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CoverArticle CE Continuing Education

Chronic Kidney
Acute Manifestations
and Role of Critical
Care Nurses
Sharon K. Broscious, RN, DSN, CCRN
Judith Castagnola, RN, MSN

D espite the improved diagno-
sis and treatment of kidney disease,
late diagnosis with resultant perma-
the other 122374 had a functioning
transplant. The adjusted rate of
CKD for the white population was
nent damage to the kidneys still 1060 cases per million; for the African
occurs. A work group established by American population, 4467 cases per
the National Kidney Foundation, the million; and for the Native American * This article has been designated for CE credit.
Kidney Disease Outcome Quality population, 2569 cases per million. A closed-book, multiple-choice examination fol-
lows this article, which tests your knowledge of
Initiative (KDOQI), was asked to In 2002, Medicare expenses for the following objectives:
develop clinical practice guidelines CKD treatment increased 11% over 1. Identify the expected outcomes of patients
with chronic kidney disease (CKD)
and a uniform classification system the level in 2001; Medicare expenses
2. Describe the pathophysiology of CKD
for chronic kidney disease (CKD). were $17 billion and non-Medicare
3. Discuss the impact of CKD in relation to
CKD is a public health issue because expenses were $8.2 billion. From body systems
of its increasing incidence and the the individual perspective, Medicare
high cost of interventions.1 An addi- costs per year are approximately Authors
tional concern is the increasing inci- $53000, with deductibles and copay- Sharon K. Broscious is an associate
dence of kidney disease in African ments bringing the total to $63000 professor in the School of Nursing at
Troy University, Atlantic Region, in
Americans and Native Americans.2 per year. Total cost for the entire CKD Norfolk, Va.
According to the 2004 report program was approximately $25.2
Judith Castagnola is a facility adminis-
from the US Renal Data System,3 the billion at the end of 2002.3 trator at DaVita Peninsula Dialysis in
number of patients with CKD receiv- The KDOQI has identified 5 stages Newport News, Va.
ing therapy in 2002 was 431284. of kidney failure (Table 1) on the basis Corresponding author: Sharon K. Broscious, Troy Uni-
This number is a 4.6% increase over of glomerular filtration rate (GFR).4 versity, Atlantic Region, 5425 Robin Hood Rd, Ste B1,
Norfolk, VA 23513. (e-mail:
the number for the year 2001. The Normal GFR in men is 125 to 150
To purchase electronic or print reprints, contact The
adjusted rate for CKD was 1435 mL/min per 1.73 m2 (1.73 m2 is InnoVision Group, 101 Columbia, Aliso Viejo, CA
cases per million population—72% considered the standard normal body 92656. Phone, (800) 809-2273 or (949) 362-2050
(ext 532); fax, (949) 362-2049; e-mail,
of patients were undergoing dialysis; surface area). Chronic kidney failure CRITICALCARENURSE Vol 26, No. 4, AUGUST 2006 17

we use tain homeostasis (Figure 1). ological changes that occur when the 25% of the cardiac output per minute. consequently. 4. Kidney damage is defined as pathologic abnormalities or sive crisis and metabolic acidosis. shortness Institute of Diabetes and Digestive the process of kidney damage could of breath. or exposure to Society of Nephrology have recently interventions. AUGUST 2006 http://ccn. extremities. Several Unfortunately. Diet in Renal Disease Study equation symptoms of newly diagnosed ESRD.210 (if 8 situation by critical care nurses is Electrocardiography showed left African-American) 18 CRITICALCARENURSE Vol 26. with or without kidney dam. 4 Severe decrease in GFR 15-29 J. The immediate the functioning units of the kidneys.4 End-stage renal disease (ESRD) is kidneys fail. decrease in GFR and arteriovenous nicking. Glomerular filtration rate (GFR). Each kidney has approximately 1 and kidney function cannot maintain comes are also presented. J. arteriolar narrowing. resulting in ESRD. when nephrons have been damaged. hypertension. In this article. renal function is significantly risk factors for ESRD as diabetes increasing swelling in both lower impaired. urinary prob.4 with permission.742 (if female) × 1. neys receive approximately 20% to or more. Table 1 Chronic kidney disease defined by the National Kidney Foundation* ventricular hypertrophy and ST-T waves consistent with a strain pattern. . patients at this time reserve of nephrons that enables require dialysis or transplantation.aacnjournals.2 occurred once before recently but function is the estimated GFR. He also stated that recommended the Modification of an acute care facility with signs and he was not taking any medication. Because of the lack lems. The National Kidney Disease kidney failure when renoprotective hypertension.73 m2 for 3 months a case study to review the pathophysi. patients may come to toxic substances. chest pain. Pathophysiology The kidneys act as regulators for is defined by the KDOQI as having essential. damage to the kidneys is permanent interventions and the expected out. came to the emergency However.M. his blood as the formula to calculate GFR9: What do critical care nurses need to pressure was 222/142 mm Hg.203 thorough assessment of this complex was 24/min with bibasilar crackles. many of the body’s functions and kidney damage lasting for 3 months tems are altered when kidney func. million nephrons. even ESRD is at the far end of the spectrum J. fever and chills. resulting in admission to blood is filtered through the nephrons. proteinuria. including abnormalities in blood or urine tests or imaging studies. × 0. markers of damage. and increasing age. was admitted to the intensive 5 Kidney failure <15 (or dialysis) care unit with a diagnosis of ESRD due to hypertension with hyperten- *Chronic kidney disease is defined as either kidney damage or a glomerular filtration rate less than 60 mL/min per 1. On physical examination. The kid- 60 mL/min per 1. a 34-year-old African Amer.. because multiple body sys. ican man. providing a large life.154 × (age [years])-0. and the American of early signs and symptoms and neurological changes.73 m2 for 3 months or longer.5 Case Study homeostasis to be maintained.73 m2 A funduscopic examination showed bilateral chronic and new hemor- 1 Kidney damage with normal >90 or increased GFR rhages (cotton wool hemorrhages 2 Kidney damage with mild 60-89 and exudates). equations are available to estimate asymptomatic in the early stages of said he had no history of headaches. No.M. confusion or other Kidney Foundation.7 of progressive renal dysfunction. vomiting or Education Program of the National strategies6 that could slow or reverse diarrhea. GFR. his know about CKD and its treatment heart rate was 110/min with S3 and GFR = 186 × (serum creatinine to improve patients’ outcomes? A S4 gallops. control complex processes that main- or more or having a GFR less than tion is impaired. Reprinted from the National Kidney Foundation. A similar swelling had best laboratory indicator of kidney family history. patients are often had cleared up spontaneously. mL/min Stage Description per 1.M. and his respiratory rate [mg/dL])-1.8 The mellitus. age. Labora- 3 Moderate decrease in GFR 30-59 tory results are reported in Table 2. and Kidney Diseases.4. described as the stage of CKD when the critical care unit. when 90% of nephrons are Healthy People 2010 identifies the 5 department with a 6-day history of lost. weight loss. the National be implemented.

