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Chronic Kidney Disease

Transcript: Chronic Kidney Disease Early stages may be completely asymptomatic/ may present with non-specific symptoms such as general malaise, loss of appetite. As kidney function decreases, the following can occur (the Highs and the Lows). The Highs HTN. Why? Fluid overload. Why? Kidneys become less efficient at excreting fluid + activation RAAS. Increased urea. Why? Decreased ability of the kidney to excrete urea. Uraemia may lead to pericarditis, encephalopathy. 'Uraemic frost' Hyperkalaemia. Malaise + fatal cardiac arrhythmia. Usually only a problem once GRF<20-25 Fluid overload. Present as oedema+/- pulmonary oedema. Hyperphosphataemia. Failing kidneys unable to excrete phosphate. High phosphate levels direct stimulus to vascular calcification and may explain increased cardiovascular risk factor in CKD patients Causes Based on Glomerular Filtration Rate (GFR). Stage 1: GFR 90+. Normal kidney function but urine findings/structural/genetic trait points to kidney disease Stage 2: GFR 60-89. Mildly reduced kidney funtion Stage 3: further subdivided into 3A: GFR 45-59, 3B: GFR 30-44. Mildly reduced kidney function Stage 4: GFR 15-29. Severely reduced kidney function. Stage 5: GFR < 15. End stage renal failure AKA 'established renal failure' Screening in the general public; not recommended, however the following groups of patients may benefit from screening and subsequent early identification of CKD. Hypertensive patients History of cardiovascular disease Marked obesity DM Family history of CKD requiring dialysis Age>60 Screening involves: GFR Urine to albumin creatinine ration Urine dipstick CKD: Progressive loss of renal function. Biochemically shown by increased serum creatinine and low GFR. X5 different stages based on GFR. X3 main causes; HTN, DM + glomerulonephritis Treatment should focus on treating underlying cause, HTN, hormonal imbalance and cardiovascular risk factors Screening Investigations Conclusion Classification Signs + Symptoms Definition Aim of the management is to slow down/halt progressing to stage 5. X3 broad ways to do this; 1) Treat underlying pathology contributing kidney disease 2)Well controlled blood pressure (usually ARBs + ACEIs) 3)Treat the 'highs' and 'lows'; erythropeitin + calcitriol 4) Commonest cause of death in CKD patients is cardiovascular disease rather tham renal failure, therefore cardiovascular risk factors should be aggressively managed. Once stage 5 is reached, management is then in form of renal replacement therapy, dialysis/renal transplant Important to differentiate between CKD and Acute Renal Failure (ARF). Best way to this (serial) Serum Creatinine Levels; CKD: gradual rise in serum creatinine levels over months/years VS ARF: Sudden increase over several days/weeks If serial measurements are unavailable it may be necessary to treat, briefly as ARF until it has been biochemically establishes that the renal impairment is irreversible. Other tests: Abdominal USS. Size of kidneys. CKD patients usually have smaller kidneys (<9 cm). Notable exceptions are PCKD + diabetic nephropathy MAG3 scan. Nuclear medicine to confirm blood flow + establish differential function between two kidneys. Treatment Questions? The Lows: Anaemia. Why: Decreased erythropoietin synthesis Decreased calcium. Why? 1, 25 dihydroxyvitamin D3 defiency. Congenital/Inherited: Polycystic kidney disease, Congenital obstructive uropathy, Tuberose sclerosis Glomerular Disease: SLE, Wegner's, accelerated HTN, Diabetes, Glomerulonephritis, sickle cell Vascular Disease: Smal + medium vessel vasculitis Tubulointerstial disease: TB, Schistosomiasis, drug toxicity leading tubulointerstitial nephritis Urinary tract obstruction: Calculus, BPH, Pelvic tumours Progressive loss of renal function reduction in kidney function must be present >/= 3 months raised creatinine + low GFR Worldwide prevalence: 23-36% Associated with premature mortality USS of CKD kidney vs Normal kidney

