CKD Module 1

8/4/2019 CKD Module 1

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Achieve your goals.

Make a difference.Join a community of caring.

DiscoverNephrology Nursing

American Nephrology Nurses Association

www.annanurse.org

This presentation is supported by an unrestricted educational grantprovided by the Nurse Competence in Aging Initiative.
http://www.annanurse.org/http://www.annanurse.org/


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Stage 1 - Kidney Damage (Normal or GFR >90)

Action taken by Medical Personnel:

Diagnosis and Treatment

Treat comorbid diseases Slow progression of disease through diet and medication

Stage 2 - Mild Kidney Damage (GFR


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Stage 3 - Moderate Kidney Damage (GFR


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Stage 5 - Kidney Failure (GFR


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Chronic Kidney Disease (CKD)

Chronic Kidney Disease (CKD) is a progressive loss of renal function.The etiology of CKD can be from a variety of diseases including butnot limited to:

Diabetes Mellitus Glomerularnephritis

Interstitial nephritis Vasculitis

Chronic pyelonephritis Obstructive disorders

Hypertension

Hereditary disease

Congenital disorders Cystic disease


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The Kidney

The kidneys weigh about 1/2 pound each.

They are located in the retroperitonealspace.

They are about the size of an adult fist

They are shaped like a kidney bean.

They are attached to the blood stream

through the renal arteries.


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Nephrons

Nephrons are themicroscopic functionalunit of the kidney.


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Functions of the Kidneys

Remove wastes

Remove excess fluid

Secrete erythropoietin

Regulate bone metabolism

Regulate blood pressure

Regulate acid-base balance

Regulate electrolyte balance


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What is Renal Failure?

Acute Renal Failure

Chronic Renal Failure


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Symptoms of Chronic Renal Failure (Uremia)

Loss of appetite

Nausea/vomiting

Headache

Shortness of breath

Itching

Bone disease

Anemia

Proteinuria

Weakness, insomnia

Hypertension

Edema


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Symptoms of Chronic Renal Failure (Uremia)

Loss of appetite

Nausea/vomiting

Headache

Shortness of breath

Itching

Bone disease

Anemia

Proteinuria

Weakness, insomnia

Hypertension

Edema


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Renal Replacement Therapy (RRT)(Used for Patients at Stage 5)

HemodialysisPeritoneal Dialysis

Transplantation

No therapy


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History of Dialysis

1913 Artificial kidney used in animals.

1935 Heparin purified.

1942 First patient treated with dialysis machine. 1950s Hemodialysis used to treat acute renal failure.

1960 External arteriovenous shunt developed by Drs. Scribner andQuinton.

1965 Internal arteriovenous fistula developed by Drs. Brescia and Cimino.

1972 Medicare ESRD Program established.

1989 - Recombinant human erythropoietin (Epogen) approved by the FDA.


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History of Dialysis

1913 Artificial kidney used in animals.

1935 Heparin purified.

1942 First patient treated with dialysis machine. 1950s Hemodialysis used to treat acute renal failure.

1960 External arteriovenous shunt developed by Drs. Scribner and Quinton.

1965 Internal arteriovenous fistula developed by Drs. Brescia andCimino.

1972 Medicare ESRD Program established.

1989 Recombinant human erythropoietin (Epogen) approved by theFDA.


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Types of Hemodialysis Treatments In Hospital Some communities have dialysis center

located in the hospital.

In-center Most people on dialysis dialyze in a dialysis clinic.

Self-care There are some facilities where patients withoutpartners can do their own care in a clinic setting.

Home Patients are trained along with a partner todialyze at home.

Nocturnal Nocturnal dialysis involves dialyzing 5 to 7nights a week for 8 to 10 hours.

May or maynot have partners


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Basic Treatment

Hemodialysis removes

solutes (waste particles)and fluid from the bloodacross a semipermeablemembrane in a filter(dialyzer).


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Components for Hemodialysis Access to circulation: need to

pull blood from, and returnblood to the body, at a speed

of 200-500 mL/ min

Dialyzer (artificial kidney)

Dialysate (Bath)

Dialysis machine

Water treatment


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of 200-500 mL/ min


Dialysate (Bath)

Dialysis machine

Water treatment


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of 200-500 mL/ min


Dialysate (Bath)

Dialysis machine

Water treatment


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of 200-500 mL/ min


Dialysate (Bath)

Dialysis machine

Water treatment


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of 200-500 mL/min


Dialysate (Bath)

Dialysis machine

Water treatment


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Caring for the Dialysis Patient includes:

RRT (Renal Replacement Therapy).

