Escolar Documentos
Profissional Documentos
Cultura Documentos
removing waste products from the body, keeping toxins from building up in the
bloodstream
producing hormones that control other body functions, such as regulating blood pressure
and producing red blood cells
regulating the levels of minerals or electrolytes (e.g., sodium, calcium, and potassium)
and fluid in the body
The two kidneys in our body possess tiny filtering units, called nephrons, each of which is made
up of a glomerulus (which acts as a kind of sieve to prevent important components such as red
blood cells from being removed), and a tubule (a tube through which fluid passes).
It's entirely possible to live a full, healthy life with only one kidney – one fully functioning
kidney can do the work of two – but it's essential to watch for signs of any problems with the
remaining kidney.
External Anatomy
The left kidney is located at about
the T12 to L3 vertebrae, whereas the right
is lower due to slight displacement by the
liver. Upper portions of the kidneys are
somewhat protected by the eleventh and
twelfth ribs. Each kidney weighs about
125–175 g in males and 115–155 g in
females. They are about 11–14 cm in
length, 6 cm wide, and 4 cm thick, and are
directly covered by a fibrous capsule
composed of dense, irregular connective
tissue that helps to hold their shape and protect them. This capsule is covered by a shock-
absorbing layer of adipose tissue called the renal fat pad, which in turn is encompassed by a
tough renal fascia. The fascia and, to a lesser extent, the overlying peritoneum serve to firmly
anchor the kidneys to the posterior abdominal wall in a retroperitoneal position. On the superior
aspect of each kidney is the adrenal gland. The adrenal cortex directly influences renal function
through the production of the hormone aldosterone to stimulate sodium reabsorption.
Internal Anatomy
A frontal section through
the kidney reveals an outer
region called the renal
cortex and an inner region
called the medulla. The renal
columns are connective tissue
extensions that radiate
downward from the cortex
through the medulla to separate
the most characteristic features of the medulla, the renal pyramids and renal papillae. The
papillae are bundles of collecting ducts that transport urine made by nephrons to the calyces of
the kidney for excretion. The renal columns also serve to divide the kidney into 6–8 lobes and
provide a supportive framework for vessels that enter and exit the cortex. The pyramids and renal
columns taken together constitute the kidney lobes.
Renal Hilum
The renal hilum is the entry and exit site for structures servicing the kidneys: vessels,
nerves, lymphatics, and ureters. The medial-facing hila are tucked into the sweeping convex
outline of the cortex. Emerging from the hilum is the renal pelvis, which is formed from the
major and minor calyxes in the kidney. The smooth muscle in the renal pelvis funnels urine via
peristalsis into the ureter. The renal arteries form directly from the descending aorta, whereas the
renal veins return cleansed blood directly to the inferior vena cava. The artery, vein, and renal
pelvis are arranged in an anterior-to-posterior order.
Cortex
In a dissected kidney, it is easy to identify the cortex; it appears lighter in color compared
to the rest of the kidney. All of the renal corpuscles as well as both the proximal convoluted
tubules (PCTs)and distal convoluted tubules are found here. Some nephrons have a short loop
of Henle that does not dip beyond the cortex. These nephrons are called cortical nephrons.
About 15 percent of nephrons have long loops of Henle that extend deep into the medulla and are
called juxtamedullary nephrons.
Chronic kidney disease (CKD) is divided into 5 stages based on the level of kidney
function. Stages are determined through certain tests performed by your doctor, including a test
used to calculate the estimated glomerular filtration rate (eGFR), which measures how well your
kidneys are cleaning your blood. Kidney disease is a progressive disease, meaning that kidney
function can continue to decline over time, eventually resulting in kidney failure.
Anyone can get chronic kidney disease at any age. However, some people are more likely than
others to develop kidney disease. You may have an increased risk for kidney disease if you:
have diabetes
have high blood pressure
have a family history of kidney failure
are older
belong to a population group that has a high rate of diabetes or high blood pressure, such
as African Americans, Hispanic Americans, Asian, Pacific Islanders, and American
Indians.
Being diagnosed with chronic renal failure can be very frightening.The future of the
condition, however, depends on the medical problem that caused the kidney failure, how much
kidney damage has occurred, and what, if any, complications are present.
anemia
There are many diseases that cause chronic renal disease; each has its own pathophysiology.
