The purpose of this activity is to enable the learner to identify and aid in the management of patients with kidney disease.
It is estimated that over 20 million people have a diagnosis of kidney disease in the U.S. (National Kidney Foundation, 2016a). Kidney disease can be acute or chronic. However, chronic kidney disease is a precursor to End Stage Renal Disease (ESRD). Over the last several years, kidney disease has been on the rise in the elderly, over 65, population and a slight increase in the 20-year-old to 64-year-old population (“Health statistics,” 2016). People at risk for kidney disease has also been on the rise. A leading cause of kidney failure is diabetes. Approximately 44% of patients who are diagnosed with kidney failure have diabetes. Just as many also have high blood pressure. As more people are being diagnosed with diabetes and hypertension, it is expected that more cases of kidney failure and resulting ESRD will occur. Other populations at risk are those with a family history of kidney disease (National Kidney Foundation, 2016b ) Furthermore, certain ethnic populations such as African Americans, Hispanic, American Indian, and Pacific Islanders seem to have a higher risk factor for kidney disease than the general population (National Kidney Foundation, 2016b).
The Certified Nursing Assistant (CNA) often cares for patients with diabetes as well as other conditions that can lead to kidney failure. Health care professionals can influence the health of patients at risk for kidney disease as well as patients who already have kidney disease or ESRD.
Mrs. G is a new patient in your care. She is living at home with her daughter. When you arrive for your first visit, you notice that Mrs. G seems confused. Her daughter has not been getting daily weights. She tells you that it is very difficult for her to get her mother to the scale every day. Upon further observation, you notice that Mrs. G has very dry skin. The daughter also reports that she has been incontinent at times and has been drinking a lot of water since yesterday. What do you do?
Mr. C is a patient you are caring for today. He is diagnosed with ESRD and has a fistula in his right arm. You notice that there are new orders to monitor and record input and output as well as get daily weights and blood pressure. You are also to make sure his diet is low in sodium, potassium, and protein. His breakfast consists of bacon, banana, three eggs, and crackers. He is drinking an 8oz cup of coffee and 4oz of water. He has a urinal at his bedside, and you note that it contains about 200ml of urine from last night. What do you do?
The renal system consists of the kidneys, ureters, bladder, and urethra. This system functions to maintain the body’s fluid volume, control blood pressure, regulates erythropoietin production, vitamin D activation, acid-base regulation, and excretion of waste products from the blood (Grossman and Porth, 2014).
The kidneys are bean shaped and are located in the upper abdomen on either side of the spine. The right kidney is slightly lower than the left kidney. The kidney is responsible for regulating fluid volume throughout the body as well as regulating blood pressure, urine production and stimulating erythropoietin production for red blood cells. (Grossman and Porth, 2014). The filtration system of the kidney works by processing blood in the nephrons. There are over one million nephrons is each kidney. They are small and closely packed together. Through a series of tubules, the blood returning to the heart and lungs passes through the nephron to be cleaned or filtered. All waste products such as urea and salts as well as excess water are removed and processes in the outer layer of the kidney to produce urine. Urine then flows down the ureters and into the bladder where is it stored (Pulliman, 2012). When the bladder is full, nerve cells send a message to the brain to tell the bladder to contract to stimulate the need to urinate. Urine travels down the urethra and out of the body.
The body is composed of 60% - 45% of water depending on age (Patton & Thibodeau, 2016). Losing more than 1% of body fluids can cause significant problems, including kidney failure (Patton & Thibodeau, 2016). Typically, the average person urinates as much as 3 pints of urine a day (Sorrentino & Remmert, 2016). However, changes occur to the renal system through aging that may increase or decrease the frequency of urination (Hegner & Acello, 2014). The bladder decreases in size and can hold less urine. Function, therefore, increases at rest causing the patient to urinate more at night. Bladder muscles can also weaken, causing leakage or in adequate emptying. Prostate glands in men can enlarge causing dribbling, obstruction, or retention. These are important considerations to understand when working with all patients (Hegner & Acello, 2014). However, in patients with kidney disease age is an important factor to consider in care.
In kidney disease, the kidneys are not able to remove the waste products from the blood (Hegner & Acello, 2014). As the waste builds up in the blood, almost all organs in the body are affected. When the kidneys fail to maintain fluid balance and remove waste from the blood, the patient is in kidney failure. Kidney failure can be acute or chronic. Kidney failure can lead to End Stage Renal Disease (ESRD) where the kidneys can no longer function on their own.
There are several common conditions that if left untreated can lead to permanent damage to the kidneys and cause kidney disease. Below is a list of these conditions with their definitions (Hegner & Acello, 2014):
Cystitis- is inflammation of the bladder.
