DEFINITIONChronic kidney disease (CKD)or chronic renal failure (CRF), as it was historically termedis a term that encompasses all degrees of decreased renal function, from damagedat risk through mild, moderate, and severe chronic kidney failure. CKD is a worldwide public health problem. In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. The Kidney Disease Outcomes Quality Initiative (KDOQI) of the National Kidney Foundation (NKF) established a definition and classification of CKD. These guidelines have allowed better communication among physicians and have facilitated intervention at the different stages of the disease. The KDOQI defines CKD as either kidney damage or a decreased glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2 for 3 or more months. Whatever the underlying etiology, once the loss of nephrons and reduction of functional renal mass reaches a certain point, the remaining nephrons begin a process of irreversible sclerosis that leads to a progressive decline in the GFR. The different stages of CKD form a continuum. The KDOQI classification of the stages of CKD is as follows: Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2) Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m2) Stage 3: Moderate reduction in GFR (30-59 mL/min/1.73 m2) Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m2) Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m2 or dialysis)In stage 1 and stage 2 CKD, reduced GFR alone does not clinch the diagnosis, because the GFR may in fact be normal or borderline normal. Other markers of kidney damage, including abnormalities in the composition of blood or urine or structural abnormalities visualized by imaging studies, establish the diagnosis in such cases. Hypertension is a frequent sign of CKD but should not by itself be considered a marker of it, because elevated blood pressure is also common among people without CKD. In an update of its CKD classification system, the National Kidney Foundation (NKF) advised that GFR and albuminuria levels be used together, rather than separately, to improve prognostic accuracy in the assessment of CKD. More specifically, the guidelines recommended the inclusion of estimated GFR and albuminuria levels when evaluating risks for overall mortality, cardiovascular disease, end-stage kidney failure, acute kidney injury, and the progression of CKD. Referral to a kidney specialist was recommended for patients with a very low GFR (< 15 mL/min/1.73 m) or very high albuminuria (>300 mg/24 h)Patients with stages 1-3 CKD are frequently asymptomatic. Clinical manifestations resulting from low kidney function typically appear in stages 4-5.

6 | Page

CAUSECauses of chronic kidney disease (CKD) include the following: Diabetic kidney disease Hypertension Vascular disease Glomerular disease (primary or secondary) Cystic kidney diseases Tubulointerstitial disease Urinary tract obstruction or dysfunction Recurrent kidney stone disease Congenital (birth) defects of the kidney or bladder Unrecovered acute kidney injuryVascular diseases that can cause CKD include the following: Renal artery stenosis Cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA)positive and perinuclear pattern antineutrophil cytoplasmic antibody (P-ANCA)positive vasculitides ANCA-negative vasculitides Atheroemboli Hypertensive nephrosclerosis Renal vein thrombosis

DIAGNOSTIC TESTTo determine whether you have chronic kidney disease, you may need tests and procedures such as: Blood tests. Kidney function tests look for the level of waste products, such as creatinine and urea, in your blood. Urine tests. Analyzing a sample of your urine may reveal abnormalities that point to chronic kidney failure and help identify the cause of chronic kidney disease. Imaging tests. Your doctor may use ultrasound to assess your kidneys' structure and size. Other imaging tests may be used in some cases. Removing a sample of kidney tissue for testing. Your doctor may recommend a kidney biopsy to remove a sample of kidney tissue. Kidney biopsy is often done with local anesthesia using a long, thin needle that's inserted through your skin and into your kidney. The biopsy sample is sent to a lab for testing to help determine what's causing your kidney problem.

