UNIT NINE
714
Understanding the Urinary System
production. Nutritional deficiencies and blood loss during dial- ysis also contribute to anemia. Injections of epoetin (Epogen, Procrit), a synthetic form of erythropoietin, can help restore RBC production and prevent anemia. Impaired WBC and immune functions contribute to an increased risk for infec- tion. The patient should be protected from potential sources of infection. Impaired platelet function creates a risk for bleed- ing. The patient should be protected from injury, and signs of bleeding, such as blood in stool or emesis, must be reported. Therapeutic Measures for Kidney Disease Renal insufficiency and chronic kidney disease are treated based on symptoms with a restricted diet and fluid intake, medications, and careful monitoring for onset of serious problems or kidney failure (stage 5) that warrants kidney replacement therapy (dialysis or transplant). A kidney trans- plant can return the patient to a nearly normal state of health and functioning. Diet Dietary recommendations are individualized by the dieti- tian and HCP based on the patient’s needs. Most patients are given iron, folic acid, vitamins, and minerals to supple- ment the restricted diet (see “Nutrition Notes: Understanding Dietary Changes in Renal Disease”). Because restrictions are complex, the diet may frustrate patients. The dietitian should be consulted for education and assistance. The nurse can help the patient identify foods they like within the diet plan. Nutrition Notes Understanding Dietary Changes in Chronic Kidney Disease Patients with CKD can have complex dietary requirements and need the guidance of a dietitian who specializes in renal treatment. Dietary restrictions vary according to the patient’s renal disease type and treatment. Renal diets are individualized. Educating patients to associate adherence to their diet with relief of symptoms is important. General guidelines include the following: • Fluid restriction may vary daily according to urine output. Patients receiving hemodialysis may have 1,000 mL daily plus the previous day’s urine output, if they still void. • Adequate caloric intake is needed to maintain ideal body weight and protein stores. Simple carbohydrates and monounsaturated and polyunsaturated fats are given freely because their end products, carbon dioxide and water, are less likely to tax the kidney than protein. • A low-protein diet is prescribed when the patient has renal function impairment to reduce damage to the nephrons. Protein is increased for dialysis to compensate for losses into the dialysate solution. Proteins of high biological value (eggs and meat) can be prescribed because they are more easily converted to body protein
than those of low biological value. Vegetarian diets may be used to provide adequate protein as well as lower lipids. Plant proteins are chosen carefully to manage potassium and phosphorus serum levels. • Potassium is restricted for patients with hyperkalemia when the cause is CKD. • Sodium restriction is based on elevated blood pressure, degree of edema, and laboratory findings. • Calcium may be increased or supplemented because of poor absorption related to faulty vitamin D activation. • Phosphorus is restricted when its levels are elevated due to low calcium levels. • Saturated fat and cholesterol are restricted for patients with hyperlipidemia. Renal diets are individualized. Educating patients to associate adherence to their diet with relief of symptoms is important. Medications Early in the disease, diuretics are given to increase output. ACE inhibitors, ARBs, calcium channel blockers, or beta blockers may be used to control hypertension. Phosphate binders are given with meals (they must be given at the beginning of the meal to effectively bind with the phosphate in the food) to reduce phosphate levels. Calcium and vita- min D supplements are used to raise calcium levels. Both the active and storage forms of vitamin D should be consid- ered to decrease fractures, cancer, and infection rates and to improve cardiac function. Medications are used to lower potassium levels if needed. All medication therapy is closely monitored because diseased kidneys are unable to effec- tively remove medications from the body. As renal function decreases, the patient who requires insulin may need smaller doses of some long-acting insulins. Dialysis Dialysis is started when the patient develops symptoms of severe fluid overload, elevated potassium levels, acidosis, pericarditis, vomiting, lethargy, fatigue, or symptoms of uremia that are life-threatening. Both peritoneal dialysis and hemodialysis involve the movement and diffusion of parti- cles from an area of high concentration to an area of low con- centration through a semipermeable membrane. Substances move from blood through the semipermeable membrane into the dialysate. Fluid and electrolyte imbalances can be corrected with dialysis. Dialysis can also be used to treat medication overdoses. Research is ongoing in the development of a wearable artificial kidney to provide mobility and freedom from hemodialysis sessions and also for a bioartificial kidney for implantation. HEMODIALYSIS. Hemodialysis involves the use of an artificial kidney to remove waste products and excess fluid from the
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