CHAPTER I

INTRODUCTION

A. Background
Kidney disease is a disorder that affects the kidney organ arising from various factors,
such as infections, tumors, congenital abnormalities, metabolic or degenerative diseases, and
others. These disorders can affect the structure and function of the kidneys with varying severity.
Patients may feel pain, experience urinary disorders, and others. Sometimes kidney disease
patients don't feel any symptoms at all. In the worst case, the patient can be threatened with life
if he does not undergo periodic hemodialysis (dialysis) or kidney transplant to replace his
damaged kidney organ.
In Indonesia, kidney disease that is quite often found is kidney failure and kidney stones.
Defined as chronic kidney failure if you have been diagnosed with chronic kidney failure
(minimum pain for 3 consecutive months) by a doctor.
Kidney Failure occurs when the kidneys are unable to hold strong metabolic waste of the
body or perform its regular functions. A material that is usually eliminated in urine accumulates
in body fluids due to impaired renal excretion and causes impaired endocrine and metabolic
functions of fluids, electrolytes and wet acids. every year 50,000 people in America die from
sedentary kidney failure.
Developing countries like Indonesia still put kidney failure into ten deadly diseases.
Acute kidney failure that is not handled properly can cause chronic kidney failure where the
sufferer is required to undergo hemodialysis. For patients with chronic kidney failure,
hemodialysis will prevent death.

B. Problem Formulation
1. What is the basic concept of CKD?
2. How is nursing care for CKD patients?

C. Purpose of Writing
1. To find out the basic concepts of CKD.
2. To find out nursing care in CKD patients.

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 CHAPTER II
DISCUSSION

A. Basic Concepts
1. Definition of CKD
Chronic renal failure (CRF) is the result of development and the inability of the return of
nephron function. Serious clinical symptoms often do not occur until the number of nephrons
that function becomes damaged at least 70-75% below normal. In fact, the blood electrolyte
concentration is relatively normal and normal body fluid volume can still be recovered until the
number of functioning nephrons decreases below 20-25 percent.
Chronic Kidney Disease (CKD) is a case of decreased kidney function that occurs in
acute (recurrent) and chronic (chronic). Chronic Kidney Disease occurs when both kidneys are
unable to maintain the environment in a state that is suitable for survival. Damage to both
kidneys is irreversible. CKD is caused by various diseases. Brunner and Suddarth (2014)
explained that when patients have sustained kidney damage that requires continuous kidney
replacement therapy, the patient's disease condition has entered into the late stages of chronic
kidney disease, also known as chronic kidney failure.
From some of the above meanings it can be argued that chronic renal failure is
irreversible kidney damage so that kidney function is not optimal and is needed for therapy that
helps kidney performance and in some conditions a kidney transplant is required.

2. Etiology of CKD
Below are some causes of CKD according to Price and Wilson (2006) including intestinal
tubular infections, inflammatory diseases, hypertensive vascular disease, connective tissue
disorders, congenital and hereditary disorders, metabolic disease, toxic nephropathy, obsessive
nephropathy. Some examples of these diseases are:
a. Tubulointerstinal infections such as chronic pyelo nephritis and reflux nephropathy.
b. Inflammatory diseases such as glomerulonephritis.
c. Vascular diseases such as hypertension, benign nephrosclerosis, malignant
nephrosclerosis, and renal artery stenosis.

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 d. Connective tissue disorders such as systemic Lupus erythematosus, polyarteritis nodosa,
and progressive systemic seklerosis.
e. Congenital and hereditary disorders such as polycystic kidney disease, and renal tubular
acidosis.
f. Metabolic diseases such as diabetes mellitus, gout, and hyperparathyroidism, and
amyloidosis.
g. Toxic nephropathes such as analgesic abuse, and tin nephropathy.
h. Obstructive nephropathy such as the upper urinary tract consisting of stones, neoplasms,
retroperitoneal fibrosis. The lower urinary tract consisting of prostate hypertrophy,
urethral stricture, congenital anomalies of the urinary vesicles and urethra.