52 protein.81-1. 1142. 3. mmol/L 127 129 135-147 uria occurs in Potassium.5 mmol/L Bicarbonate 21-28 mmol/L in the urine.aacnjournals.4 (8-18) are protein- mmol/L (mg/dL) uria and Creatinine.8 3. Protein- Sodium.0) glomeruli mmol/L (mg/dL) with a result- Hemoglobin. AUGUST 2006 19 . J. No.35 (9.73 m2. U/L known as hypertensive On the basis of this formula.M.42-0.20-2.0 response to Chloride. Other factors that contribute to the http://ccn.05 (8.47 (189) 66. development Table 2 J.32 pH 7. had a GFR of 3 mL/min per 1.3) cause sclerotic mmol/L (mg/dL) changes in the Phosphorus.9 mmol/L Bicarbonate 12. the effects of kidney failure Blood pressure Drug metabolites and other on the body’s homeostatic mecha.8-10. 9.9 mm Hg PO2 81. High blood Uric acid.58 ( CRITICALCARENURSE Vol 26.04 (185) 2.5-5.9 mm Hg PCO2 18. 2. Body water regulation Excretory regulation ure. 67. Figure 1 Homeostatic functions of the kidney.9-505.9 3. mmol/L 90 89 95-105 damage of the Carbon dioxide.2 (21.6) 1865. 4.1) 3.4 (21.9 12 23-30 mmol/L glomeruli.6 (4-8.2) 2. wastes nisms are the same. espe- Arterial blood gases pH 7. 1909.9-6. Sodium function in homeostasis Potassium Alterations in Phosphorus Metabolic (endocrine) regulation Regulatory Functions Calcium Erythropoietin Body Water Regulation Acid-base balance Magnesium Renin-angiotensin-aldosterone Fluid volume is altered when the Metabolic compensation Vitamin D kidney loses its ability to excrete water because of damaged nephrons and the resultant decreased GFR.2) µmol/L (mg/dL) increased renin.M.1 mm Hg PCO2 33-44 mm Hg Bicarbonate 11. The next section Uric acid provides a comparison of the nor- Normal mal homeostatic regulations and the Electrolyte balance kidney alterations assessed in J.5) µmol/L (mg/dL) pressure can Calcium.87 (12) 0.6-1.’s laboratory results of fluid vol- Laboratory test Admission results Results after dialysis Reference intervals ume overload Serum urea nitrogen.91 (12. Whatever the underlying cause Urine output Nitrogenous waste products of CKD.0 (19. mmol/L 5.4) 2.61 (2.M.5-5. meeting the definition of kidney fail.10 Base excess -12 Base excess -9 Base excess not determined This damage PO2 45.44 pH not determined cially albumin on room air PCO2 22.1) 53-106 (0.2) Not determined 237.7 mm Hg PO2 75-100 mm Hg to the kidneys Urinalysis 4+ protein Not determined from hyper- 2+ hematuria Not determined tension is also Alkaline 536 378 30-120 phosphatase.252 Not determined 0. g/L 83 Not determined 140-180 ant loss of Hematocrit 0.

