Chronic Kidney Disease Clinical Manifestations Psychologic changes • Personality and behavioral changes • Emotional

Chronic Kidney Disease Diagnostic Studies • History and physical examination • Laboratory tests •

Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All

Chronic Kidney Disease Diagnostic Studies • Laboratory tests (cont’d) • • Urinalysis Urine culture

Chronic Kidney Disease Diagnostic Studies • Renal scan • CT scan • Renal biopsy

Chronic Kidney Disease Collaborative Care Conservative therapy • Correction of extracellular fluid volume overload

Chronic Kidney Disease Collaborative Care Conservative therapy • Antihypertensive therapy • Measures to lower

Chronic Kidney Disease Collaborative Care Drug therapy • Hyperkalemia • IV insulin • IV

Chronic Kidney Disease Collaborative Care Drug therapy • Hyperkalemia (cont’d) • Sodium polystyrene sulfonate

Chronic Kidney Disease Collaborative Care Drug therapy • Hypertension • • • Weight loss

Chronic Kidney Disease Collaborative Care Drug therapy • Hypertension (cont’d) • Antihypertensive drugs Diuretics

Chronic Kidney Disease Collaborative Care Drug therapy • Renal osteodystrophy • Phosphate intake restricted

Chronic Kidney Disease Collaborative Care Drug therapy • Renal osteodystrophy (cont’d) • Phosphate binders

Chronic Kidney Disease Collaborative Care Drug therapy • Renal osteodystrophy (cont’d) • Controlling secondary

Chronic Kidney Disease Collaborative Care Drug therapy • Anemia • Erythropoietin Epoetin alfa (Epogen,

Chronic Kidney Disease Collaborative Care Drug therapy • Anemia (cont’d) • Iron supplements •

Chronic Kidney Disease Collaborative Care Drug therapy • Anemia (cont’d) • Folic acid supplements

Chronic Kidney Disease Collaborative Care Drug therapy • Dyslipidemia • Goal • Lowering LDL

Chronic Kidney Disease Collaborative Care Drug therapy • Dyslipidemia (cont’d) • Fibrates • Fibric

Chronic Kidney Disease Collaborative Care Drug therapy • Complications • Drug toxicity • Digitalis

Chronic Kidney Disease Collaborative Care Nutritional therapy • Protein restriction • 0. 6 to

Chronic Kidney Disease Collaborative Care Nutritional therapy • Sodium restriction • Diets vary from

Chronic Kidney Disease Collaborative Care Nutritional therapy • Potassium restriction • 2 to 4

Chronic Kidney Disease Collaborative Care • Phosphate restriction • 1000 mg/day • Foods high

Nursing Management Nursing Assessment • Complete history of any existing • • renal disease,

Nursing Management Nursing Diagnoses • Excess fluid volume • Risk for injury • Imbalanced

Nursing Management Planning • Overall goals • Demonstrate knowledge and ability to comply with

Nursing Management Planning • Overall goals (cont’d) • Continue with activities of daily living

Nursing Management Nursing Implementation • Health promotion • Identify individuals at risk for CKD

Nursing Management Nursing Implementation • Acute intervention Daily weight Daily BPs Identify signs and

Nursing Management Nursing Implementation • Acute intervention • Medication education • Motivate patients in

Nursing Management Nursing Implementation • Ambulatory and home care • When conservative therapy is

Nursing Management Evaluation • Maintenance of ideal body weight • Acceptance of chronic disease

Chronic Kidney Disease Gerontologic Considerations • About 35% of ESRD patients are 65 or

Chronic Kidney Disease Gerontologic Considerations • Diminished cardiopulmonary • • function Bone loss Immunodeficiency

Chronic Kidney Disease Gerontologic Considerations • Altered protein synthesis • Impaired cognition • Altered

Chronic Kidney Disease Gerontologic Considerations • Most common cause of death in the elderly