3. Pathophysiology of CKD
pathophysiology of chronic kidney disease depends initially on the underlying disease,
but in subsequent developments the process occurs more or less the same. Reduction of kidney
mass results in structural and functional hypertrophy remaining (surviving nephrons) as a
compensatory effort mediated by vasoactive molecules such as cytokines and growth factors.
This results in hyperfiltration, which is followed by increased capillary and glomerular blood
flow. This adaptation process is short-lived, finally followed by a maladaptation process in the
form of remaining sclerosis nephrons. This process is finally followed by progressive nephron
function, even though the underlying disease is no longer active. The increased activity of the
intrarenal reninangiostensin-aldosterone-aldosterone axis contributes to the occurrence of
hyperfiltration, sclerosis and progression. The long-term activity of the renin-angiostensin-
aldosterone axis, partly mediated by growth factors such as transforming growth factor β (TGF-
β). Some things that are also considered to play a role in the progression of chronic kidney
disease are albuminuria, hypertension, hyperglycemia, dyslipidemia. There is interindividual
variability for the occurrence of sclerosis and glomelurus and tubulointersitial fibrosis. In the
earliest stages of chronic kidney disease, there is a loss of renal reserve in conditions where the
basal LFG (Glomelurus Filtration Rate) is still normal or even increases. Then slowly but surely,
there will be a progressive decrease in nephron function, which is characterized by an increase in
serum urea and creatinine levels. Up to 60% of the LFG, the patient still has no complaints
(asymptomatic), but there has been an increase in serum urea and creatinine levels.

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 4. Clinical Manifestation
According to Suyono (2001) explains that clinical manifestations in chronic renal failure
are as follows:
a. Disorders of the gastrointestinal system
1) Anorexia, nausea, vomitus associated with disorders of protein metabolism in the
intestine, formation of toxin substances due to metabolism of intestinal bacteria such as
ammonia andguanidine melil and muose intestinal swelling.
2) The uremic factor is caused by excessive urea in saliva converted by bacteria in the
mouth to ammonia so that the breath smells of ammonia.
3) Erosife gastritis, peptic ulcer and uremic colitis.

b. Hematology system
1) Anemia that can be caused by a variety of factors, including: Reducedproduction
erythropoitin, hemolysis due to reduced life span of erythrocytes in the atmosphere of
uremia toxin, iron deficiency, folic acid, etc. due to reduced appetite, bleeding, and bone
marrow fibrosis due to hyperthyroidism secondary.
2) Disorders offunction platelet and thrombocytopenia.

c. The nervous system and muscles

1) Restless Leg Syndrome, patients feel sore on their legs so they are always moved.
2) Burning Feet Syndrome, the feeling of ants and burning, especially on the soles of the
feet.
3) encephalopathy Metabolic, weakness, sleeplessness, impaired concentration, tremor,
asterixis, myoclonus, seizures.
4) Myopathy, weakness and hypertrophy muscular, especially proximal extremity.

d. Cardiovascular system
1) Hypertension due to accumulation of fluid and salt or increased activity of the renin
angiotensin aldosterone system.
2) Chest pain and shortness of breath due to pericarditis or heart failure due tofluid
accumulation hypertensive.

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 3) Heart rhythm disorders due to atherosclerosis, electrolyte disorders and metastatic
classification.
4) Edema due to fluid retention.

e. Endocrine system
1) Sexual disorders, libido, fertility, and erection decrease in men due to testosterone and
spermatogenesis decreased. In women menstrual disorders arise, disorders ovulation, to
amenorrhea.
2) Glucous metabolic disorders, insulin resistance and impaired insulin secretion.
3) Disorders of fat metabolism.
4) Impaired vitamin D metabolism

5. Management
a. Management therapy The
aim of management is to maintain kidney function and homeostasis as long as possible.
All factors that contribute to chronic kidney failure and all reversible factors (eg obstruction) are
identified and treated. Management is achieved mainly with drugs and diet therapy, although
dialysis may also be needed to reduce the level of uremic waste products in the blood (Brunner
and Suddarth, 2014).
Complications can be prevented or delayed by prescribing antihypertension,
erythropoitin, iron supplements, phosphate supplements, and calcium (Brunner and Suddarth,
2014).

b. Antihypertensive and cardiovascularagents

Hypertensioncan be managed by controlling intravascular fluid volume and various
antihypertensive drugs. Heart failure and pulmonary edema may also require treatment with fluid
restriction, a low sodium diet, diuretic agents, inotropic agents such as digitalis or dobutamine,
and dialysis. Metabolic acidosis caused by chronic kidney failure usually produces no symptoms
and does not require treatment, but sodium bicarbonate or dialysis supplements may be needed to
correct acidosis if it causes symptoms (Brunner and Suddarth, 2014).