A decreased arterial PCO2 cal relationship between phosphorus because of decreased oncotic pres. Fluid tory acid carbon dioxide.M.12 Results of J. allowing H+ to enter and risk for fatal dysrhythmias. Nor. 4. 9. This loss of albumin Hg.05 mmol/L (8. increasing his In CKD. Three adrenal cortex. indicating impaired nium is decreased. vitamin D to its active form: 1. This mechanism potassium as a result of decreased tory tests showed a calcium level of helps to remove H+ while generating GFR.9 mmol/L. and free or ionized. resulting acidosis due to kidney failure. CKD also has an 108-112/min). base GFR is less than 30 to 50 mL/min of albumin in the urine contributes excess -12. The and a decreased sodium level (dilu. HCO3. in an effort to maintain extra. metabolic serum calcium level can decrease extremities.7 Results of Serum phosphorus and calcium age not only to the glomueruli but J. vascular clinical manifestations. aldosterone is released from the body attempts to compensate for in the serum level of calcium. when metabolic aci. crackles in the lungs.8 The loss of 7. dihydroxycholecalciferol.10 Because of the recipro- lar space to the interstitial space acidosis. Potas. an albumin level of 32 acids such as sulfuric and phosphoric when albumin level decreases.M. this increased retention sure.11 J.1 mmol/L. In mally the kidney conserves HCO3. However.1 mg/dL).9 mmol/L. attached to other complexes. the presence of S3 and S4 heart of the anion gap. the extracellular space in exchange for phosphorus excretion and a recip- nism involved with acid-base balance H+. causing a widening had proteinuria. be buffered in the bone.11 Impaired Acid-Base Balance imately 12 mmol/L.’s labora- excreted in the . In addition.8 mmol/L. J. The kid- phate (one of the body’s buffering neys normally excrete 40 to 60 mmol Alterations in systems). 2. The third excrete hydrogen ions (H+). cellular acid-base balance.M. Calcium is found in 3 retention in turn results in the devel.’s anion gap vitamin D synthesis results in Metabolic acidosis is associated was 127 – (90 + 11. mechanism that affects serum levels in the use of bicarbonate (HCO3-) of calcium is the endocrine system. cardiovascular assessment find. additional mechanisms can affect to reabsorb sodium and water.9) = 25. and serum carbon dioxide per 1. rocal decrease in calcium level.M. Because some J.M. Electrolyte Balance When the serum level of calcium Two other buffering systems are in Multiple electrolyte levels are decreases. when the calcium is bound to protein. tein. products from protein metabolism 20 CRITICALCARENURSE Vol 26. results in H+ combining with phos. and excretes H+. total ings included 3+ edema of the lower glomeruli are damaged. When also to the arteriolar walls. No. Metabolic acidosis also of potassium daily. the parathyroid gland place that assist in compensating for altered in patients with CKD. of 22. are often associated with CKD because sating for the decreased serum level which combines with chloride and is of the inability of the kidney to excrete of calcium. blood pressure of 222/142 mm acid are retained..M. gap can be used to determine the forms in the blood: attached to pro- opment of respiratory and cardio. and elevated potassium levels released from the bone and compen- tubule cells to form ammonium.25- The normal anion gap is approx. Hydrogen ions combine sium levels may be normal until late in hormone. increases its secretion of parathyroid the acidosis. As a response to decreased increased respiratory rate as the of phosphorus results in a decrease GFR. from the intracellular compartment to (12. sinus tachycardia (heart rate calculated mathematically: level of calcium. J. anions to maintain acid-base balance.91 mmol/L nephron function.11.73 m2.’s laboratory tests revealed a pH levels are also altered in CKD. AUGUST 2006 http://ccn. In CKD. The anion calcium level. Anion gap = Na+ – (Cl. because of impaired dosis is present.nephrosclerosis and may cause dam. causing the kidneys the acidosis by exhaling the respira. all indicating metabolic is impaired.’s potassium Excretory Function contributes to a shift of calcium from level was 5.2 mg/dL) and a HCO3-. g/L.+ HCO3-) kidneys normally convert inactive tional hyponatremia). The third mecha. nitrogenous waste the bone. effect on vitamin D synthesis. potassium ions shift phosphorus level of 3. causing calcium to be with ammonia produced in the renal ESRD. phosphorus excretion to fluid shifting from the intravascu. excretion of ammo.aacnjournals.32.8 The anion gap is can contribute to a decreased serum sounds.9 mm Hg results from an and calcium. decreased absorption of calcium in with CKD because the tubules cannot supporting the diagnosis of metabolic the gastrointestinal tract. cause of the metabolic acidosis.

as GFR decreases. The decreased changes associated with CKD affect indicator of CKD related to diabetes. dehydration.are retained in the body. (19. Finally. to angiotensin II by angiotensin- levels of urea nitrogen alone can indi. Glomerular damage was tively. had a 1909. and his platelet Because the pathophysiological permeability.’s to acidosis. the approach to assessment is used here.10 J. ure had contributed to the hyperten- overload from the CKD or an undi.. and swelling. Albumin is a sensitive counts were adequate. cytic anemia. It was unknown and his serum creatinine level was results in a normochromic. For J. striction.2 mg/dL). Assessment Findings glomeruli with the resultant increased ocrit was 0. and although his with CKD is essential. such as Alterations in Metabolic/ Angiotensin II produces 2 . which releases aldosterone.M. neys. The per. No. In tant water reabsorption by the kid- today. a plasma protein. increasing the risk for bleeding. This slightly tribute to anemia by shortening the to kidney failure or if the kidney fail- decreased ratio could reflect fluid life span of the red blood cells.M.13 Although J. mally reabsorb little urea. This elevated level of nervous system. increase in blood pressure through urea nitrogen–creatinine ratio (normal itubular capillary endothelium in stimulation of the adrenal cortex. AUGUST 2006 http://ccn. normo.14 Renin unknown whether the hypertension tion of uric acid by the kidney and is an enzyme released from the jux. Additionally. but the ratio is not which is needed to stimulate bone sodium reabsorption and concomi- considered as an important indicator marrow to release red blood cells. 