Chronic Kidney Disease

Transcript: Etiology Chronic Kidney Disease vs Hyperthyroidism There are 5 stages of the disease. Once a patient reaches the 5th stage the kidneys are no longer able to remove waste. At this point the patient will need to be put on dialysis until transplant. Can also occur in result of diabetes Diagnosis Nausea Depression Weight change Weakness Joint pain Constipation Dry hair Sweating Can also test the urine for additional blood or proteins Scintigraphy-a technique in which a scintillation counter is used with a radioactive tracer to obtain an image of a bodily organ or a record of its functioning. Isotope iodine-131 used Treatment Similarities Symptoms Muscle cramping Puffiness of the eyes increased urination Etiology Symptoms Cold intolerance Irregular menstrual periods Goiter- visibly enlarged thyroid Slowed heart rate Breast development in men Difficulty getting pregnant Frequent bowel movements Irregular heartbeat Chronic Kidney Disease Diagnosis • Too much iodine • Graves disease -autoimmune disease • Inflammation of the thyroid • Noncancerous growths of thyroid or pituitary gland • Some tumors of the testes or ovaries • Taking too much thyroid hormone Symptoms Can be diagnosed through high blood pressure or by taking blood tests to check imbalances In some cases both start to severely affect the quality of life for the patients Hyperthyroidism Prognosis There is no treatment but by controlling blood pressure and maintaining healthy diet and exercise the disease slows Treatment Prognosis Etiology Fatigue Trouble concentrating Trouble sleeping Change in appetite Restlessness Swelling Dry skin Prognosis Synthetic thyroxine, identical to the thyroid hormone Radioactive iodine- destroys the thyroid gland and stops the excess production of hormones Surgery to remove the thyroid Diagnosis That's all folks Both are passed on through genetics which means if a relative has it then other family members are at risk Rarely is life threatening unless caused by Graves disease. sometimes can be cured without treatment. however slight change in diet to avoid excess iodine which interferes with medication.

Chronic Kidney Disease

Transcript: Chronic Kidney disease Diabetes Definition 26 million people have chronic kidney disease and 20 million are undiagnosed or are at risk for CKD CKD is the gradual loss of the ability of the kidneys to remove wastes, concentrate urine, and conserve electrolytes. The most accurate way to measure the function of the kidneys is the glomerular filtration rate (GFR) stage 1: renal damage with normal GFR <90 stage 2: renal damage with mild decrease in GFR 60-89 stage 3: moderate damage and decrease in GFR 30-59. anemia and bone metabolism disorders are more common. stage 4: Severe reduction in GFR 15-29 stage 5: GFR<15. patient is unable to maintain essential life functions unless dialysis is done. signs and symptoms decreased urine output fluid rention causing edema in the legs, ankle and feet. fatigue, drowsiness shortness of breath seizures or coma in severe cases chest pain related to pericarditis. anorexia, nausea, vomiting mental slowness and depresion in later stages ESRD can produce hypertension and congestive heart failure medically managed stage 1 and 2: decreasing the retention of nitrogenous wastes and controlling hypertension, fluids, and electrolyte imbalances. this can be done by a diet of low protein ad limiting fluid, sodium and potassium intake. dialysis treatment: a few ounces of blood is cleansed with a special filter, the dialysis access is surgically cleaned and during treatment an intravenous cannula is inserted into the vascular access. they may be performed at a center 3-4 times a week or in home with a hemodialysis machine. oral complications CKD can cause other conditions such as diabetes, anemia, cardiovascular disease, and mineral bone disorder. xerostomia, candidiasis and angular stomatitis. uremic stomatitis which looks like red, burning mucosa covered with gray exudates and later by ulcerations bleeding with petechiae mineral bone disorder may have abnormal calcium deposits on teeth, soft tissues and organs. it may also show narrowing of the pulp chamber, radiolucent osseous lesions and enamel hypoplasia modifications to dental treatment once an acceptable level of oral hygiene has been established, no contraindications exists to routine dental care. Patient receiving dialysis: a fistula is used to insert the tube for dialysis. this tube can become infected and produce infective endocarditis. the clinician should be aware of any shunts in the patients arm when doing blood pressure. many patients will also have other conditions like diabetes and congestive heart failure. along with the other conditions, come many medications. Dental care must only be provided if the patient is medically stable. treatment planning and recommendations during dialysis: a pt will be on a renal diet which will result in greater calcium deposits. as kidney disease progresses, uremia can result which alters the blood and saliva pH. suggest for patients to chew xylitol gum, sucking on frozen grapes, and sucking on a button tied with 20 inch string to avoid choking. after a transplant: only emergency cleanings should be done and consultation must be done to decide the medical status of the patient. recommendations for homecare meticulous oral self care twice daily antimicrobial rinses use of xylitol containing products. Defintion Most widespread disease that affects over 21 million people a year and 6.2 million don't even know they have it.it is actually a group of disorders characterized by abnormally increased blood glucose levels resulting from defective insulin secretion or defective insulin action. Four types type 1 type 2 Gestational other Type 1 is insulin deficient. There is an absolute deficiency of insulin and the patient will be required to take an injection of insulin for the rest of their lives. Onset is usually young, but may occur at any age. type 2 is insulin resistant. 90-95% of the diabetic disorders consist of type 2 and most are obese. Usually in people over 40, but may occur at any age. Gestational diabetes occurs in 4% of pregnancies in the united states. It is caused by the differences in hormones and glucose that is shared with the fetus. GDM usually reverts following the birth because these levels will even out. other specific types of diabetes mellitus. This is where the cause could be related to other diseases such as pancreatic disease, endocrine disease, chemical induced agents and genetic syndromes. Signs and Symptoms hypoglycemia type 1: loss of weight, loss of strength, irritability, drowsiness, bed wetting and blurred vision type 2: same as type 1, as well as nausea, dry flushed skin, loss of sensation and gastrointestinal upset. medically managing 1. Self managing blood glucose levels using small automated devices, testing should be done four times a day by pricking a finger and placing a drop of blood on a test strip. 2. Hemoglobin A 1c test. this test is done by a physician to monitor glycerin control. normal levels is <6%. 3. type 1 insulin therapy. type one uses it for