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 c. Antisezure agents Neurological
abnormalities can occur, so patients must be observed if there is a twitch for the initial
phase, headache, delirium, or seizure activity. If seizures occur, seizure onset is recorded along
with the type, duration, and general effects on the patient, and immediately inform the lecturer
immediately. Intravenous diazepam (valium) or phenytoin (dilantin) is usually given to control
seizures. Patient beds must be provided with safety so that when the seizure patient does not fall
and get injured (Brunner and Suddarth, 2014).

d. Dialysis therapy
Hyperkalemi is usually prevented by ensuring adequate dialysis, removing potassium and
careful monitoring of all oral and intravenous drugs. Patients must have a low potassium diet.
Kayexalate, cation resins are sometimes given orally if needed. Patients with increased
symptoms of chronic progressive kidney failure. Dialysis usually starts when patients cannot
maintain a reasonable lifestyle with conservative treatment (Brunner and Suddarth, 2014).

There is also a plan for managing kidney failure according to its degree.
1) With LFG more than or equal to 90%, namely with basic disease therapy, comorbid
conditions, evaluation of deteriorating kidney function, minimizing cardiovascular risk
2) with LFG 60-89% by inhibiting worsening kidney function
3) with LFG 30 -59%, namely by evaluating and treating complications
4) with 15-29% LFG by providing preparation for renal replacement therapy
5) with LFG below 15% by providing a kidney replacement.

B. Nursing care for clients with chronic kidney failure

1. Focus Assessment
Assessment of the focus of chronic kidney failure according to Doenges (2000), namely:
a. Activity / Rest
Symptoms:
1) Fatigue extremities, weakness, malaaise.
2) Sleep disorders (insomnia, anxiety, somnolence).

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 Signs:
Muscle weakness, loss of tone, decreased range of motion.

b. Circulation
Symptoms:
1) History of long or severe hypertension.
2) Palpitations, chest pain (angina).
Signs:
1) Hypertension, increased jugular vein, strong pulse, general tissue edema and
pitting on the soles of the feet and palms.
2) Heart dysretmia.
3) The pulse is weak, and smooth, orthostatic hypotension shows hypovolemia
which is rare in late disease.
4) Pericardial friction rub (response to residual accumulation).
5) Pale, yellowish skin.
6) Bleeding.

c. Ego Integrity
Symptoms:
1) factors Stress, for example: financial, relationships, and so on.
2) Feelings of helplessness, no hope, no strength.
Signs:
Resist, anxiety, fear, anger, easily aroused, personality changes.

d. Elimination of
Symptoms of
1) decreased frequency of urine, oligury, anuria (advanced kidney failure)
2) Abdomen bloating, diarrhea, or constipation.
Signs:
1) Change in color of urine, for example: concentrated kuninng, red, cloudy brown,
oliguria, can be anuria.

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e. Food and fluids
Symptoms:
1) Rapid BB increase (edema) decreased BB (malnutrition).
2) Anorexia, heartburn, nausea, vomiting.
3) Bad mouth metallic taste (ammonia breathing)
4) Use of diuretics.
Signs:
1) Abdominal distention or ascites, final stage enlargement of the liver.
2) Reduction of skin turgor and fatigue.
3) Edema.
4) Muscle reduction, fat loss, subcutaneous, not powerful appearance.

f. Neurosensory
Symptoms:
1) Headache and blurred vision.
2) Muscle cramps / seizures: "restless leg syndrome"; numbness and burning
sensation in the feet.
3) Numbness / tingling and weakness, especially the lower extremities (peripheral
neuropathy)
Signs:
1) Impaired mental status, for example decreased field of attention, inability to
concentrate, memory loss, disorder, decreased level of consciousness, stupor,
coma.
2) Seizures, muscle fasciculation, seizure activity.
3) Thin hair, brittle and thin nails.