4.4. Renin then acts on which are permeable to urea.’s hemo- and result from damage of the globin level was 83 g/L.M. had no history toms of anemia. resulting gouty arthritis with deposits of uric decreases in blood flow to the kidney. and hyperten.8 The ulation of the renin-angiotensin- purine metabolism that is filtered in resultant stimulation of the renin. contributed to the hypertension and elevated. more urea is reab. 10:1 to 20:1) was once used to assess the kidneys produces erythropoietin. uric acid increased J. J. Angiotensin I in turn is converted sorbed. could have caused signs and symp. converting enzyme in the lungs. which can damage the platelets would not function effec- glomeruli. platelet count was adequate. it was function results in decreased excre. a thor- glomerular disease. and elevated blood pressure. increasing the findings from fluid overload. causing kidney function. nor. changes in intravascular pressure increased fluid retention and stim- Uric acid is an end product of or sympathetic stimulation. The tubules. increased serum levels of urea nitro.M. poietin. because J. contributed to the renal failure or may result in the development of taglomerular cells in response to the renal failure contributed to the 22 CRITICALCARENURSE Vol 26. redness. The serum tors in patients with CKD. the low hemoglobin level contributes sion. the glomeruli and secreted into the angiotensin-aldosterone system hypertension can lead to the devel- distal tubule. primary hypertension that had led ing in a ratio of 9:1.M. Failure of this mechanism 221/142 mm Hg. elevation of serum levels Endocrine Functions The first is a short-acting vasocon- of both urea nitrogen and creatinine Anemia results from several fac.’s risk of gout angiotensinogen. developing with symptoms such as and converts it to angiotensin I. J.05 mmol/L (185 mg/dL). result. The second action is an indicates kidney failure.10 Impaired glomerular contributes to the retention of water opment of CKD.M.’s serum level of urea nitro. A systems of kidney disease. addition. Uremia can also con. he did have hyper. The retention of water and agnosed liver disease.8 J. cate other abnormalities.M. Although elevated serum particularly in the great toe. ough nursing assessment of patients sion.’s changes in tubular fluid composition. in azotemia. However. associated with glomerulonephritis potential for bleeding.4 μmol/L (21. In addition.M. uremia inactivates erythro. because less hemoglobin production of angiotensin certainly alkaline phosphatase level was also is available in the body to buffer acids. on admission whether J. tension. his hemat. uremia causes impaired the cardiovascular and respiratory Proteinuria and hematuria are platelet aggregation. Cardiovascular evidenced by the 4+ protein and 2+ Renin is released in response to Hypertension is a result of hematuria. joint pain. hemoglobin level and hematocrit every body system (Figure 2).aacnjournals. aldosterone system.’s blood pressure was gen was 66. as evidenced by the acid in joints or soft tissue. uric acid level was 1142 μmol/L or stimulation by the sympathetic gen and creatinine.M.6 mg/dL).

retinopathy. Bruises. deep breaths associated nursing assessment includes inspect- manifestation of ESRD. all Respiratory in the mouth break down urea into indicating significant hypertension. decreased PO2 Musculoskeletal Clinical les. a metallic showed arteriovenous nicking and trolyte levels. weakness. reestablish skin color changes ashen abnormal heart sounds. J. taste in the mouth. as a com. pallor. manifested in Kussmaul respirations. Gastrointestinal bleeding The sinus tachycardia could have result from fluid overload. cardiac dys. nausea. No.M. to impaired platelet nursing gastrointestinal tract altered motor function aggregation assessment is breath Figure 2 Clinical manifestations of chronic kidney disease. moni- ops from the accumulation of toxins. azotemia. acidosis. circulatory overload evi. proteinuria. The vomiting. An increased respiratory rate may ammonia. the anemia. Halitosis. AUGUST 2006 23 . Electrolyte imbalances such as analysis. gray to yellowish. indicating long. compensatory mechanism to elimi. or from decreased PaO2. from altered platelet function and been a compensatory mechanism pensatory mechanism for metabolic increased gastric acid secretion from for the decreased PaO2. Uremic pericarditis.M. J. although CRITICALCARENURSE Vol 26. also lead to dysrhythmias. with metabolic acidosis occur as a ing oral mucous membranes. and ulcers in the cotton wool hemorrhages with exu.M. fatigue. and calcium. lethargy. confusion. trophy and a strain pattern on the hyperkalemia and hypocalcemia can electrocardiogram. hypertension. pathological fractures piratory rate. and elec. fluid normal pH.M. mouth may occur because bacteria dates (hypertensive retinopathy). by crack- crackles. weight loss. encephalopathy. and vomiting are frequent findings an S3 (fluid overload) and S4 gallop denced by congestive heart failure in patients with CKD. toring weight. Anorexia. Peripheral neuropathy. Funduscopic examination rhythmias. halitosis.aacnjournals. dry skin. respi- ratory rate and pattern. chronic kidney increased res- Renal hyperparathyroidism. bleeding due bleeding in lethargy. Neurological Anemia. of the nursing assessment is periph. and results of arterial blood gas ment revealed left ventricular hyper. nausea.’s clinical assess. hematuria. vitamin D impairment. electrocardiographic changes. sounds. pruritus. restless legs.’s acid- base results were Gastrointestinal Hematological described pre- Anorexia. disease Decreased urine output. said that he did not have these signs tension). (decreased compliance and hyper. and symptoms. J. retention with peripheral edema and/or dry brittle hair and nails pulmonary edema Fluid overload Immune with pul- Increased risk of infection monary con- Respiratory gestion was Increased respiratory rate. dysrhythmias. change in level of consciousness. or the fluid Although not identified as Kussmaul mone10 may occur. hyperuricemia J.M. 4. nate carbon dioxide in an Cardiovascular Integumentary attempt to High blood pressure. another respirations. increased heart rate. often devel. hypertension. The focus Gastrointestinal standing left ventricular failure. decreased Renal osteodystrophy. focus of the metallic taste in mouth. The focus of the overload. did not have this manifestation. viously. decreased manifestations of PaO2. and pulmonary edema. checking stool for http://ccn. increased release of parathyroid hor- the metabolic acidosis. Auscultation of heart sounds revealed eral edema.