SIGNS AND SYMPTOMSSigns and symptoms of chronic kidney disease develop over time if kidney damage progresses slowly. Signs and symptoms of kidney disease may include: Nausea Vomiting Loss of appetite Fatigue and weakness Sleep problems Changes in urine output Decreased mental sharpness Muscle twitches and cramps Hiccups Swelling of feet and ankles Persistent itching Chest pain, if fluid builds up around the lining of the heart Shortness of breath, if fluid builds up in the lungs High blood pressure (hypertension) that's difficult to controlSigns and symptoms of kidney disease are often nonspecific, meaning they can also be caused by other illnesses. And because your kidneys are highly adaptable and able to compensate for lost function, signs and symptoms may not appear until irreversible damage has occurred.

Precipitating Factors:DMHypertensionDietSmokingPredisposing Factors:Hereditary> 60 yrs. oldAutoimmune DisordersPATHOPHYSIOLOGYA. Diagram

Decreased Renal blood flow

DehydrationPolyuriaLow RBC countLegends:Laboratory resultsSigns and SymptomsNext flowOsteodystrophyHypocalemiaDec. Ca absorptionHyperphosphatemiaDec. Phosphate excretionFail to produce erythropoietinDeathComaInc. waste in bloodWeight LossDec. appetiteNausea and VomitingAmmonia BreathCNS changesProteinuriaUremiaDec. excretion of wasteHyperkalemiaCHFHTNWater retentionDec. Na reabsorption in tubuleDec. Potassium excretionFurther loss of nephron functionInability to concentrate urineInc. Serum CreatinineInc. BUNLoss of Na in urineHyponatremiaHypertrophy of remaining nephronsDecreased glomerular filtrationMetabolic AcidosisDec. Hydrogen excretion

EdemaShortness of breathAnemiaFatigue

B. Narrative

Chronic Renal Failure is the gradual loss of kidney function. First of all, your kidneys function as a filter to excrete wastes and excess fluids from your body that is in the form of urine. When chronic kidney disease reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can build up in your body.Predisposing factors would include a.) Hereditary in which there is a history of your father or mother having the same disease, b.) > 60 years old, in which older people have low functioning kidneys, and c.) Autoimmune disorders such as lupus can damage blood vessels and can make antibodies against kidney tissue.Precipitating factors would include a.) Diabetes Mellitus and b.) Hypertension, which are mostly the duo that contributes to having CRF. Both contributes in damaging the kidneys when uncontrolled. C.) Diet, which is about high protein and cholesterol, can later on lead to kidney damage and d.) Smoking can contribute to damages in blood vessels which then increase risks for hypertension and later on, CRF.In the early stages of chronic kidney disease, you may have few signs or symptoms. There will be decreased in glomerular filtration as seen in lab results (Inc. BUN and Creatinine). Later on, the body will compensate by means of working hard which then contributes to its enlargement. Furthermore, there will be an inability of the kidney to filtrate and malfunctioning in the absorption and excretion of minerals, which then causes a number of problems such as hypocalcemia and edema. There is also failure to produce Erythropoietin, a hormone released by the kidneys, which then contributes to having Anemia, easy fatigability and shortness of breath. Chronic kidney disease may not become apparent until your kidney function is significantly impaired. If untreated, it can later on lead to coma, and death.

COMPLICATIONChronic kidney disease can affect almost every part of your body. Potential complications may include: Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid in your lungs (pulmonary edema) A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart's ability to function and may be life-threatening Heart and blood vessel disease (cardiovascular disease) Weak bones and an increased risk of bone fractures Anemia Decreased sex drive or impotence Damage to your central nervous system, which can cause difficulty concentrating, personality changes or seizures Decreased immune response, which makes you more vulnerable to infection Pericarditis, an inflammation of the sac-like membrane that envelops your heart (pericardium) Pregnancy complications that carry risks for the mother and the developing fetus Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival

TREATMENTA. Medical Management

Generic Name: Calcium AcetateBrand Name: PhosLoClassification: Mineral and electrolyte replacements/supplementsIndication: PO, IV: Treatment and prevention of hypocalcaemia. Control of hyperphosphatemia in end stage renal disease.Action: Essential for nervous, muscular, and skeletal systems. Maintain cell membrane and capillary permeability. Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscle. Essential for bone formation and blood coagulation. Therapeutic effects: Replacement of calcium in deficiency states. Control of hyperphosphatemia in end stage renal disease without promoting aluminum absorption.Contraindication: Hypercalcemia; Renal calculi; ventricular fibrillation. Use cautiously in: Patients receiving digitalis glycosides; severe respiratory Insufficiency; renal disease; cardiac disease.Adverse Reaction/Side effects: CNS: syncope (IV only), tingling; CV: Cardiac arrest (IV only), arrhythmias, bradycardia. GI: constipation, nausea, vomiting. GU: calculi, hypercalciuria. Local: phlebitis (IV only)Dosage: PO (Adults): Hyperphosphatemia in end stage renal disease Amount necessary to control serum phosphate and calcium.Nursing Interventions:1. Observe patient for signs and symptoms of hypocalcemia (paresthesia, muscle twitching, laryngospasm, colic, cardiac arrhythmias, Chvosteks or Trousseau sign). Notify physician.2. Monitor blood pressure, pulse, ECG frequently throughout parenteral therapy. May cause vasodilation with resulting hypotension, bradycardia, arrythmias, and cardiac arrest. Transient increases in blood pressure may occur during IV administration, especially in geriatric patients or in patients with hypertension.3. Laboratory Considerations: Monitor serum calcium or ionized calcium chloride, sodium, potassium, magnesium, albumin, and parathyroid hormone concentrations before and periodically during therapy for treatment of hypocalcemia.4. Do not administer concurrently with foods containing large amounts of oxalic acid (spinach, rhubarb), phytic acid (cereals, brans), or phosphorous (milk or dairy products).

Generic Name: DigoxinBrand Name: LanoxinClassification: antiarrhythmics, inotropicIndication: Treatment of CHF. Tachyarrhythmias: atrial fibrillation and atrial flutter.Action: Increases the force of myocardial contraction. Prolong refractory period of the AV node. Decreases conduction through the SA and AV nodes. Therapeutic Effects: increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect).Contraindication: Hypersensitivity; uncontrolled ventricular arrhythmias; AV block; idiopathic hypertrophic subaortic stenosis.Adverse Reactions/Side Effects: CNS: fatigue, headache, weakness. EENT: blurred vision, yellow or green vision. GI: anorexia, nausea, vomiting, diarrhea. Metab: electrolyte imbalances with acute digoxin toxicity.Route/Dosage: PO (Adults): 0.751.25 mg IV: 0.1250.25 mg IV.

Nursing Interventions:1. Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate. 2. Avoid IM injections, which may be very painful.3. Follow diluting instructions carefully, and use diluted solution promptly.4. Avoid giving with meals; this will delay absorption.5. Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine, and cardiac monitor readily available in case toxicity develops.6. Weigh patient every other day with the same clothing and at the same time. Record this on the calendar.7. Advise patient to do not start taking any prescription or over-the-counter products without talking to your health care provider. Some combinations may increase the risk of digoxin toxicity and may put the patient at risk of adverse reactions.8. Have regular medical checkups, which may include blood tests, to evaluate the effects and dosage of this drug.9. Report unusually slow pulse, irregular pulse, rapid weight gain, loss of appetite, nausea, diarrhea, vomiting, blurred or yellow vision, unusual tiredness and weakness, swelling of the ankles, legs or fingers, difficulty breathing.