However, there are common mechanisms for disease progression.
1. Pathologic features include fibrosis, loss of renal cells, and infiltration of renal tissue
by monocytes and macrophages.
2. Proteinuria, hypoxia, and extensive angiotensin II production all contribute to the
pathophysiology. In an attempt to maintain GFR, the glomerular hyperfiltration; this
results in endothelial injury.
3. Proteinuria results from increased glomerular permeability and increased capillary
pressure.
4. Hypoxia also contributes to disease progression. Angiotensin II increases
glomerular hypertension, which further damages the kidney.
Predisposing Factors
Diabetes, which is the most common risk factor for chronic kidney failure in the
United States
Age 60 or older
Kidney disease present at birth (congenital)
Family history of kidney disease
Autoimmune Disorder (Lupus erythematosus)
Bladder outlet obstruction (BPH and Prostatitis)
Race (Sickle cell disease)
Precipitating Factors
Schematic Diagram
Prognosis
The prognosis of patients with chronic kidney disease is guarded asepidemiological
data has shown that all cause mortality(the overall death rate) increases as kidneyfunction
decreases. The leading cause of death in patients with chronic kidney disease is cardiovascular
disease, regardless of whether there is progression to stage 5.While renal replacement
therapies can maintain patients indefinitely and prolong life, the quality of life is severely
affected.
Renal transplantation increases thesurvival of patients with stage 5 CKD significantly
when compared to other therapeutic options; however, it is associated with an increased short-
term mortality (due tocomplications of the surgery). Transplantation aside, high intensity home
hemodialysis appears to be associated with improved survival and a greater quality of life ,when
compared to the conventional three times a week hemodialysis and peritoneal dialysis.
Assessment and Diagnostic Findings
Laboratory studies required to establish the diagnosis of CRF include:
Glomerular filtration rate. GFR and creatinine clearance decrease while serum
creatinine (more sensitive indicator of renal function) and BUN levels increase.
Sodium and water retention. Some patients retain sodium and water, increasing the
risk for edema, heart failure, and hypertension.
Acidosis. Metabolic acidosis occurs in ESRD because the kidneys are unable to
excrete increased loads of acid.
Anemia. In ESRD, erythropoietin production decreases and profound anemia results,
producing fatigue, angina, and shortness of breath.
Urine
o Volume: Usually less than 400 mL/24 hr (oliguria) or urine is absent
(anuria).
o Color: Abnormally cloudy urine may be caused by pus, bacteria, fat,
colloidal particles, phosphates, or urates. Dirty, brown sediment indicates
presence of RBCs, hemoglobin, myoglobin, porphyrins.
o Specific gravity: Less than 1.015 (fixed at 1.010 reflects severe renal
damage).
o Osmolality: Less than 350 mOsm/kg is indicative of tubular damage, and
urine/serum ratio is often 1:1.
o Creatinine clearance: May be significantly decreased (less than 80
mL/min in early failure; less than 10 mL/min in ESRD).
o Sodium: More than 40 mEq/L because kidney is not able to reabsorb
sodium.
o Protein: High-grade proteinuria (3–4+) strongly indicates glomerular
damage when RBCs and casts are also present.
Blood
o BUN/Cr: Elevated, usually in proportion. Creatinine level of 12 mg/dL
suggests ESRD. A BUN of >25 mg/dL is indicative of renal damage.
o CBC: Hb decreased because of anemia, usually less than 7–8 g/dL.
o RBCs: Life span decreased because of erythropoietin deficiency, and
azotemia.
o ABGs: pH decreased. Metabolic acidosis (less than 7.2) occurs because of
loss of renal ability to excrete hydrogen and ammonia or end products of
protein catabolism. Bicarbonate and PCO2 Decreased.
o Serum sodium: May be low (if kidney “wastes sodium”) or normal
(reflecting dilutional state of hypernatremia).
o Potassium: Elevated related to retention and cellular shifts (acidosis) or
tissue release (RBC hemolysis). In ESRD, ECG changes may not occur
until potassium is 6.5 mEq or higher. Potassium may also be decreased if
patient is on potassium-wasting diuretics or when patient is receiving
dialysis treatment.
o Magnesium, phosphorus: Elevated.
o Calcium/phosphorus: Decreased.