from the gastrointestinal tract. whereas drome progressing to pain. in patients with CKD can range as a result of scratching of the skin impaired B. which is Current Standards of Care and motor and sensory function.M. No.6 mg/dL).47 mmol/L through the skin. The focus of the Finally motor function may be (8. had no indica. according to the KDOQI from pallor related to the anemia to of the nursing assessment is detection clinical action plan for CKD. increased and decreased bone density creatinine leads to azotemia. shortness as soon as possible. was a yellow-brown or gray aspect from of signs and symptoms of anemia. and on assessment was completed in the Bruises may also occur because of laboratory evaluation of hematocrit emergency department. gait and fine motor movement.8. The focus of the nursing nursing assessment is fluid balance impaired with resultant changes in assessment is monitoring calcium (intake and output.10 tem result in peripheral neuropathy. J. bone changes are associated with ization and death. fatigue. urine nerves as a result of uremic toxins hormone.aacnjournals. in the vertebrae. Three CKD that often results in hospital- CKD on the peripheral nervous sys. of . (2) In patients with CKD. signs or symptoms. Signs and edema) and monitoring of labora- J.M.8 The including pallor. gist was consulted and a double- 24 CRITICALCARENURSE Vol 26.M. from confusion and difficulty con. focus of the nursing assessment is These findings are described as ure. Because J. output decreases. and the results showed decreases in hemoglo. and of CKD create a need for immediate Pruritus often occurs in patients prolonged QT interval.” The effects of to allow absorption of calcium. this syndrome: (1) osteomalacia due particularly affecting the lower to inadequate absorption of calcium Renal extremities.2 mg/dL). a nephrolo- impaired platelet function and and hemoglobin and iron levels. a urinary pigment. renal replacement therapy1 started urochrome.10 Early which is manifested as bands of products such as urea nitrogen and findings include restless leg syn. interventions and constant monitor- with CKD because of the excretion ing. assessed by testing for the Chvostek The clinical manifestations due sign and the Trousseau phenomenon.10 The centrating to seizures and coma. bin level and hematocrit. The skin is often Decreased erythropoietin levels (189 mg/dL) and his creatinine level dry because of decreased activity of result in anemia. 4. the immediate clinical action required skin may undergo changes in color. had none of these neurological symptoms of hypocalcemia include tory results. The focus for J.occult blood. and impaired phagocytosis. and tachycardia. by the patients. had Immunological odor.10 and phosphorus levels. uric acid retention may lead to gout. The cause of these neu. daily weight. J. Impaired Renal osteodystrophy results from of an impaired inflammatory and thinking processes are sometimes the loss of calcium in the bones and infectious response. urinary rological effects is thought to be osteitis fibrosa or bone demineral. tions of tightness in the legs. Musculoskeletal examination for signs or symptoms mic encephalopathy. signs and symptoms are related to atrophy and demeylination of the ization due to increased parathyroid fluid balance. his calcium level was 2. as GFR decreases. and noting breath increased capillary fragility.’s serum level of of waste products and phosphate10 Hematological urea nitrogen was 67.’s laboratory was 1909. AUGUST 2006 http://ccn.8 J. and (3) osteosclerosis. sweat glands and oil glands.M. sensa. After the initial nails and hair may become brittle.8. The Increased levels of uremic tox- focus of the nursing assessment ins can lead to impaired immune Neurological includes inspection of the skin for and inflammatory responses with Central nervous system findings color changes or impaired integrity resultant defects in granulocytes.M. although Proteinuria and hematuria were dis- pain in a stocking-like pattern. and tions of skeletal deficiencies.4 μmol/L (21. The focus of the neuromuscular irritability manifested nursing assessment is mental status by paresthesia and tetany. to the pathophysiological changes Integumentary muscle cramps.05 mmol/L cussed previously.and T-cell functioning. hypotension. none of these manifestations. Retention of waste and electrolyte imbalances. Infection is a described as “BUN [blood urea ineffective conversion of vitamin D common occurrence in patients with nitrogen] blunting.

the cycle repeats constantly large central vein such as ment and is often used Decreased flow rates with while the patient is on dialysis. The the internal jugular vein in emergent situations catheter lead to low urea reduction rate total amount of blood outside the Potential for discomfort at body at any time is approximately catheter exit site and devel- opment of poor body image 200 to 300 mL. procedure.M.5F venous or subclavian venous sites the total volume of each lumen (the or 12F. at exit site. few problems for dialysis) connecting an artery to It is long lasting and is May not enlarge enough to The mechanics of hemodialysis.M. those venous catheter and an indwelling for as long as 3 months. A vascular access for arterial flow and venous return is needed for the or operating suite. a vein associated with fewer provide a good blood flow with all access types. to a vein potential for an allergic a semipermeable membrane). J. thrombosis.M.aacnjournals. as well (Table 3). mias. to equal ysis catheter has a large lumen. and a dressing was placed over the tions initiated because of J. No.’s criti- therefore.’s situation. Using the subclavian lumen volume is printed on each of blood throughout the hemodialy- site can cause venous stenosis and lumen of the catheter).’s acute permanent access that once matured. emergent nature of J. A catheter sis procedure. fluid restriction and a renal diet of http://ccn. 20-cm–long catheter was inserted patient. Additional immediate interven- future access for fistulas or grafts. a femoral site is chosen. however.lumen percutaneous catheter was Table 3 Access sites for hemodialysis inserted. the pro. where it thetic material tunneled Higher incidence of stenosis is cleansed by osmosis and diffusion under the skin than with fistula One end of graft is con. The know which site will be used. creating the low-molecular-weight solutes across other. 4. used in 3-6 weeks arteriovenous fistula dialyzer14 (artificial kidney).’s critical condition.” Once lar or the subclavian site is used. Shorter maturation time Higher incidence of thrombo- the blood then passes through the manent access created than fistula. maintaining aseptic technique.M. while catheters must be longer than if the a temporary access was required. The triple lumen gives an sis. and/or obtaining dialysis procedure. per facility protocol. nutri. bloodstream partment. 