Chronic Kidney Disease

Transcript: Causes: Signs/Symptoms: Treatment: Drink alcohol in moderation Follow instructions on over-the-counter medications Maintain a healthy weight Don't smoke Diabetes High Blood Pressure The prognosis of patients with kidney failure varies from person to person due the unpredictable nature of the disease. Factors including: the duration, chances of complications, probable outcomes, and recovery period are all determined by assessing the patient’s distinctive characteristics. Early stages, illness: Headaches Weight loss Later stages: Abnormally discolored skin Muscle twitching/Cramping Sleeping problems Vomiting Prevention: Chronic Kidney Disease Lifestyle changes Don't smoke Eat meals that are low in fat and cholesterol Regular exercise Avoid eating too much salt or potassium Vitamins Kidney transplant Dialysis Chronic Kidney Disease •Damage to nerves of the legs and arms (peripheral neuropathy) •Dementia •Bone, joint, and muscle pain Prognosis: Complications:

Chronic Kidney Disease

Transcript: Table 1: Stages of diabetic nephropathy (Hill, 2009) Interventions Monitor daily weights (Weight reflects changes in fluid volume) Monitor Input and Output (Important with patients with fluid overload) Sodium Restricted Diet (2.3g/day-favors renal excretion of excess fluid) Implement fluid restriction (decreases intravascular volume and myocardial workload) Teach dietary restrictions : electrolytes, protein, fluid (Shown to decrease weight gain between dialysis treatments) (Ackley & Ladwig, 2011). Clinical Manifestations Lab and Diagnostic Tests Hypertension: r/t sodium and H2O retention and alterations of renin-angiotensin system Hyperkalemia: r/t decreased renal function, increased tissue catabolism, and shift of potassium into extracellular fluid secondary to metabolic acidosis Peripheral neuropathy r/t effects of uremia on peripheral nerves (Lewis et al, 2010). Summary *clinical manifestations vary *changes are very gradual Juanita 46 years old Native American Type 2 Diabetes Mellitus for 21 years Developing Chronic Kidney Disease (Van Leeuwen, Poelhuis-Leth, and Bladh, 2011). Post Test (Lewis et al., 2010) (Lewis et al., 2010) pump the blood safely clean the wastes from the blood monitor blood pressure and the rate of fluid removal from the patient’s body The hemodialysis machine will pump your blood through a canister called a ‘dialyzer’, which acts as a kidney by filtering the body’s waste products and fluids. (National Kidney and Urologic Diseases Information Clearinghouse, 2011) Client Scenario Nursing Diagnosis (Lewis et al., 2010) Excess Fluid Volume r/t edema resulting from oncotic fluid shift caused by serum protein loss and renal retention of salt and water Introduce client scenario Explain diabetic nephropathy & it's clinical manifestations Discuss diagnostic studies Identify indications and process of dialysis Provide related nursing diagnoses and interventions Summary of presentation Hemodialysis References: Objectives (Robins, 2010) Diabetes is the leading cause of kidney disease worldwide. occurs in 30–40% of diabetics after 25–40 years preventable occurrence prevalent in certain ethnic group (Evans & Capell, 2000) Interventions: Listen to the concerns of the client to convey a caring attitude and foster a relationship to determine how client is handling the situation Allow client time to mourn loss of body function so that client can deal with feelings and identify ways of coping with losses more effectively Include family members in discussions of client's concerns to enable them to assist the client and foster their support and understanding (Lewis et al, 2010). Dialysis Machine (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2010) Anorexia, Nausea, and Vomiting: buildup of toxins in the body; irritation of the GI tract Concentration Problems: hypermagnesia; neurologic changes; axonal atrophy and demyelination of nerve fibers Which comes first: the pruritis or the infection? (Casey, 2011: infection causes pruritis; Lewis et al., 2010: scratching can cause infections). Edema: retained Na Weight Gain: direct