Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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Table 37.6 Chronic Kidney Disease Summary
Table 37.7 Stages of Chronic Kidney Disease
Signs and Symptoms
Kidney Function Description
Glomerular Filtration Rate (GFR) mL/min
See Figure 37.6.
Stage
Diagnostic Tests/Findings
1
Slight decrease
90 or greater
Glomerular filtration rate decreased pH—Metabolic acidosis RBCs decreased Elevated: Serum blood urea nitrogen, creatinine, magnesium, potassium Urinalysis abnormal Urine sodium level less than 10 mEq/L
2
Mild decrease
60–89
3a
Moderate decrease 45–59
3b
Moderate decrease 30–44
4
Severe decrease
15–29
Therapeutic Measures
Diet and Fluid Restriction Dialysis Transplant Accelerated atherosclerosis Anemia Anorexia Dry itchy skin, ecchymosis Headache
5
Dialysis/Transplant
Less than 15
Complications
damage caused by infection, dehydration, medications, heart failure, and use of contrast media. The goal of care is to pre- vent further damage, if possible, through control of blood glucose levels and blood pressure. End-stage renal disease occurs when 90% of the nephrons are lost. Patients at this stage experience chronic and persistent abnormal kidney function. Serum BUN and serum creatinine levels are always elevated. These patients may make urine but not filter out the waste products, or urine production may cease. Dialysis or a kidney transplant is required for survival. Uremia (urea in the blood) is present in CKD. Patients even- tually develop problems in all body systems (Table 37.8). If left untreated, the patient with uremia will die within a short time. Etiology The causes of CKD are numerous. The most common include diabetes mellitus resulting in diabetic nephropathy, chronic high blood pressure causing nephrosclerosis, glomerulone- phritis, and autoimmune diseases. Social determinants of health influence development and progression of CKD. Symptoms of Kidney Disease Patients with either AKI or CKD have multiple symptoms. Figure 37.6 illustrates symptoms; some of the more common ones are explained next. Disturbance in Water Balance Disturbances in the removal and regulation of water balance in the body occur with exhibition of signs of fluid accumu- lation. Edema, an early symptom, is seen in the extremities, abdomen, and sacral area when supine. Patients may report shortness of breath. Crackles and wheezes (signs of fluid accumulation) may be present on auscultation of the lungs. The patient may be hypertensive. These patients may produce a large amount of dilute urine ( polyuria ), small amounts of urine (oliguria), or no urine (anuria).
Heart failure Hypertension Impotence Osteomalacia Osteoporosis
Platelet dysfunction Pulmonary edema Uremic encephalopathy Uremic pericarditis
Priority Nursing Diagnoses
Excess Fluid Volume Decreased Activity Tolerance Impaired Skin Integrity
Healthy People 2030 has 14 objectives related to CKD, including its goal of reducing the burden of chronic kid- ney disease and related complications (Office of Disease Prevention and Health Promotion, 2020). Pathophysiology When a large proportion of the body’s nephrons are dam- aged or destroyed, AKI or CKD occurs. As the nephrons die off, the undamaged ones increase their work capacity. The patient may experience significant kidney damage without showing symptoms. CKD is a progressive disease process. In the early, or silent, stage (decreased renal reserve), the patient is usually without symptoms, even though up to 50% of nephron function may have been lost (Table 37.7). The renal insufficiency stage occurs when the patient has lost 75% of nephron function and some signs of mild kidney disease are present. Anemia and the inability to concentrate urine may occur. Serum BUN and serum creatinine levels are slightly elevated. These patients are at risk for further
• WORD • BUILDING • polyuria: poly—much + uria—urine
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