Generic Name: ErythropoietinBrand Name: EpogenClassifications: HematopoieticIndications: This medication is a haematopoietic agent, prescribed for anemia in people with chronic kidney failure. It helps in the formation of red blood cells by the bone marrow.Action: Epogen stimulates erythropoiesis by the same mechanism as endogenous erythropoietin.Contraindication: Contraindicated in patients with uncontrolled hypertension and hypersensitivity. Caution should be exercised in patients with history of blood clotting problems, cancer, sickle cell anemia, thalassemia, porphyria, blood clot events, heart attack, infections, seizures, stroke, tumors, heart disease, any allergy, who are taking other medications, during pregnancy and breastfeeding.Adverse Reaction/Side Effects: CV: Hypertension; vascular access thrombosis; DVT; thrombosis; MI, pulmonary embolism. CNS: Headache; dizziness; insomnia; depression; seizures. Derm: Pruritus, rash, urticaria, erythema. GI: nausea. Hemat: Leukopenia. Musc: myalgia, bone pain, muscle spasm. Resp: cough, URTI, respiratory tract infection.

Nursing Intervention: 1. Instruct patients to read the Medication Guide before starting therapy and at regular intervals during treatment.2. Inform patients of the risks and benefits of epoetin alfa prior to treatment.3. Inform patients with cancer that they must sign the patient-health care provider acknowledgement before the start of each treatment course with epoetin alfa.4. Inform patients of the increase risks of mortality, serious CV reactions, thromboembolic reactions, stroke, and tumor progression.5. Inform patients to undergo regular BP monitoring, adhere to prescribed antihypertensive regimen, and follow dietary restrictions.6. Inform patients to contact their health care provider for new-onset neurologic symptoms or change in seizure frequency.7. Inform patients of the need to have regular laboratory tests for Hgb.8. Inform patients of the risks associated with benzyl alcohol in neonates, infants, pregnant women, and breast-feeding mothers.9. Instruct patients who self-administer epoetin alfa of the importance of following instructions for use; dangers of reusing needles, syringes, or unused portions of single-dose vials; proper disposal of syringes, needles, and unused vials, and of the full container.

B. Surgical Management

1. Kidney TransplantIndication The surgical implantation of a human kidney from a compatible donor in a recipient. This procedure is performed as an intervention in irreversible kidney failure. The kidney is surgically placed extraperitoneally in the iliac fossa. The renal artery is anastomosed to the recipients hypogastric internal or external iliac artery (Occasionally the aorta) and the renal vein to the recipients iliac vein. Contraindications Infection and active malignancy are the only absolute contraindications to transplantation. Some physical conditions markedly increase the risk for the client, however, primarily long term immunosuppressive medications are necessary to avoid graft rejection. Clients with liver disease, psychological disorder, advanced atherosclerosis, hypertension, respiratory disease, and gastrointestinal bleeding need particularly consideration. The primary factor limiting the number of transplantation done is the availability of kidneys.

Complications Graft rejection. The manifestations of renal transplant rejection include fever, graft tenderness, at the site of the transplanted kidney, anemia, and malaise. Urinary Tract Complications. Several complications may occur in the urinary tract. Although it is rare, spontaneous rupture of the kidney may occur because of rejection or ischemic damage. Leaking of the urine from the ureter-bladder anastomosis causes the development of a urinoma, which eventually puts pressure on the kidney and ureter, reducing renal function. Long-term uremia and steroid therapy may predispose the client to ureteral, bladder, or caliceal-cutaneous fistulae. Other urinary tract complications include ureteral, bladder, or pelvic leaks, as well as obstruction, reflux, and lymphoceles. Cardiopulmonary Complications. Hypertension occurs in 50% to 60% of adult recipients and may be caused by renal artery stenosis, acute tubular necrosis, acute and chronic graft rejection, hydronephrosis, hyperaldostorenism, large-dose steroids, and cyclosporine. Cardiac dysrhythmias and heart failure may result from fluid and electrolyte imbalances. Pneumonia caused by bacteria and fungi is the most frequent respiratory complication. Other respiratory problems include pulmonary edema, pulmonary emboli, and reactivated tuberculosis. Other complications. The reproductive problems associated with CRF commonly disappear after transplantation. The incidence of gynecologic malignancies is higher than in general population, with cervical cancer dominating. Successful pregnancies has been completed after transplantation, although there is a risk for both the fetus and the mother with a transplanted kidney.