Proteins (especially albumin): Decreased serum level may reflect protein loss via
urine, fluid shifts, decreased intake, or decreased synthesis because of lack of essential
amino acids.
Serum osmolality: Higher than 285 mOsm/kg; often equal to urine.
KUB x-rays: Demonstrates size of kidneys/ureters/bladder and presence of
obstruction (stones).
Retrograde pyelogram: Outlines abnormalities of renal pelvis and ureters.
Renal arteriogram: Assesses renal circulation and identifies extravascularities,
masses.
Voiding cystourethrogram: Shows bladder size, reflux into ureters, retention.
Renal ultrasound: Determines kidney size and presence of masses, cysts, obstruction
in upper urinary tract.
Renal biopsy: May be done endoscopically to examine tissue cells for histological
diagnosis.
Renal endoscopy, nephroscopy: Done to examine renal pelvis; flush out
calculi, hematuria; and remove selected tumors.
ECG: May be abnormal, reflecting electrolyte and acid-base imbalances.
X-ray of feet, skull, spinal column, and hands: May reveal
demineralization/calcifications resulting from electrolyte shifts associated with CRF.
Medical Management
The patient with ESRD requires astute nursing care to avoid the complications of reduced renal
function and the stresses and anxieties of dealing with a life-threatening illness.
Nursing Assessment
Assess fluid status (daily weight, intake and output, skin turgor, distention of neck
veins, vital signs, and respiratory effort).
Assess nutritional dietary patterns (diet history, food preference, and calorie counts).
Assess nutritional status (weight changes, laboratory values).
Assess understanding of cause of renal failure, its consequences and its treatment.
Assess patient’s and family’s responses and reactions to illness and treatment.
Assess for signs of hyperkalemia.
Diagnosis
For kidney disease diagnosis, you may also need certain 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.
Treatment
Kidney transplant
Depending on the underlying cause, some types of kidney disease can be treated. Often, though,
chronic kidney disease has no cure.
Treatment usually consists of measures to help control signs and symptoms, reduce
complications, and slow progression of the disease. If your kidneys become severely damaged,
you may need treatment for end-stage kidney disease.
Your doctor will work to slow or control the cause of your kidney disease. Treatment options
vary, depending on the cause. But kidney damage can continue to worsen even when an
underlying condition, such as high blood pressure, has been controlled.
Treating complications
Kidney disease complications can be controlled to make you more comfortable. Treatments may
include:
High blood pressure medications. People with kidney disease may experience worsening
high blood pressure. Your doctor may recommend medications to lower your blood
pressure — commonly angiotensin-converting enzyme (ACE) inhibitors or angiotensin II
receptor blockers — and to preserve kidney function. High blood pressure medications can
initially decrease kidney function and change electrolyte levels, so you may need frequent
blood tests to monitor your condition. Your doctor will likely also recommend a water pill
(diuretic) and a low-salt diet.
Medications to lower cholesterol levels. Your doctor may recommend medications called
statins to lower your cholesterol. People with chronic kidney disease often experience high
levels of bad cholesterol, which can increase the risk of heart disease.
Medications to protect your bones. Your doctor may prescribe calcium and vitamin D
supplements to prevent weak bones and lower your risk of fracture. You may also take
medication known as a phosphate binder to lower the amount of phosphate in your blood,
and protect your blood vessels from damage by calcium deposits (calcification).
A lower protein diet to minimize waste products in your blood. As your body processes
protein from foods, it creates waste products that your kidneys must filter from your blood.
To reduce the amount of work your kidneys must do, your doctor may recommend eating
less protein. Your doctor may also ask you to meet with a dietitian who can suggest ways
to lower your protein intake while still eating a healthy diet.
Your doctor may recommend follow-up testing at regular intervals to see whether your kidney
disease remains stable or progresses.
If your kidneys can't keep up with waste and fluid clearance on their own and you develop
complete or near-complete kidney failure, you have end-stage kidney disease. At that point, you
need dialysis or a kidney transplant.