result of edema Dyspnea: fluid overload Weakness: ineffective ATP conversion; inability to utilize glycogen reserves Diagnosis (Lewis et al., 2010; Robins, 2010). Diabetic Nephropathy Juanita Chronic Kidney Disease Chest X-ray: Pathophysiology Activity intolerance r/t anemia and neuropathy AEB fatigue, shortness of breath, pallor, dyspnea, and tachycardia Ackley, B. J. & Ladwig, J. B. (2011). Nursing diagnosis handbook. An evidence based guide to planning care (9th ed.). St. Louis, MO: Mosby. Casey, G. (2011). The sugar disease -- understanding type 2 diabetes mellitus. Kai Tiaki Nursing New Zealand, 17(2), 16-21. Evans, T., & Capell, P. (2000). Diabetic nephropathy. Clinical Diabetes, 18(1). Retrieved on March 6, 2013 from http://journal.diabetes.org/clinicaldiabetes/v18n12000/Pg7.htm Headley, C., & Wall, B. (2007). Flash pulmonary edema in patients with chronic kidney disease and end stage renal disease. Nephrology Nursing Journal, 34(1), 15. Hill, J. (2009). Reducing the risk of complications associated with diabetes. Nursing Standard, 23(25), 49-55. [Table] Lewis, S.M., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., & Bucher, L. (2010). Medical-surgical nursing in Canada: Assessment and management of clinical . problems. (2nd ed.). Toronto, ON: Elsevier Canada. National Kidney and Urologic Diseases Information Clearinghouse. (2011). Treatment Methods for Kidney Failure: Hemodialysis - National Kidney and Urologic Diseases Information Clearinghouse. National Kidney and Urologic Diseases Information Clearinghouse. Retrieved March 10, 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/hemodialysis Nazarko, L. (2011). Health risks in undiagnosed or poorly-controlled diabetes. British Journal Of Healthcare Assistants, 5(10), 479-482. Nurko, S. (2006). Anemia, in chronic kidney disease: Causes, diagnosis, treatment. Cleveland Clinical Journal of Medicine, 73(3), 289-297 O’Callagan,

Chronic Kidney Disease

Transcript: Chronic Kidney Disease Symptoms Include the following: Appetite loss General ill feeling and fatigue Headaches Itching and dry skin Nausea Weight loss without trying to lose weight Other symptoms that may develop , especially once the kidney function has gotten worse include the following Abnormally light or dark skin Bone pain Brain and nervous system symptoms : Drowsiness and confusion Problems concentrating or thinking Numbness in the hands, feet, or other areas Muscle twitching or cramps Breath odor Easy bruising, bleeding, or blood in the stool Excessive thirst Frequent hiccups Low level of sexual interest and impotence Menstrual periods stop (amenorrhea) Shortness of breath Sleep problems, such as insomnia, restless leg syndrome, and obstructive sleep apnea Swelling of the feet and hands (edema) Vomiting, typically in the morning Signs and tests High blood pressure is almost always present during the stages of chronic kidney disease . The health care provider may hear abnomal heart or lung sounds when listening with a stethoscope . Used from the website www.kidney.ca . Other tips for protecting the kidneys and preventing heart disease and stroke: •Do not smoke. •Eat meals that are low in fat and cholesterol. •Get regular exercise (talk to your doctor or nurse before starting to exercise). •Take drugs to lower your cholesterol, if needed. •Keep your blood sugar under control. •Avoid eating too much salt or potassium. Treatment Controlling blood pressure will slow further kidney damage ; the goal is to keep blood presure at or below 130/80 mmHg

Chronic Kidney Disease

Transcript: Chronic Kidney Disease Proudly presented by: Karissa Abuel Meagen Reyes Angela Sita Woan Ling Wong Thank You! characterized by a progressive kidney damage, diagnosed when manifested for at least 3 months, with or without a reduced kidney function (Haynes & Winearls 2010) STAGE 1 Stage 3 Definition of Chronic Kidney Disease Stage 4 Diabetes Hypertension Obesity Cardiovascular Disease Description: TABLE 1: STAGING OF CKD > or equal to 90 Causes of Chronic Kidney disease kidney damage w/ normal or increased GFR Stage 2 GFR (mL/min/1.73m2): Stage 5 62 ECG bpm