Nursing Management Of The Surgical Client Preoperative Care Before kidney transplantation, assess the clients understanding of the procedure and follow-up regimen. Also, assess the clients ability to cope up with a complex medication regimen after transplantation. The client needs to understand the transplantation and therapeutic regimen. Preoperative preparation of both the living donor and the recipient includes all aspects of general preoperative care.

Postoperative Care Assessment for renal transplant recipients is similar to that for most other postoperative clients, with the exception of the focus on renal function. Give particular attention to fluid balance, and carefully monitor intake and output (every 30-60 minutes) and weight (daily). To monitor renal function and maintain electrolyte imbalance, obtain serial laboratory determinations of haemoglobin, haematocrit, BUN (urea nitrogen), creatinine, electrolytes, WBC count, and platelets. Auscultate the kidney regularly to check for bruits, which might indicate stenosis. Monitoring of vital signs is key, because even a slight temperature increase may indicate an infection.

C. Nursing Management

When a client is thought to have CRF, take a complete history and look closely to the risk factors. Question the client about the past and present medications, diet and weight changes, energy levels and unexplained fatigue, and the pattern of urinary elimination. Assess the client for the multiple effects of CRF on all body systems, such as the presence of cardiovascular or respiratory abnormalities, neurologic changes, gastrointestinal problems, or skin changes. Assess the clients understanding of CRF, the diagnostic tests that will be done, and the possible treatment regimens. Evaluate the clients level of anxiety and ability to cope. Involve the family in the assessment to determine their ability to cope with the disease and treatments. When the client begins peritoneal dialysis, the first assessment is infection. Inspect the insertion site carefully for redness or other problems. Carefully assess the drained dialysate or effluent for cloudiness, fibrin streaks, or blood. Monitor the clients vital signs and weight closely. If the client is undergoing hemodialysis, the first assessment is for the patency of the venous access site. In a patent arteriovenous fistula or graft, a thrill or vibrating sensation should be palpable and a bruit should be audible with the stethoscope. It is vital that this site be assessed for possible occlusion or, if it is an external site, for infection. Also ascertain the client understands of the access site and its care. Provide conservative therapy, as indicated. Maintain strict fluid control; daily fluid intake should equal 500 ml (insensible loss) plus the amount of the previous 24 hours urine output; daily weight; and strict intake and output Encourage intake of high biologic value protein foods such as eggs, dairy products, and meats (causes positive nitrogen balance needed for growth and healing) Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals. Encourage alternating activity with rest. Encourage independence as much as possible. Assess the client and familys response to chronic illness. Encourage therapeutic conversations to help cope with chronic illness. Provide symptomatic treatment. Be prepared to identify and treat complications, which include hyperkalemia, pericarditis, pericardial effusion, pericardial tamponade, hypertension, anemia, and bone disease. Administer prescribed medication, which may include ion exchange resin, alkalizing agents, antibiotics, erythropoeitin, folic acid supplements, iron supplements, phosphate-binding agents, calcium supplements, histamine receptor antagonists, and proton-pump inhibitors. Prepare the client for peritoneal dialysis, if indicated. Provide proper shunt care, and assess for possible complications. (bleeding due to heparinization, hypovolemia, hypotension due to excessive water removal, dialysis disequilibrium syndrome (headache, confusion, and seizures) due to rapid removal of urea from plasma.) Provide postoperative care for any client who has undergone major surgery with special attention to catheter patency and adequacy, intake and output, fluid replacement, and protection from infection. Monitor for signs and symptoms of complications such as:1. Graft rejection (fever, elevated white blood cell count, electrolyte abnormalities, abnormal renogram)2. Infection stemming from immunosuppressive therapy (sepsis pneumonia, wound infection, and urinary tract infection)

DAVAO MEDICAL SCHOOL FOUNDATION, Inc.Medical School Drive, Bajada, Davao CityCollege of Nursing

NURSING CARE PLAN

NURSING DIAGNOSISGOAL OF CARENURSING INTERVENTIONSEVALUATION

Altered nutrition less than body requirement r/t anorexia and malnutrition secondary to renal failure.