11. been verified with a chest CRITICALCARENURSE Vol 26. commonly used are double or triple Foley catheter. site can be sis and clotting than with surgically by using a syn. Long maturation time (3-4 toneal dialysis because of J. response the blood completes the circuit and Catheter: A temporary No maturation time Increased risk of infection in access in which a Catheter can be used catheter.M. the catheter was in place. it should be used only when site. It is important to 1 is temporary and 2 are permanent cedure was done at the bedside. The dial- preferred site. AUGUST 2006 25 . Finally. After his initial dialy- dure is done by using sterile technique lumen. has good months until it can be used condition. because of the place by using “suture wings. cardiac accessible. blood samples. was now ready for dialysis cal condition included oxygen via the femoral or jugular sites are not after placement of the catheter had nasal cannula at 4L/min. particularly into the vein and then sutured in length catheter is needed. Of 3 access types. is created surgically by blood flow.M. however. Hemodialysis was selected Access type Advantages Disadvantages as the intervention rather than peri- Arteriovenous fistula: A Preferred route for dialysis. to determine what size and cations are common. Arteriovenous graft: A per. catheter is placed into a immediately after place. J. because of the The right internal jugular vein is the nurse instilled heparin into each positioning of the catheter. monitoring to assess for dysrhyth- A temporary access is placed in a Several brands and types of dial. If the jugu- infection. insertion of a peripheral intra- large central vein and can be used ysis catheters are available17. which allows a smooth flow are also used.16 interfering with any cap was then placed on each lumen. and in returns to the patient’s vascular com. was placed on a 1000-mL in an angiography suite. and a as the size and body type of the is the least desirable because compli. involves blood The forearm is the most complications than are for dialysis common site other accesses being removed from the body by the blood pump of the dialysis machine. of J. the material. Involves use of synthetic (hemodialysis works by diffusion of nected to an artery. because tional support. The proce. The central venous catheter right jugular vein was used.15 although the femoral lumen. added lumen for drug therapy.

captopril (Capoten) and nifedipine based on 500 mL/day (insensible base imbalance. calcium and phospho.19 Particularly for J. after the diagnosis of CKD is tests after dialysis are found in Table • Prevention of other cardiovas- made and initial treatment has begun. including adequate hemodial.M. Nursing prevention of end-organ damage.M. limits21 is related to several interven. The potassium restriction in preventing as decreasing blood pressure. multivi- Expected Outcomes ysis and fluid restriction. On the basis of the KDOQI guide. Education of patients focuses on and hematocrit and assessing patients conditions. teaching about foods high in sodium for clinical findings of anemia. Adequate dialysis vasodilatation. phosphorus from the body (dialysis levels of urea nitrogen and creatinine) comitant increase in serum potassium removes very little). and vascular access. physical exercise.M.M. and nutritional status intervention includes the use of ment of calcium and phosphorus required treatment. Pharmacological accomplished through the manage- rus balance. and ematical formula. Calcium channel taking the phosphate binder with the measurements from before and blockers are also effective in decreas. inhibitors. Moni- 26 CRITICALCARENURSE Vol 26. Nursing J. that must be avoided and manage. fluid volume over. cular diseases22 is accomplished the patient is referred to a surgeon sis for 3 days. the necessity of and the urea reduction ratio. ment of fluid intake. For patients on dialysis.. AUGUST 2006 http://ccn.60 g of protein. priate because not only potassium weight loss/gain. interventions focus on monitoring placed 8 days after admission. ocrit levels can be reached23 through tions. was treated with 2 g sodium. and ing assessment after a fistula is placed but also sodium and phosphorus are peripheral edema and on educating focuses on patency of the fistula. (Procardia). which decrease not only agement. Immediate maintaining weight control. The National Kidney impaired gas exchange. angiotensin-converting enzyme levels. for a patient with CKD. Because medications are determined by measurement of levels converting enzyme inhibitors must the primary method of removing of nitrogenous waste products (serum be used with caution because a con. Cardiovascular disease is the leading riovenous fistula as the preferred type tion. be given after hemodialysis to prevent Once a patient’s condition stabi. 2. this access is associated with The focus of educating patients is A physician-approved exercise pro- fewer complications and provides teaching about foods that are high gram for patients with CKD provides longer trouble-free use than does an in potassium and the importance of the positive benefits of exercise such arteriovenous graft or a catheter. dialysis in J. cause of death in patients with ESRD. The most tamins. J.’s restriction of sodium and fluid in the include monitoring hemoglobin levels case. Nursing interventions is specific therapy. in which levels may occur.M.aacnjournals. and treatment of comorbid diet. No. anemia.’s laboratory hypotension. initially received daily dialy. implications include fluid restric. lizes. choles- catheter is the access least recom. cardiac dysrhythmias. Correction of the fluid through control of hypertension and for establishment of a permanent imbalance in turn will correct fluid volume. ing blood pressure through systemic aspect of patients’ education. blood pressure. .M.M. determined by palpating a thrill and • Blood pressure within normal • Target hemoglobin and hemat- auscultating a bruit. J. and electrolyte imbalances antihypertensive medications should output of the preceding 24 hours. and daily weight. the clinical findings such as hyperten. outcome. would systemic blood pressure but also minum hydroxide) or calcium salts include the following: intraglomerular pressure by dilating (PhosLo) may be used to reach this • Adequate hemodialysis20 is the efferent arteriole. and epoetin alfa (Epogen). Disregarding terol and triglyceride levels. sium). 2 g potassium. fluid loss) plus fluid equal to the urine load.8 Angiotensin. patients about diet and exercise.8 (particularly sodium and potas. had an arteriovenous fistula referral to a dietician is also appro. • Prevention of bony changes24 is sion. Results of J. phosphate binders (alu- ing considerations for J. In addition to dietary man- The expected outcomes and nurs. Fluid volume intake is will also result in correction of acid. and mended because of the frequent potassium restriction can be fatal insomnia and the obvious benefit of complications associated with its use. the focus of treatment in CKD hypertension is fluid removal and blood cells. 4. Foundation18 recommends the arte. important nondrug management for which stimulates production of red lines.22 of access. restricted on a renal diet. the use of iron supplements. food to be effective is a significant after dialysis are entered into a math. monitoring.