g. Pain / comfort
Symptoms:
1) Pelvic pain, headache.
2) Muscle cramps / leg pain (worsening at night).
Signs:

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 1) Careful behavior / distraction, anxiety.

h. Respiratory
Symptoms:
1) Short breath, proximal noctural dyspnea.
2) Cough with no thick sputum and lots.
Signs:
1) Tachypnea, dyspnea, increased frequency and depth (kusmaul breathing).
2) Productive cough with runny and pink sputum (pulmonary edema).

i. Safety
Symptoms:
1) Itchy skin, repeated infections.
Signs:
1) Pruritus.
2) Fever (sepsis, dehydration): normothermia can actually increase in the body that
experiences lower body temperature than normal (the effect of chronic kidney
failure / depression immune response).
3) Petekie, the area of ecchymosis on the skin.
4) Bone fracture: calcium phosphate deposit (classification of metastation) on the
skin, soft tissue, joints, limited joint motion.

j. Sexuality
Symptoms:
1) Decreased libido, amenorrhea, infertility.

k. Social Interactions
Symptoms:
1) Difficulty in determining conditions, for example being unable to work,
maintaining role functions usually in a family.

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 l. Counseling / learning
Symptoms:
1) History of diabetes mellitus (DM), family (high risk for kidney failure), polycystic
disease, hereditary netresis.
2) History of exposure to toxins, drug samples, environmental poisons.
3) The use ofantibiotics is nephrotoxic currently repeated.

2. Nursing Diagnosis
clinical decision regarding a person, family, or community as a result of an actual or
potential health problem or life process. Actual problems are problems that are found at the time
of assessment, while potential problems are problems that will later occur. The theoretical
nursing diagnoses that arise in chronic renal failure are:
a. Excess volume of fluid associated with retention of Na and H2O.
b. Damage to skin integrity associated with pruritus.
c. The imbalance in nutrition intake is less than the need associated with nausea and
vomiting.
d. Activity intolerance is associated with a decrease in oxygen supply.
e. The ineffectiveness of peripheral tissue perfusion is associated with a decrease in O2
supply.
f. Pain is related to fatigue and joint pain.
g. Disorders of gas exchange associated with pulmonary edema.

3. Nursing Interventions

Nursing Diagnosis Noc Nic Nursing Implementation

Excess fluid volume desired outcomes: 1. Fluid Fluid management:
associated with the 1) Freedom of edema, management a) Weigh diapers / pads if
retention of Na and H2O. effusion, anasarca 2. Fluid needed.
2) clean breath sounds, no monitoring b) Maintain accurate records
dyspnoea or ortopneu. of intake and output.

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3) Free from jugular c) Install urine catheter if
venous distention, needed.
hepatojugular (+) reflex d) Monitor Hb results
4) Maintain central according to fluid retention
venous pressure, (BUN, Hmt, urine osmolality)
pulmonary capillary e) Monitor hemodynamic
pressure,output status including CVP, MAP,
cardiacand vital sign. PAP, and
5) Free from fatigue, PCWP.
anxiety or confusion. f) Vital sign monitor.
6) Explain the indicator of g) Monitor indications of
excess fluid. retention or excess fluid
(cracles, CVP,
edema, distension of neck
veins, ascites)
h) Assess location and extent
of edema.
i) Monitor food / liquid intake
and calculate caloric intake.
j) Monitor nutritional status.

Fluid monitoring:
a) Determine the history of
the number and type of fluid
intake and elimination.
b) Determine the possibility
of risk factors fromimbalance
fluid(hyperthermia, diuretic
therapy, renal
abnormalities,failure
heart, diaporesis, liver

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 dysfunction).
c) Monitor weight.
d) Monitor serum and urine
osmolality.
e) Vital sign monitor.
f) Monitor changes in heart
rhythm.

