NURSING CARE IN CRONIC KIDNEYS DISEASE (CKD)

GROUP 2 :

1. ASRI WULANDARI 5. GILANG YUANGGA

2. BAGAS PANDU P M
3. DIMAS PANDU D 6. LISTYA APRILIA O
4. FRUISKA 7. NILUH PUTU E
VALENTIN F 8. SINDHI MAIPURI
9. YOANITA PUTRI

PROGRAM STUDI SARJANA KEPERAWATAN

SEKOLAH TINGGI ILMU KESEHATAN KUSUMA HUSADA

SURAKARTA

2019/2020
 Nursing care in cronic kidney disease patients

A. Definition of nursing process

Introduction The nursing process is dynamic, adaptable to individual needs

and society requirements and maintains an unaltered main objective, i.e. achieving a
better state of health for the individual, family and community. The care is patient-
centered, but the patients are no longer perceived only as individuals suffering from a
disease. They are holistically assessed as people with physical, emotional,
psychological, intellectual, social and spiritual needs. These needs interrelate, are
interdependent, of equal importance and represent the foundation of nursing
interventions. The nursing process aims at applying the following steps:

1. Appraisal (the stage of data collection with the purpose of identifying current
or potential health problems);

2. Establishing the nursing diagnosis (identifying dependency problems and

saying the diagnosis clearly and precisely);

3. Planning (setting objectives and preparing a care plan for solving the nursing
diagnostic problem)

; 4. Implementation (applying the established care plan and updating it

constantly, depending on the interventions);

5. Assessment (determining the patient response to the care interventions and

setting the goals that have been achieved);

(Virginia Henderson’s Nursing Conceptual)

B. Definition of cronic kidney diseases

Chronic kidney failure is an irreversible disease due to kidney damage due to
diabetes mellitus, hypertension, glomerulonephritis, HIV infection, polycystic kidney
disease, or ischemic nephropathy (Digiulio Etall, 2014, p. 397)
Chronic kidney disease (CKD) is a failure of kidney function (nephron units)
that takes place slowly, due to a long-lasting and persistent cause, which results in the
accumulation of metabolic waste (uremic toxic) so that the kidneys cannot meet
ordinary needs again and cause symptoms of illness (Mubarak et al., 2015, p. 17)
 Etiology

1. Infections such as chronic pyelonephritis (urinary tract infections),

glomerulonephritis (inflammatory disease). Pyelonephritis is a process of
inflammatory infection that usually starts in the pelvic renal, the kidney
channel that connects to the ureter (ureter) and renal parencyma or kidney
tissue. Glomerulonephritis is caused by one of many diseases that damage
both the glomerulus and tubules. In the next stage of the disease the
overall screening ability of the kidneys is greatly reduced
2. Hypertensive vascular diseases such as benign nephrosclerosis, malignant
nephrosclerosis, renal artery stenosis caused by vascular damage in the
kidneys by an increase in acute and chronic blood pressure.
3. Congenital and hereditary disorders such as polycystic kidney disease,
renal tubular acidosis
4. Metabolic diseases such as DM (Diabetes Mellitus)
5. Toxic nephropathy such as analgesic abuse, lead nephropathy
6. Urinary stones that cause hidrolityasis

C. Clinical Manifestations
1. Nausea and vomiting
2. Decreased appetite
3. The body feels weak
4. Sleep disturbance
5. Changes in the amount of urine
6. Change in mental status
7. Muscle disorders
8. Swelling in the legs
9. Permanent itching
10. Chest pain (if there is fluid retention)
11. Hard to breathe
12. Increased blood pressure

D. Pathophysiology

Pathophysiology of CKD At the beginning of its journey, fluid

balance, salt handling, and accumulation of residual substances still vary and
 depend on the part of the diseased kidney. Until kidney function falls less than
25% to normal, clinical manifestations of chronic renal failure may be
minimal because healthy residual nephrons take over damaged nephron
function. The remaining nephrons increase their filtration, reabsorption, and
secretion speed and experience hypertrophy. As more and more nephrons die,
the remaining nephrons face a more demanding task, so that the nephrons get
damaged and eventually die. Part of this death cycle seems to be related to
demands on existing nephrons to increase protein reabsorption. As the
nephrons progressive shrinkage, scar tissue formation and renal blood flow
may decrease (Corwin, 2009).