Diet and fluid management. Medication regimens.

Rehabilitation services.

Community services.

Social support.


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Assessment of the CKD Patient

Assess fluid status

Restrict fluid intake

Control dietary intake

Properly administer medications

Evaluate blood pressure

Check access daily

Watch for side effects


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Assess fluid status





Check access daily



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Assess fluid status





Check access daily



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Assess fluid status





Check access daily



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Assess fluid status





Check access daily



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Assess fluid status





Check access daily



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Assess fluid status





Check access daily



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Potential Problems During Dialysis

Hypotension

Nausea

Cramping

Headache


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Potential Problems Between Treatments Hypotension

Symptoms: Dizziness, sweaty/clammy, nausea, cramping.

Causes: Removing too much fluid during dialysis.Co-morbid conditions.Patient may be taking B/P medications prior to dialysis.

Prevention: Take B/P medications after dialysis instead ofprior to dialysis.

If the patient experiences nausea and vomiting, report this to thedialysis staff prior to dialysis treatment.

Communicate with the dialysis staff if the patient goes to dialysiswearing a nitroglycerin patch.


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Problems Between Treatments

Nausea

Causes: Can be due to B/P, medications,uremia, and electrolyte imbalance.Evaluate the B/P to determine if nauseais related to cardiovascular instability.


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Potential Problems Between Treatments

Headaches

Leg cramps

Skin integrity


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Potential Problems Between Treatments Hypoglycemia

Symptoms: Shaking, fast heart beat, weakness.

Causes: Too little food or too much insulin.

Treatment: Test blood sugar.

Hyperglycemia

Symptoms: Extreme thirst, nausea, blurred vision.

Causes: Too much concentrated sweets not enough insulin. Treatment: Insulin as ordered by MD.


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Potential Problems Between Treatments Hypoglycemia

Symptoms: Shaking, fast heart beat, weakness.

Causes: Too little food or too much insulin.

Treatment: Test blood sugar.

Hyperglycemia

Symptoms: Extreme thirst, nausea, blurred vision.

Causes: Too much concentrated sweets not enough insulin. Treatment: Insulin as ordered by MD.


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Potential Problems Between Treatments

Access Site Bleeding

Symptoms: Excessive or prolonged bleeding at dialysis access site.

Causes: Not rotating needle sites, too much heparin.

Treatment: Manual pressure for 10 to 20 minutes; hemostaticagents may be used; in extreme cases, send the patient tothe emergency room.


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Vascular Access Types

Internal

Fistula

Graft

PTFE

Bovine

Vectra

External

Catheter


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Vascular Access

Fistula

Check for bruit and thrill daily.

May remove band-aids next morning.


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Vascular Access

Graft

PTFE

Bovine

Vectra


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Vascular Access

EXTERNAL

Catheter

Keep dressing dry.

Call dialysis unit if end caps come off.

Notify unit if dressing has drainage.


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Daily Checks of Vascular Access Inspection of Access Condition of skin over access

Redness

Auscultation of Access

Bruit +/-

Quality/character

Palpation of Access

Thrill +/-

Heat

Drainage

Swelling

Tenderness


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Post-Dialysis Care

Observe for bleeding from cannulation sites.

Hold pressure if necessary. If not controlled, immediatelynotify the nephrologist and continue to hold pressure.

Remove tape/bandage within 24hrs after dialysis.


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Typical Medications

Vitamins Multivitamins withoutminerals or vitamin D

Phosphate binders

Erythropoietin

Iron

Vitamin D

Antihypertensives


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Typical Medications

Vitamins Multivitamins withoutminerals or vitamin D

Phosphate binders

Erythropoietin

Iron

Vitamin D

Antihypertensives


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Nutrition

Nutrition plays a critical role in the managementof the CKD patient.

The diet will vary depending on the type of

disease, the CKD stage, and the type oftreatment chosen.