Dysuria- is pain or burning upon urination.
Hematuria- is blood in the urine.
Hydronephrosis- is too much fluid on the kidneys.
Nephritis- is inflammation of the kidney
Oliguria- is decreased urine production.
Renal calculi - are kidney stones.
Urinary incontinence -is loss of control over urination.
Each of these can occur alone or as part of the disease process.
Acute kidney failure occurs when blood flow to the kidney is suddenly decreased. Causes of acute kidney failure include injury, bleeding, heart attack, heart failure, infection or severe allergic reactions (Sorrentino & Remmert, 2016). Acute kidney failure can sometimes be reversed. However, if not treated, it can lead to chronic kidney failure (Sorrentino & Remmert, 2016).
Oliguria or small amounts of urine appear first. Typically, this is less than 400mL of urine in a 24- hour period and can last a few days to a few weeks. This is followed by diuresis or large amounts of urine ranging from 1000mL -500mL per day. Kidney function may improve. However, this can take up to a year. Sometimes chronic kidney failure can develop from a build-up of waste in the blood.
Chronic kidney failure is the progressive and irreversible damage to the kidneys (Sorrentino & Remmert, 2016). Over time, the nephrons are destroyed and symptoms appear when 75% of the kidney function is lost (Sorrentino & Remmert, 2016). Common causes of chronic kidney failure are high blood pressure and diabetes. The result is usually end-stage renal disease or renal failure. Once the patient is considered in renal failure, they are placed on a very strict input and output schedule. Vital signs, particularly the blood pressure, must be monitored as well as daily weights. Food is usually limited or restricted. These patients typically go on dialysis which acts as a mechanical kidney to filter the blood.
Renal failure is the inability of the kidneys to maintain fluid and electrolyte balance and excrete waste (Grossman & Porth, 2014). Several things can cause renal failure including dehydration and poor health. High blood pressure is also a culprit causing over 80% of all kidney failures (Hegnar & Acello, 2014). Those with diabetes are also at high risk for renal failure. In renal failure, as waste builds up in the blood almost every system in the body can be affected. Fluid restriction, drugs, diet and dialysis, are the typical treatments for renal failure.
In kidney disease, the most common signs to look for are a low urine output, low oral intake, output can also exceed input (Hegnar & Acello, 2014). Dehydration is noted as dark-colored urine, a strong odor to the urine, weight loss, dry skin, dry mouth, drowsiness, or confusion. Edema can also be present and typically seen in the face, legs, ankles, or feet. There may also be substances in the urine such as small particles or blood. The patient may complain of difficulty urinating or pain during urinating. They may also state that they have a pain in the lower back. Frequent, small amounts of urine, incontinence, sudden weight loss or weight gain, respiratory stress, changes in mental status, and complaints of not being able to empty the bladder are often described as well (Hegnar & Acello, 2014).
Renal dialysis is the removal of waste substances from the blood (Sorrentino & Remmert, 2016). The process is used with patients in end-stage renal disease.Hemodialysis is when a machine is used to filter the blood. Typically, patients on hemodialysis have a tube permanently placed in their arm for the procedure called a fistula (Hegnar & Acello, 2014).This arm is never to be used to measure blood pressure. Although care of the fistula is done by the nurse, observations of redness or swelling at the fistula area should be reported.
Another process is peritoneal dialysis and works by using the lining of the abdominal cavity to remove waste from the blood (Sorrentino & Remmert, 2016). This procedure can take a long time to administer and is done by a nurse. However, the patient may need vital signs taken every 15 minutes for the first two hours then every two hours during the procedure (Hegnar & Acello, 2014). Any changes in blood pressure, complaints of abdominal pain, leaking around the site, or respiratory distress should be reported immediately (Hegnar & Acello, 2014).
The first responsibility is to make sure there is a clear understanding of all orders regarding positioning, fluid intake, diet restriction, weight monitoring, vital signs schedule, and activity. The nursing assistant may be asked to strain the urine for particles, assist with urination, or collect urine samples.
Knowing how to limit fluid is also very important. Most adults take in 2 1/2 to 3 quarts of fluid a day (Hegnar & Acello, 2014). This would be approximately 600 to 800 mL of fluid in an eight-hour shift. However, there is typically more fluid intake in the a.m. Be sure to examine the patient for edema and dehydration. Output of fluid consists of urine, sweat, exhalation from the lungs, and bowel movements. However, be sure to include any diarrhea, vomit or blood loss. A normal adult loses approximately 2 1/2 quarts a day of fluid (Hegnar & Acello, 2014).