Chronic Kidney Disease

Transcript: Assessment Programs focusing on pre-licensure nursing education, workplace orientation, clinical Mentorship and continuing professional development include content about evidence-informed patient decision support. Nursing Education Strategies: Decision support concepts Application of concepts Seminar courses Clinical mentorship Case studies Scenario-based interactions Teaching about practice theories http://www.kidney-symptom.com/esrd/list_102_2.html Diagnosis Chronic Kidney Disease Planning How nurses can involve patients in making decisions about the monitoring and management of CKD • "Nurses combine effective behavioral, psychosocial strategies and self-management education processes as part of delivering self-management support” (RNAO, 2014). • Nurses utilize the “ask-tell-ask “communication technique to find out what the client already knows, and to in fill any gaps or misconceptions to ensure the client receives the information that is required to successfully manage their disease. • Nurses use the communication technique known as the “teach back” to assess a client’s understanding of information. • Nurses assist clients in using information from self-monitoring techniques such as, daily glucose and blood pressure monitoring within the home. • Nurses encourage clients to monitor any changes in their health condition through diaries, logs, and personal health records. Implementation References Planning Continued... By: Ashley, Kenny, Leanne, Nicole, Phill & Kefi Nurse: Nurses understand and realize the knowledge required to assist in a patients decision support, providing support in decision in regards to patient health record. Healthcare Organizations Incorporate decision coaching into strategic plans for the care of adults with CKD. Review the BPGs and provide healthcare workers with the policies and procedures that follow evidence-based patient decision support education programs Evaluation http://www.hospitalgiftshop.com/Shop-by-Condition-Kidney-Disease.htm Decision Support Interventions NANDA Nursing Diagnosis’ for Chronic Kidney Disease Decisional Conflict r/t support system deficit, perceived threat to value system, multiple or divergent sources of information, lack of relevant information, unclear personal values/beliefs Imbalanced Nutrition: less than body requirements r/t anorexia, nausea, vomiting, altered taste sensation, or dietary restrictions Excess Fluid Volume r/t decreased urine output, sodium retention, inappropriate fluid intake Decreased Cardiac Output r/t effects of congestive heart failure, elevated potassium levels interfering with the conduction system Impaired Urinary elimination r/t effects of disease, need for dialysis Ineffective Coping r/t depression secondary to chronic kidney disease Risk for Infection r/t altered immune functioning Death Anxiety r/t unknown outcome of disease Activity Intolerance r/t effects of anemia, CHF Factors Influencing Decisions for patients with CKD Adult with CKD: Patients have access to reliable and evidence-based information to inform their nurse that they have the confidence in decision support. Education Recommendation Registered Nurses Association of Ontario (2009). Clinical Best Practice Guidelines: Decision support forAdults Living with Chronic Kidney Disease. Retrieved from http://rnao.ca/bpg/guidelines/decision-support-adults-living-chronic-kidney-disease Ladwig, G., & Ackley, B. (2014). Mosby's Guide to Nursing Diagnosis, 4th Edition. [VitalSource Bookshelf version]. Retrieved from http://online.vitalsource.com/books/978-0-323-08920 outline/52 Nurses collaborate with clients to; establish goals, develop action plans that enable achievement of goals, and monitor progress towards goals. For example a client could set a goal of following their dietitian’s recommended low protein, low sodium kidney diet, that could assist with delaying the progression of their kidney disease improving their quality of life. Other special diets include: low phosphorus (e.g. cheese, chocolate, ice cream, legumes, milk, nuts, seeds and yogurt), low fat, low potassium, and fluid restrictions can all contribute the self-management of a client with chronic kidney disease. Nurses assist with the planning and connecting of their clients to relevant resources in the community for the self-management of their disease. Nurses assist with the planning of hemodialysis appointments if that is part of their client's treatment plan. Nurses teach and assist clients to use problem-solving techniques Example Questions for exploring the need for resources: Tell me about your living arrangement. Who do you live with? Do you need any help to take your medications? If so, who helps you? Who prepares your meals? How do you get to your appointments? Common health decisions faced by patients with CKD Treatment Options: • Interpersonal relationships (opinions of others, knowing others experiences, interactions between providers and patient, self-perceived burden to family and trust

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