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Dietary Considerations

PROTEIN 1.0-1.2g/kg/day 50% high biologic value

POTASSIUM 40-70 mEq (1500-2500mg)/day

SODIUM 750-1000 mg/day

PHOSPHORUS 600-1200 mg/day

CALORIES >35 kcal/kg/day

FLUIDS 1 to 1.5 liters/day plus urine output


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Dietary Considerations

PROTEIN 1.0-1.2g/kg/day 50% high biologic value

POTASSIUM 40-70 mEq (1500-2500mg)/day

SODIUM 750-1000 mg/day

PHOSPHORUS 600-1200 mg/day

CALORIES >35 kcal/kg/day

FLUIDS 1 to 1.5 liters/day plus urine output


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Social Services

Social services are provided topatients and their families and aredirected at supporting and maximizingthe social functioning and adjustment

of the patient.


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Stressors Associated with Dialysis

Actual or threatened loss

Distortion of body image

Dependency on machines and medical team

Fear of death vs. fear of living

Patient self-concept

Capacity to control

Helplessness


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Communication Between Dialysis Center and LTC

Transportation Family Issues

Financial Concerns


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End-of-Life Issues

Assess patient for supportsystems, emotional status,and perceived quality oflife.


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Communication

Treatment Communication

Long-Term Care Plan

Short-Term Care Plan


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Coordination of Laboratory Requirements

CKD patients who receive dialysis in-center will usually have monthly labwork drawn at the dialysis center.

Some tests, such as H/H and

calcium, may be drawn weekly.


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Lab Draw Sites

Specific lab draw sites are chosen for the CKDpatient.

The dialysis staff draws the lab specimen fromthe blood lines during treatment.

For non-dialysis staff: DO NOT performvenipucture from the arm that has the fistulaor graft.


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Chemistry Values Normal for CKD

Bun 21 mg/dL 101 mg/dL

Creatinine 2.5 mg/dL 14.2 mg/dL

Sodium 115 meq/L 160mg/dL

Potassium 3.5meg/L 5.5 mEq/L

Calcium 9mg/dL 11 mg/dL

Phosphorus 4.5 mg/dL 5.5 mEq/L

Glucose 70 mg/dL 110 mg

Albumin 3.5 mg/dL 5.0 mg/dL

Hemoglobin 11g/dL 13 g/dL

Hematocrit 33% 39% (if anemic)

Hepatitis Status Negative for HbSAG Positive for HbSAB

Residual Renal Function May have some, and amount would becollected and calculated into the urinecreatinine clearance equation.

Test Low High


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Test Low High


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Test Low High


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Test Low High


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ReferencesGutch,C.F., et al. (1999). Hemodialysis for nurses and dialysis personnel (6 th ed.). St. Louis, MO: Mosby,

Inc.

McCann, L. (1997). Pocket guide to nutrition assessment of the renal patient(2nd ed.) (pp. 9-15). NewYork: The National Kidney Foundation on Renal Nutrition.

National Kidney Foundation. (2003). Kidney disease outcome quality initiative.

USRDS. (2001).

U.S. Renal Data System. (2003). USRDS 2003 annual data report: Atlas of end-stage renal disease in theUnited States. Bethesda, MD: The National Institutes of Health, National Institute of Diabetes andDigestive and Kidney Diseases.

Youngerman-Cole, S. (2003). End-stage renal disease. Boise, ID: Healthwise, Inc. Retrieved September9, 2003, from http://yalenewhavenhealth.org/library/healthguide/en-us/

support/topic.asp?hwid=aa106246


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Glossary Artificial Kidney (Dialyzer) A device that allows for purification of the blood. During the dialysis

treatment, blood and dialysate flow through the dialyzer separated by a semipermeable membrane.The pores in the membrane allow the removal of waste products and excess fluid.

Dialysate (Bath) Fluid consisting of treated water, electrolytes, and buffers that can be mixed to theindividual patient needs. It passes through the dialyzer to remove waste products and excess water.

Diffusion The movement of a substance from an area of high concentration to an area of low

concentration. Diffusion is the main transport principle for solute (waste products) in hemodialysis

Dryweight The weight a patient is estimated to have with normal blood pressure and no fluidretention.

FistulaA surgically created connection between a patients own artery and vein.

Graft An implant connecting an artery and a vein.

Heparin A drug used in the dialysis treatment to prevent clotting of blood in the dialyzer. Waste Products Substances formed from the breakdown of proteins, nutrients, etc (urea,

creatinine).

CKD Module 1

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