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Focus on Chronic Kidney Disease (Relates to Chapter 47, “Nursing Management: Acute Renal Failure and Chronic Kidney Disease, ” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease • 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease • 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Clinical Manifestations • Uremia • Syndrome that incorporates all signs and symptoms seen in various systems throughout the body Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Urinary system • Polyuria • Results from inability of kidneys to concentrate urine • Occurs most often at night • Specific gravity fixed around 1. 010 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Urinary system • Oliguria • Occurs as CKD worsens • Anuria • Urine output <40 ml per 24 hours Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances • Defective carbohydrate metabolism • Caused by impaired glucose use • From cellular insensitivity to the normal action of insulin • Patients with diabetes who become uremic may require less insulin than before onset of CKD • Insulin dependent on kidneys for excretion Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Metabolic disturbances • Elevated triglycerides • Hyperinsulinemia stimulates hepatic production of triglycerides • Altered lipid metabolism • ↓ Levels of enzyme lipoprotein lipase • Important in breakdown of lipoproteins Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances • Potassium • Hyperkalemia • Most serious electrolyte disorder in kidney disease • Fatal dysrhythmias • Results from decreased excretion by kidneys, breakdown of cellular protein, bleeding metabolic acidosis, food intake, medications Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances • Sodium • May be normal or low • Because of impaired excretion, sodium is retained • Water is retained • Edema • Hypertension • CHF Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances • Calcium and phosphate alterations • Magnesium alterations • Metabolic acidosis • Results from • Inability of kidneys to excrete acid load (primary ammonia) • Defective reabsorption/regeneration of bicarbonate Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Clinical Manifestations Hematologic system • Infection • • • Changes in leukocyte function Altered immune response and function Diminished inflammatory response Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Hematologic system • Increased incidence of cancer • • • Lung Breast Uterus Colon Prostate Skin Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Cardiovascular system • Hypertension • Heart failure • Left ventricular hypertrophy • Peripheral edema • Dysrhythmias • Uremic pericarditis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Respiratory system • Kussmaul respiration • Dyspnea • Pulmonary edema • Uremic pleuritis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Respiratory system • Pleural effusion • Predisposition to respiratory infections • Depressed cough reflex • “Uremic lung” Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Gastrointestinal system • Every part of GI is affected • Due to excessive urea • Mucosal ulcerations • Stomatitis • Uremic fetor (urinous odor of the breath) • GI bleeding • Anorexia • N/V Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Neurologic system • Expected as renal failure progresses • Attributed to • Increased nitrogenous waste products • Electrolyte imbalances • Metabolic acidosis • Axonal atrophy • Demyelination of nerve fibers Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Neurologic system • Altered mental ability • Seizures • Coma • Dialysis encephalopathy • Peripheral neuropathy Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Neurologic system • Restless leg syndrome • Muscle twitching • Irritability • Decreased ability to concentrate Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Musculoskeletal system • Metastatic calcifications • Muscles, lungs, skin, GI tract, eyes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Integumentary system • Most noticeable change • Yellow-gray discoloration of the skin • Due to absorption/retention of urinary pigments • Pruritus • Uremic frost • Dry, pale skin Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Integumentary system • Dry, brittle hair • Thin nails • Petechiae • Ecchymoses Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Reproductive system • Infertility • Experienced by both sexes • Decreased libido • Low sperm counts • Sexual dysfunction Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Endocrine system • Manifestations of hypothyroidism • Thyroid function may yield low to low-normal levels of T 3 and T 4 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Clinical Manifestations Psychologic changes • Personality and behavioral changes • Emotional ability • Withdrawal • Depression Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Diagnostic Studies • Laboratory tests (cont’d) • • Urinalysis Urine culture Hematocrit Hemoglobin • Renal ultrasound • Renal scan Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Collaborative Care Conservative therapy • Antihypertensive therapy • Measures to lower potassium • Adjustment of drug dosages to degree of renal function Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Drug therapy • Hyperkalemia • IV insulin • IV glucose to manage hypoglycemia • IV 10% calcium gluconate • Raises threshold for excitation • Sodium bicarbonate • • Shift potassium into cells Correct acidosis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Drug therapy • Hyperkalemia (cont’d) • Sodium polystyrene sulfonate (Kayexalate) • Cation-exchange resin • Resin in bowel exchanges potassium for sodium • Evacuates potassium-rich stool from body • Educate patient that diarrhea may occur due to laxative in preparation Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Drug therapy • Hypertension • • • Weight loss Lifestyle changes Diet recommendations • Sodium and fluid restriction Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Drug therapy • Hypertension (cont’d) • Antihypertensive drugs Diuretics β-Adrenergic blockers Calcium channel blockers Angiotensin-converting enzyme (ACE) inhibitors • Angiotensin receptor blocker agents • • Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Drug therapy • Renal osteodystrophy • Phosphate intake restricted to <1000 mg/day • Phosphate binders • Calcium carbonate (Tums) • Bind phosphate in bowel and excreted • Sevelamer hydrochloride (Renagel) • Lowers cholesterol and LDLs Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Drug therapy • Renal osteodystrophy (cont’d) • Phosphate binders (cont’d) • Should be administered with each meal • Side effect: Constipation • Supplementing vitamin D • Calcitriol (Rocaltrol) • Serum phosphate level must be lowered before administering calcium or vitamin D Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Collaborative Care Drug therapy • Anemia • Erythropoietin Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks • Side effect: Hypertension • • • Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

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

Chronic Kidney Disease Collaborative Care Drug therapy • Dyslipidemia • Goal • Lowering LDL below 100 mg/dl • Triglyceride level below 200 mg/dl • Statins • HMG-Co. A reductase inhibitors • Most effective for lowering LDL Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Collaborative Care Drug therapy • Complications • Drug toxicity • Digitalis • Antibiotics • Pain medication (Demerol, NSAIDs) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Nutritional therapy • Protein restriction • 0. 6 to 0. 8 g/kg body weight/day • Water restriction • Intake depends on daily urine output Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care Nutritional therapy • Potassium restriction • 2 to 4 g • High-potassium foods should be avoided • • Oranges Bananas Tomatoes Green vegetables Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Collaborative Care • Phosphate restriction • 1000 mg/day • Foods high in phosphate • Dairy products • Most foods high in phosphate are also high in calcium Copyright © 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 Copyright © 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 Copyright © 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 Copyright © 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 Copyright © 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation • Acute intervention Daily weight Daily BPs Identify signs and symptoms of fluid overload • Identify signs and symptoms of hyperkalemia • Strict dietary adherence • • • Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation • Acute intervention • Medication education • Motivate patients in management of their disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Nursing Implementation • 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 Copyright © 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 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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

Chronic Kidney Disease Gerontologic Considerations • Diminished cardiopulmonary • • function Bone loss Immunodeficiency Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Gerontologic Considerations • Altered protein synthesis • Impaired cognition • Altered drug metabolism Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Gerontologic Considerations • Most common cause of death in the elderly ESRD patient • Cardiovascular disease (MI, stroke) • Withdrawal from dialysis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.