There may be an order to monitor and record input and output for the patient. Measuring is typically done in liters or milliliters. A container or graduate is usually provided for this. It is helpful to know how many ounces are in the milliliters. For example, 8 ounces equals 240 mL, 16 ounces equals 480 mL, and 4 ounces equals 120 mL (Hegnar & Acello, 2014). If the patient has an IV or gastric tube, it is recorded separately. If the patient is incontinent, weighing the briefs or sheets can give an estimated output. If the output of urine falls below 30 mL in an hour, it is important to notify the nurse immediately (Hegnar & Acello, 2014).
Vital signs, particularly blood pressure should be taken daily. Blood pressure should be taken in the supine, sitting, and standing positions. Additionally, daily weights are also important to measure if the patient is retaining fluid. Weights should be obtained the same time every day for accuracy. If the weight increases or decreases by 2%, be sure to inform the nurse immediately (Hegnar & Acello, 2014).
It will also be important to monitor the patient’s intake of fluids or food as well as monitoring for any signs of confusion, dehydration, or incontinence. If the patient is bedridden, prevention of pressure ulcers and range of motion may be ordered. Measures to prevent itching such as bath oils, lotions or creams can be used on dry skin. Frequent oral hygiene should also be performed as dry mouth can occur (Hegnar & Acello, 2014). Providing frequent rest periods and emotional support is also important.
Additionally, foods provided should be low in protein, potassium, and sodium (National Kidney Foundation, 2016). Protein can build up and cause more waste in the bloodstream. Sources of protein are typically from animal and plants. Examples our eggs, beans, fish, and chicken. Sodium can cause fluid buildup and should be monitored carefully (National Kidney Foundation, 2016). Observe for signs of edema and high blood pressure (Hegnar & Acello, 2014). Sources of sodium are salt, tenderizers, steak sauce or barbecue sauce. Other sources are crackers, nuts, bacon, and most processed foods or lunchmeat. Instead, suggest the patient use of fresh onion, garlic, lemon juice, salt-free or low sodium salts. Foods high in potassium can affect the heart and muscles (National Kidney Foundation, 2016). These foods include squash, artichoke, bananas, cantaloupe, oranges, black beans, carrots, and chocolate. Instead, suggest apples, blueberries, grape, strawberries, cucumbers, lettuce, rice noodles, or eggplant.
Report to the nurse any observations of confusion, change in mental status, blood pressure change, weight change, or any changes in input or output (Hegnar & Acello, 2014). Report any changes to the patient's current health status including bleeding, bruising, or any other problems with urination. Report any new information that is given to you or that you observe such as blood in the urine, difficulty urinating or painful urination. Describe any edema or skin changes as well. Any changes in the patient’s medical condition should also be reported. This may include sudden incontinence, mood changes, or injury, or respiratory distress. Observation is important when administering care for the patient (Hegnar & Acello, 2014). Also, observe for any safety issues such as dizziness when ambulating or pain in abdomen or lower back.
When caring for a patient with kidney disease, several factors need to be considered. The age and condition of the patient need to be observed and any comorbid diagnosis noted. Understanding and following orders given for each patient is important in their care. Each patient may have a different care plan according to their needs and disease process. To provide appropriate care, the CNA should understand the disease process and what symptoms to observe for in each patient. Observing the patient for sign and symptom of distress or discomfort and offering allowed interventions will help the patient to live a productive and happier life.
First, check the order and treatment plan for Mrs. G. Is she on a fluid restriction? A food restriction? Should input and output be monitored? Next, ask about her fluid and food intake. Discuss with the daughter what foods she is eating and how much fluid she is getting a day. Also, ask about Mrs. G’s output. Does the daughter notice that she is urinating less or more? Is the urine darker or have an odor? How long has Mrs. G been incontinent? The daughter may not have these answers and you may need to educate her on what to look for when caring for her mother. Continue your observation of Mrs. G’s skin looking for pressure ulcers and additional areas of dry skin. Observe her behavior and speech. Does she seem confused? Is she restless or calm? You will report your observations and what was reported to you to the nurse. You will also need to educate the daughter on how to move her mother appropriately and how to get daily weights. You can help the daughter create a chart to monitor daily weight, input and output.
The breakfast of bacon, banana, 3 eggs and crackers is not appropriate for Mr. C’s condition. A better choice for his breakfast would be one egg for protein, strawberries for potassium, ½ of an English muffin, grape juice or water and if requested he can have low sodium salt. You also need to document his input and output as well as his daily weight. If possible, get his weight in the morning. Be sure to document the time you took his weight so others know to get his weight at the same time. Document output as urine/200mL. Document his input of fluid as breakfast-360mL. Next, you will get his blood pressure and document it along with the time it was taken. You will not have to clean the fistula but make sure you do not take the blood pressure in the right arm where the it is located.
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