18.htm#ckdex2.14. Pathophysiology: Clinical cal practice guidelines for nutrition in Concepts of Disease Processes. 2000. Accessed May 15.kidney. 2006. St chronic renal failure. Understanding /professionals/kdoqi/guidelines_bone of nurses and/or dieticians. Porth CM. This assessment will enable the early 12. May 15. Accessed May 15. 22. Available at: http:// /divisions/KUH/KidneyHP2010. McCance KL. Available at: http://www. and Kidney Disease. Fluid and Electrolyte Balance. /professionals/kdoqi/guidelines_ckd/ex2 2. 2006. disease: guideline. Copstead LC. kidney disease: update 2000. cal practice guidelines for cardiovascular cal practice guidelines for chronic kidney disease in dialysis patients. remission. A thor. Am J Kidney Dis. and finally maintenance of immune Biological and Behavioral Perspectives.kidneyatlas.357:1601-1608. Hemodialysis catheter place- Acknowledgments ment and management. http://www. Trerotola SO. www. Kaufman J. 1998. regression of chronic and disease in chronic kidney /KLS/gfr.htm. Pa: WB Saunders Co. May total protein intake is restricted. K/DOQI clini- disease: executive summary. Kapoian T. Altered Health States.kidney. Available at: ness of interventions. National Kidney Foundation. Dialysis access and recirculation.37(suppl 1): 1. The interpretation and reporting of these data are the responsibility of the author(s) and in 17. 3rd ed.39(suppl 1):S1-S266.html#11. 4th ed. 2006. Mo: /index. References 2000. 15. 819-824. assessment of protein- uria. function. 6th ed. Mosby. US Renal Data System. Institutes of Health. The evolution and function of cen- no way should be seen as an official policy or interpreta. 4. 2006. Available at: http://www. Accessed ment.html. National Kidney Foundation.kidney.kidney. Metheny N. Lancet. 2006. Avail- renal disease. Philadelphia.htm. K/DOQI clini- dietary regulation. Williams & Wilkins. along quacy: update 2000. National Institute of antihypertensive agents in chronic kidney Diabetes and Digestive and Kidney Dis.htm. Am J Kidney Dis. 24.68:799-780. Proteins of high 4. K/DOQI clini- maintenance of fluid balance. 6th ed. eds. National Kidney Foundation. K/DOQI clini- Renal Disease in the United States.nih. Pathophysiology Concepts of patients with CKD is clear. K/DOQI clini- objectives: chronic kidney disease.htm. 2006. Anatomy and physiology of the kidney.kidney. Accessed May /guide_1. 2006.14:416-424. detection of systemic alterations 806. and strat. Wallace M. National Kidney Foundation.htm. The significant role of critical at: http://www. 1999:5. No. Recognizing chronic renal fail- evaluation of patients’ outcomes are ure. Henrich WL. tral venous catheters for dialysis.kidney. Nursing.QXD. Cannon JD.usrds. National Kidney Foundation. able at: http://www. Bethesda. 827-828. Wilson L. 8. Bennet WM. Remuzzi G. http://www.34:50-53. questions about GFR estimates. National Kidney Foundation.kidney.html#hd. 3. January 2004. Md. Mo: Mosby. 2006. Pa: Lippincott is essential in evaluating each patient.cfm. Pa: Lippincott. Available at: cal practice guidelines for chronic kidney http://www. Price 5. Also available at: 23. National Kidney Foundation. Frequently asked /guidelines_updates/ serving size is an important activity 7.aacnjournals.kidney. 2006. 2001. Renal Data System. Available at: http:// Louis. 2002. National Kidney Foundation. K/DOQI clini- cal practice guidelines for chronic kidney tion of appropriate Accessed May 15. Radiology. 13.toring calcium and phosphorus levels Annual Data Report: Atlas of End-Stage 21. National cal practice guidelines on hypertension and would also be part of the nursing role. Kidney Learning CRITICALCARENURSE Vol 26. Guideline 1: Definition and stages /guidelines_cvd/overview. albumin level)25 is managed through www. cal practice guidelines for chronic kidney 19. AUGUST 2006 27 . ification. 2000. National Kidney Foundation. K/DOQI clini- with monitoring albumin levels. 2006. Healthy People 2010 20. classification. Accessed May 15. The data reported here have been supplied by the US 215:651-658. 16. 2006. http://ccn. 14. related to CKD and the implementa. Schieppati A. /guidelines_updates/doqi_uptoc. Accessed May 15. 2000. Semin tion of the US government. 2001. Atlas of Kid- ney Disease. Heuther SE. 2006. S137-S181. Ash SR. Banasik JL. St Louis. Available at: biological value are essential because disease: evaluation. K/DOQI clini- cal practice guidelines for vascular access. www. Pathophysiology: /guidelines_updates/doqiupan_iv. National Kidney Foundation. 810-811. 803-804.1-5. 25. Accessed May Conclusion 9.pdf. Philadelphia. In: nurses can determine the effective. Available at: ing and maintenance of skin K/DOQI clini. National Institute of Diabetes and Digestive . 2003. Available Accessed May 15. care nurses in providing care to 10.ccc . 2001. Accessed May 15.htm#ckdex1. Providing dietary education Philadelphia. Evaluation and treat- /guidelines_ckd/p1_exec. heal. cal practice guidelines for bone metabolism on appropriate protein foods and disease: guideline 2. AORN J. Available cal practice guidelines for hemodialysis ade- at: Education of patients about the /professionals/kdoqi/guidelines_ckd management of CKD and continued /p5_lab_g5. Accessed May 15. K/DOQI clini. 2006. 15. K/DOQI clini- 6. 2004.kidney. Ruggenenti P. Nosher J. 2nd ed. Available at: http://www. ough assessment of all body systems cal practice guidelines for anemia of chronic /guidelines_ckd/ex2. Adequate protein levels result in 2002. USRDS 2004 Accessed May 15. 2006. www.kidney • Adequate nutrition (based on eases. Available at: http:// .org/book5/adk5-05. disease.niddk. National Kidney Foundation. 808. Accessed of chronic kidney disease. http://www. Sherman also essential so that critical care RA. Accessed May 15.