Although kidney disease continues, the amount of solute that must

be excreted by the kidneys to maintain homeostasis has not changed, although
the number of nephrons in charge of performing this function has
progressively decreased. Two important adaptations are carried out by the
kidneys in response to the threat of fluid and electrolyte imbalance. The
remaining nephrons have hypertrophy in their efforts to carry out the entire
workload of the kidneys. An increase in filtration speed, solute load and
tubular reabsorption in each nephron even though the GFR for all nephron
masses contained in the kidney falls below the normal value. This adaptation
mechanism is quite successful in maintaining body fluid and electrolyte
balance to very low levels of kidney function (Price, 2010).

But finally, if about 75% of the mass of the nephron has been
destroyed, the filtration speed and solute load for each nephron are so high
that the glomerular-tubular balance (the balance between increased filtration
and increased reabsorption by tubules can no longer be maintained. Flexibility
in both the excretion process and the process of conserving solutes and water
is reduced, a slight change in food can change the delicate balance, because
the lower the GFR (which means the fewer nephrons) the greater the change
in excretion rate per nephron, the loss of the ability to concentrate or thin the
urine causing specific gravity urine remains at a value of 1,010 or 285 mOsm
(ie the same as plasma) and is a cause of symptoms of polyuria and nocturia
(Price, 2010)

E. Complication
1. Anemia
2. Stomach or intestinal bleeding
 3. Muscle, bone and joint pain
4. Changes in blood sugar
5. Damage to the nerves of the feet and hands (peripheral neuropathy)
6. Dementia
7. A buildup of fluid around the lungs (pleural effusion)
8. Complications of the heart and blood vessels (Congestive heart failure,
coronary artery disease, high blood pressure, pericarditis, stroke

F. Classification

Following are the stages of CKD according to the guidelines:

Stage Definition eGFR

Kidney disease with normal or increased eGFR
Stage 1 >90 mL/min/1.73 m2

Kidney disease with a mild decrease in eGFR

Stage 2 60-89 mL/min/1.73 m2

Kidney disease with mild to moderate eGFR

Stage 3a 45-59 mL/min/1.73 m2

Kidney disease with moderate-severe eGFR

Stage 3b reduction 30-44 mL/min/1.73 m2

Kidney disease with eGFR weight loss

Stage 4 15-29 mL/min/1.73 m2

Kidney failure
Stage 5 <15 mL/min/1.73 m2

G. Supporting Investigation
1. Laboratory examination

Blood laboratories: BUN, creatinine, electrolytes (Na, K, Ca, phosphate),

hematology (hemoglobin, platelets, Ht, leukocytes), proteins, antibodies (loss
of protein and immunoglobulin)

2. Urine Test: Color, PH, BJ, turbidity, volume, glucose, protein, sediment,
SDM, ketone, SDP, TKK / CCT
3. ECG examination: To look for left ventricular hypertrophy, signs of
pericarditis, arrhythmias, and electrolyte disturbances (hypercalcemia,
hypocalcemia)
4. Ultrasound examination: Assessing the size and shape of the kidney, renal
cortex thickness, renal parenchymal density, pelvic localized anatomy,
proximal ureter, bladder and prostate
5. Radiology Examination: Renogram, Intravenous Pyelography, Retrograde
Pyelography, Renal Aretriography and Venography, CT Scan, MRI, Renal
Biopsy, chest x-ray examination, bone x-ray examination, plain abdominal
radiograph
 NURSING CONCEPT