Nutritional imbalance is Criteria results are 1. Nutrition Nutrition management:

less than needs alleviated: management a) Assess for food allergies.
related to nausea and 1) There is an increase in 2. Nutrition b) Collaboration with
vomiting body weight in monitoring nutritionists to determine the
accordance with goal number of calories and
2) Ideal body weight nutrients needed by patients.
according to height can c) Encourage patients to
identify nutritional needs increase Fe intake.
3) There are no signs of d) Give sugar substance.
malnutrition e) Make sure the diet eaten
4) Showing improvement contains high fiber to prevent
in tasting function from constipation.
swallowing
5) No weight loss Nutrition monitoring:
a) The patient's body weight
is normal.
b) Monitor for weight loss.
c) Monitor the type and
amount of activity normally
done.
d) Monitor the environment
during meals.
e) Monitor pale, reddish, and

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 dryness intissue
conjunctival.

Disorders of gas exchange Criteria results: 1. Airway Airways Management:

associated with pulmonary 1) Demonstrate ventilation management a) Position the patient to
edema and oxygenation 2. Resiratory maximize ventilation.
adequate. monitoring b) Perform chest physioterpi
2) Maintain lung hygiene if necessary.
and free from signs of c) Auscultation of lung
respiratory distress. sounds, note if there is
3) Vital signs in normal additional lung sound.
vulnerability. d) Pay attention to fluid
intake.
e) Monitor respiration and
Ostatus2.

Resiratory monitoring:
a) Monitor the average depth,
rhythm and effort of
respiration.
b) Record chest movements
observe symmetrical use of
additional muscles, retract
supraclavicular muscles.
c) Monitor breath sounds.
d) Monitor breath patterns
(badipneu, takipneu, kusmaul,
hyperventilation, cheyne
stokes, biot)
e) Monitor fatigue of the
diaghfrahma muscle

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 (paradoxical movement).
f) Ausculating breath sounds,
noting additional ventilation
and sound reduction / absence
areas.
g) Auscultation of pulmonary
sounds to evaluate the actions
taken.

4. Evaluation

The evaluation phase can be done formatively and summatively. Formative evaluation is
an evaluation carried out during the process of nursing care. While summative evaluation is the
final evaluation. Effective evaluation needs to be based on measurable criteria and reflects the
expected outcome of the treatment.

Subjective: Things that are found by the family subjectively after the intervention is done.

Objective: Things that are met objectively after the nursing intervention is done.

Evaluation is expected that the client's condition can meet the following criteria
(Herdman, 2011):

a. Excess volume of fluid relates to retention of Na and H2O.

S: The client said there was no swelling.
O: Free from edema. Free from distention of the jugular vein. Free from fatigue.

b. The imbalance in nutrition intake is less than the need associated with nausea and
vomiting.
S: The client says nausea and vomiting are reduced, nutrient intake is increasing, being
able to spend the diit given, says weight increases.
O: There is an increase in body weight according to the goal. Weight according to height.
There are no signs of malnutrition. Increase the function of tasting and swallowing. There
is no weight loss.

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c. Disorders of gas exchange associated with pulmonary edema
S: The client says he has not experienced shortness of breath anymore, the client says
more relaxed.
O: Demonstrate increased ventilation and adequate oxygenation. Vital signs are normal.

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 CHAPTER III
CLOSING

A. Conclusion
Chronic Kidney Disease (CKD) is a case of decreased kidney function that occurs acutely
(recurring) and chronic (chronic). Chronic Kidney Disease occurs when both kidneys are unable
to maintain the environment in a state that is suitable for survival. Damage to both kidneys is
irreversible. CKD is caused by various diseases.
There are several causes of CKD according to Price and Wilson (2006) which include
intestinal tubular infections, inflammatory diseases, hypertensive vascular disease, connective
tissue disorders, congenital and hereditary disorders, metabolic diseases, toxic nephropathy,
obsessive nephropathy.

B. Suggestion
Thus this paper is made, hopefully useful for readers in general and for speakers in
particular. The speaker realizes there are still many shortcomings in the preparation of this paper,
therefore the constructive criticism and suggestions are expected to be the next perfection of the
paper.

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 REFERENCES

Brunner & Suddarth. (2014). Textbook of Medical-Surgical Nursing. 13th edition. America:
Woltes Kluwer Health

Doenges, Marilyn E. 1999. Nursing Care Plans, Edition 3. Jakarta: EGC

Smeltzer Suzanne, C (1997). Medical Surgical Textbook, Brunner & Suddart. Issue 8. Jakarta:
EGC

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