Dialysis. Dialysis artificially removes waste products and extra fluid from your blood when
your kidneys can no longer do this. In hemodialysis, a machine filters waste and excess
fluids from your blood. In peritoneal dialysis, a thin tube (catheter) inserted into your
abdomen fills your abdominal cavity with a dialysis solution that absorbs waste and excess
fluids. After a period of time, the dialysis solution drains from your body, carrying the
waste with it.
Kidney transplant. A kidney transplant involves surgically placing a healthy kidney from
a donor into your body. Transplanted kidneys can come from deceased or living donors.
You'll need to take medications for the rest of your life to keep your body from rejecting
the new organ. You don't need to be on dialysis to have a kidney transplant.
For some who choose not to have dialysis or a kidney transplant, a third option is to treat kidney
failure with conservative measures. However, once you have complete kidney failure, your life
expectancy generally would be only a few months.
Potential future treatments
Regenerative medicine holds the potential to fully heal damaged tissues and organs, offering
solutions and hope for people who have conditions that today are beyond repair.
Using healthy cells, tissues or organs from a living or deceased donor to replace damaged
ones
Delivering specific types of cells or cell products to diseased tissues or organs to restore
tissue and organ function
For people with chronic kidney disease, regenerative medicine approaches may be developed in
the future to help slow progression of the disease.
Depending on your situation, kidney function and overall health, your dietitian may recommend
that you:
Avoid products with added salt. Lower the amount of sodium you eat each day by
avoiding products with added salt, including many convenience foods, such as frozen
dinners, canned soups and fast foods. Other foods with added salt include salty snack
foods, canned vegetables, and processed meats and cheeses.
Choose lower potassium foods. Your dietitian may recommend that you choose lower
potassium foods at each meal. High-potassium foods include bananas, oranges, potatoes,
spinach and tomatoes. Examples of low-potassium foods include apples, cabbage, carrots,
green beans, grapes and strawberries. Be aware that many salt substitutes contain
potassium, so you generally should avoid them if you have kidney failure.
Limit the amount of protein you eat. Your dietitian will estimate the appropriate number
of grams of protein you need each day and make recommendations based on that amount.
High-protein foods include lean meats, eggs, milk, cheese and beans. Low-protein foods
include vegetables, fruits, breads and cereals.
Monitoring
Monitoring patients with CKD requires regular blood and urine testing. The frequency
and type of bloods that are required changes throughout the stages and it is important to get this
right (see Table 1). When testing blood, it is important to remember that prior to the test, patients
should be asked not to exercise or eat meat for 12 hours beforehand.1 It is also recommended
that blood samples should be processed no longer than 12 hours from venepuncture. When
testing for microalbuminuria, an early morning urine sample is preferable, and testing should be
avoided in an acute illness or menstruation.2
In addition achieving good glycaemic control, managing any cardiovascular risk factors
will contribute to the preservation of kidney function and should play an integral part of an
individual's treatment plan if applicable.
Despite best intentions, a proportion of people with CKD will see their condition progress
and as a result will need specialist assessment. Following discussion, people with the following
should be considered for referral into secondary care specialist renal services:
and enabling people to be aware of their condition, and educating them to make informed
Educating patients on the importance of blood pressure control ensuring they are aware
that reducing raised blood pressure is a key factor in preventing progression of CKD.
Nursing Diagnosis
1. The patient will have negative or equal intake and output during hospitalization.
2. The patient will have decreased peripheral edema of 1+ or less within 48 hours.
3. The patient will have 30 cc or greater of urinary output during a 24 hour period.
4. The patients BUN and creatinine will be within normal range within 36 hours.
5. The patient will weigh 165lbs or less by discharge.
6. The patient will verbalized the importance of daily weights and limiting salt intake by
discharge.
7. The patient will name 5 foods that contain high salt intake to avoid by discharge.
8. The patient will verbalize understanding about how hemodialysis works before dialysis.
5 Possible Diagnosis
1. Decreased Cardiac Output.
2. Fluid and Electrolyte imbalances.
3. Imbalanced Nutrition.
4. Ineffective Breathing Pattern.
5. Impaired Skin Integrity.
Nursing Interventions
Decreased cardiac output does not occur with the outcome criteria:
maintain cardiac output and blood pressure with evidence of cardiac frequency in the
normal range, strong peripheral pulses, and the same with capillary refill time.