A. Assessment

1. Activity and rest

2. Fatigue, weakness, malaise, sleep disorders, muscle weakness and tone,
decreased ROM
3. Circulation
4. History of long or severe hypertension, palpitations, chest pain, increased
JVP, tachycardia, orthostatic hypotension, friction rub
5. Ego Integrity
6. Stress factors, feelings of helplessness, no strength, reject, anxiety, fear, anger,
irritable
7. .Eliminasi
8. Decreased frequency of urine, oliguri, anuri, discoloration of urine,
concentrated urine red / brown, cloudy, diarrhea, constipation, abdominal
bloating
9. Food / Liquid
10. Increased BB due to edema, decreased BB due to malnutrition, anorexia,
nausea, vomiting, metallic taste in the mouth, ascites, decreased muscle,
decreased subcutaneous fat
11. Neurosensori
12. Headaches, blurred vision, muscle cramps, seizures, numbness, tingling,
mental status disorders, decreased attention span, inability to concentrate,
memory loss, chaos, decreased level of consciousness, coma
13. Pain / Comfort
14. Pelvic pain, headache, muscle cramps, leg pain, distraction, restlessness
15. Breathing
16. Kusmaul breathing (fast and shallow), paroxysmal nocturnal dyspnea (+),
cough product with frotty sputum if pulmonary edema occurs
17. .Security
18. Itchy skin, recurrent infections, pruritus, fever (sepsis and dehydration),
petechiae, ecchymoses, bone fractures, calcium phosphate deposits in the skin,
limited ROM
19. Sexuality
20. Decreased libido, amenorrhea, infertility
 21. Social Interaction
22. Unable to work, unable to carry out roles as usual
B. Diagnose
1. Excess fluid in the body is related to unbalance intake and outflow
characterized by edema extremity
2. Ineffective breath pattern associated with a buildup of fluid in the lungs
characterize by shortness of breath
C. Nursing Intervention
no Diagnose NOC NIC
1 Excess fluid in the body After taking nursing
is related to unbalance action for 2x24 hours, its
intake and outflow expected that excess
characterized by edema fluid volume can be
extremity overcome with the
expected results:
1. intake and
outtake balance
2. electrolyte
balance
3. the patients is not
edema
- Maintaining the
electrolyte
balance
1. Assessment of the
electrolyte status: -
serum level of
electrolytes - daily
changes in body
weight
2. indication of fluid
intake and loss
3. Identification of
persistent skin fold
or edema
4. monitoring blood
pressure, pulse,
respiration rate.
5. Identifying fluid
intake: -
medication, food,
IV (drips), fluids
administered per
os.
6. Nurses will explain
the patient and his
carers about the
importance of food
and fluid
restrictions.
2 Activity intolerance is After taking nursing energy management
related to oxygen actions for 2x24 hours, 1. observation of the
supply imbalance clients can perform patient's level of
daily life activities fatigue after
independently with the activity
expected outcome 2. help the patient
criteria: identify the choice
1. oxygen of activities to be
saturation carried out
when on the
move can be 3. encourage the
controlled patient to choose
2. respiratory rate activities that build
when active resilience
within normal 4. monitor the
limits patient's oxygen
response
5. collaborate with
family to monitor
patient activity
 References

-Almatsier, Sunita. 2009. Diet Guides. Jakarta: Gramedia Main Library.

-Brooker, C. 2008. Nursing Encyclopedia. Jakarta: EGC.

-Corwin, Elizabeth J. 2009. Handbook of Pathophysiology, Ed. 3. terj. Egi Komara.

Jakarta: EGC.

-Lutfia, Tika. 2012. "CLIENT NURSING CARE WITH CHRONIC KIDNEY

FAILURE IN NY. K IN THE DAHLIA ROOM UNGARAN HOSPITAL ".
http://digilib.unimus.ac.id/files/disk1/135/jtptunimus-gdl-tikalutfia-6702-2-babii.pdf.

-Miller, Scott. 2013. "Chronic Kidney Disease".

http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm (accessed 18 October
2014).

- -Price. A. Sylvia & Wilson. M. Lorraine. 2010. Pathophysiology of Clinical

Concepts of Disease Processes. Jakarta: EGC.