75% to 80% 9. Arteriovenous fistula 6. and proteinuria 8. K a 9. Because of increasing incidence and the high cost of interventions endocrine system in CKD in relationship to hypocalcemia? b. K a 3. d. Obesity. Dermatitis. Discuss the impact of CKD in relation to body systems 1. Which of the following best describes the response to decreased b.(Cl. sodium. what percentage of blood is a.CE Test Test ID C064: Chronic Kidney Disease: Acute Manifestations and Role of Critical Care Nurses Learning objectives: 1. 30 to 50 mmol daily d. Which of the following cardiovascular changes do critical care d. hyperglycemia. Describe the pathophysiology of CKD 3./ [0. disease b. Which of the following best describes the normal excretion of potassium by the kidneys? a. Dehydration. CCRN Program evaluation Name Member # Yes No Objective 1 was met K K Address Objective 2 was met K K City State ZIP Objective 3 was met K K Content was relevant to my Country Phone Mail this entire page to: nursing practice K K My expectations were met K K E-mail AACN This method of CE is effective RN Lic. Hypertension. Diabetes mellitus. BSN. Contact hours: 2. cardiac dysrhythmia.+ HCO3-) access for permanent vascular access? b. Aldosterone is released from the adrenal cortex. increasing the a. resulting in reabsorption of c. and dysostosis a. proteinuria. Endocarditis. and myelolysis sodium and water. approximately water. osteitis fibrosa. resulting in reabsorption of d. No. hypertension. sodium.1 + log (HCO3. Identify the expected outcomes of patients with chronic kidney disease (CKD) 2. Which of the following best illustrates the correct anion gap equation? 11. Anion gap = Cl. and osteophlebitis glomerular f iltration rate? c. K a 6. a. b. Cortisol is released from the adrenal medulla. 250 to 400 mL 5. RN. and hypotension a. osteomyelitis. 4. Which of the following best describes the function of the a. 200 to 300 mL water and sodium. decreasing the 2. K a 8. Infusaport c. As blood completes the circuit during dialysis. b. K a 5. how much blood is outside the body at any time? c. Osteomalacia. 35% to 45% d. Increasing age. The parathyroid glands secrete parathyroid hormone. 80 to 100 mmol daily Test answers: Mark only one box for your answer to each question. In relationship to cardiac output. and osteosclerosis 4. Anion gap = Na+ + (Cl. Osteomatosis. 1/St RN Lic. CA 92656 K easy K medium K difficult To complete this program. 2/St 101 Columbia for this content K K The level of difficulty of this test was: Payment by: K Visa K M/C K AMEX K Discover K Check Aliso Viejo.0 Fee: $12 Passing score: 8 correct (73%) Category: A Test writer: Todd M.aacnjournals. and hypercholesterolemia nurses need to monitor during their assessment of the patient with CKD? 3. K a Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Test ID: C064 Form expires: August 1. The parathyroid glands secrete parathyroid hormone. 1. Card # Expiration Date (800) 899-2226 it took me hours/minutes. Ash catheter d. Arteriovenous graft d. K a 7. K a 2. Which of the following are 3 risk factors for end-stage renal disease amount of calcium released from the bone into the vascular system. Because of increasing cost of insurance premiums and loss of insurance a. AUGUST 2006 http://ccn. Anion gap = Na+ . 28 CRITICALCARENURSE Vol 26. 20 to 40 mmol daily b. K a 11. Aldosterone is released from the adrenal cortex. resulting in excretion of 10. The thyroid gland decreases secretion of thyroid hormone. Which of the following are associated with renal osteodystrophy? a. K a 10. Peripheral edema. Grivetti. Antidiuretic hormone is released resulting in reabsorption of water. The thyroid gland increases it secretion of thyroid hormone. 40 to 60 mmol daily c. pulmonary edema. 100 to 300 mL d.+ HCO3-) a. Why is chronic kidney disease (CKD) a public health issue? ? 7. The National Kidney Foundation recommends which type of a. according to Healthy People 2010? d. and smoking c. Gastroesophageal reflux disease. and electrolyte levels f iltered through the nephrons per minute in normal homeostasis? b. stimulating . 2008.03 × PCO2]) b. K a 4. 75 to 150 mL and potassium.+ (Na+ / HCO3-) c. coronary artery disease. 45% to 50% d. and family history amount of calcium released from the bone in the vascular system. Because of limited access to dialysis centers and limited public education of the the release of cortisol into the blood. Anion gap = 6. gastrointestinal bleeding. desmosis. 20% to 25% c. b. and potassium. and congestive heart failure c. Peripheral neuropathy. smoking. Signature The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. c. You may photocopy this form. and hypotension b. Because of limited access to dialysis centers and the high cost of interventions the amount of calcium excreted. decreasing d. osteoperiostitis.