Intervention:
1 Auscultation of heart and lung sounds.
R: The presence of tachycardia, irregular heart rate.
3 Investigate complaints of chest pain, note the location, radiation, severity (0-10 scale).
R: HT and CRF can cause pain.
Fluid and Electrolyte imbalances related to secondary edema (fluid volume unbalanced
because of the retention of Na and H2O).
Goal:
Maintain ideal body weight without excess fluid with outcome criteria: no edema, the balance
between inputs and outputs.
Intervention:
1 Assess fluid status with daily weigh, balance input and output, skin turgor, vital signs.
Imbalanced Nutrition, Less Than Body Requirements related to anorexia, nausea, vomiting.
Goal:
Maintain adequate nutrient inputs to the outcome criteria: demonstrate stable weight.
Intervention:
Goal:
Breathing pattern back to normal / stable.
Intervention:
4 Limit to move.
R: Reduce workload and prevent tightness or hypoxia.
Goal:
The integrity of the skin can be maintained with the outcome criteria: Maintain intact
skin, Shows behaviors / techniques to prevent damage to the skin.
Intervention:
1 Inspection of the skin to change color, turgor, vascular, note the presence of redness.
R: Indicates area of poor circulation or damage that may lead to the formation of pressure sores /
infections.
2 Monitor fluid intake and hydration of the skin and mucous membranes.
R: Detecting the presence of dehydration or overhydration affecting circulation and tissue
integrity.
7 Instruct the patient to use a damp and cold compresses to put pressure on the area pruritis.
R: Eliminate the discomfort and reduce the risk of injury.
LABORATORY RESULT
DIFFERENTIAL COUNT
Neutrophil 0.55 0.50-0.70
Lymphocyte 0.15 (L) 0.20-0.40
Monocyte 0.11 (H) 0.03-0.08
Eosinophils 0.17 (H) 0.01-0.04
Basophils 0.02 (H) 0.00-0.01
DRUG STUDY
Patient’s name: XxX.
Diagnosis: Chronic Kidney Disease
Generic Name: Mechanisms of Side Effects/ Adverse Nursing
Erythropoietin Action Reaction Responsibilities
(EPO)
CNS: Before starting
Brand Name: Mimics effects of asthenia, dizziness, therapy, evaluate
Epogen erythropoietin. fatigue, headache, patient’s iron status.
Functions as a paresthesia, seizures. Patient should
Dosage: growth factor and as CV: receive adequate
4TU 2 x a week SQ a differentiating edema, hypertension, iron supplementation
factor, enhancing increased clotting of beginning no later
RBC production arteriovenous grafts. than when epoetin
GI: alfa treatment starts
Indications: abdominal pain and and continuing
constipation (in children) throughout therapy.
Anemia caused by diarrhea, nausea, vomiting. Patient may need
Chronic renal Classification MUSCKULOSKELETAL: vitamin B 12 and
failure. arthralgia folic acid .
Haematopoietic RESPIRATORY:
Cough, shortness of Monitor BP before
breath. therapy. Blood
SKIN: pressure may
infection site reactions, increase, especially
rash, urticaria. when hematocrit
increases in the early
part of therapy.
Monitor blood
counts; elevated
hematocrit may
cause excessive
clotting
Tell patient to
monitor blood
pressure athome and
to adhere to dietar
REFERENCE:
https://www.scribd.com/doc/19675249/Chronic-Kidney-Disease
https://www.scribd.com/doc/136233844/Chronic-Kidney-Disease-Pathophysiology-Schematic-
Diagram
https://www.fairview.org/patient-education/86310
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002014000100009
https://www.uptodate.com/contents/chronic-kidney-disease-beyond-the-basics
http://www.registerednursern.com/nursing-care-plan-and-diagnosis-for-renal-failure/
http://www.scielo.br/scielo.php?pid=S010321002016000500486&script=sci_arttext&tlng=en
https://journals.rcni.com/nursing-standard/chronic-kidney-disease-risk-factors-assessment-and-
nursing-care-ns2006.11.21.10.48.c6381
https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/tests-
diagnosis
https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/diagnosis-treatment/drc-
20354527