Demonstrate behaviors, lifestyle changes to regain and maintain an appropriate weight. Normalize Vital signs. Have a good appetite. Understand the importance of nutritious food (Veggies, Fruits.) Have a balance intake and output. Comply with the treatment regimen.

Assess general appearance and monitor vital signs. Assist in developing individual regimen. Provide diet modification as indicated. Encouraged the patient to avoid sodium rich food. Promote relaxing environment conducive for resting. Proved patients safety. Encouraged the patient to change position every 2 hours. Encourage to do passive range of motion exercise. Regulate above IVF as ordered. Administer medication. As ordered.

In my 8 hours span of care , Goal partially met;

Patient demonstrated behavior to regain and maintain appropriate weight. Patients have slightly good appetite. Patient understands the importance of nutritious intake. Had a balanced intake and output. Patient comply with the treatment.

DAVAO MEDICAL SCHOOL FOUNDATION, Inc.Medical School Drive, Bajada, Davao CityCollege of Nursing

NURSING CARE PLAN

NURSING DIAGNOSISGOAL OF CARENURSING INTERVENTIONSEVALUATION

Impaired urinary elimination r/t loss of kidney functions secondary to renal failure.

Normalized Vital signs. Verbalized understanding of condition. Participate in measures to correct/ compensate for defects

Monitor and record vital signs. Review laboratory test for changes in renal function. Determine clients pattern of elimination. Palpate the patients bladder. Investigate pain, noting location. Note condition of skin and mucous membrane. Note urine color, consistency and amount. Observe for signs of infection. Encouraged to verbalized feelings/concerns. Emphasized the need to adhere with prescribed diet. Emphasize the importance of having a good hygiene. Administer medication, as ordered.

In my 8 hours span of care, Goal partially met;

Patient participates in complying treatment regimen. Patient verbalizes understanding of condition.

DAVAO MEDICAL SCHOOL FOUNDATION, Inc.Medical School Drive, Bajada, Davao CityCollege of Nursing

NURSING CARE PLAN

NURSING DIAGNOSISGOAL OF CARENURSING INTERVENTIONSEVALUATION

Risk for impaired skin Integrity r/t reduced activity/immobility secondary to renal failure..

Normalize Vital signs. Perform ADL without assistance. Ambulate properly. Participate in the treatment. Have a good skin condition. Have balanced intake and output.

Check and record patients vital signs. Encourage patient to comply with treatment regimen. Monitor patients fluid intake and hydration of skin. Change patient position frequently. Provide soothing skin care (apply ointments or creams.) Advised patient to report id experience itching. Advised patient to use cool, moist compress to apply pressure ( Rather than scratch) Administer medication as ordered.

In my 8 hours span of care, Goal partially met; Patients perform ADL with minimal assistance. Assess for patients skin; Intact skin noted. Patient demonstrate behavior/ techniques to prevent skin breakdown.

BIBLIOGRAPHY

Books Medical-surgical 2010 chapter 38 Management of Clients with Renal Failure pg.963

E-sources: http://emedicine.medscape.com/article/238798-overview#a0101 http://www.mayoclinic.org/diseases-conditions/kidney-disease/basics/complications/con-20026778 http://www.mayoclinic.org/diseases-conditions/kidney-disease/basics/symptoms/con-20026778 http://www.mayoclinic.org/diseases-conditions/kidney-disease/basics/tests-diagnosis/con-20026778 http://emedicine.medscape.com/article/238798-overview#aw2aab6b2b3 http://www.nursing-nurse.com/medical-and-nursing-management-of-chronic-renal-failure-422/2/