NURSING CARE IN CRONIC KIDNEYS DISEASE (CKD)

GROUP 2 :

1. ASRI WULANDARI 6. LISTYA APRILIA O

2. BAGAS PANDU P 7. NILUH PUTU E
3. DIMAS PANDU D 8. SINDHI MAIPURI
4. FRUISKA VALENTIN F 9. YOANITA PUTRI
5. GILANG YUANGGA M

NURSING GRADUATE STUDIES PROGRAM

COLLEGE OF HEALTH SCIENCES KUSUMA HUSADA
SURAKARTA
2019/2020
 Nursing Care In Cronic Kidney Disease Patients

A. Definition of nursing process

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)
 Chronic kidney disease (CKD) or chronic kidney disease is defined as
kidney damage for at least 3 months with or without a decrease in glomerular
filtration rate (GFR) (Nahas & Levin, 2010). CKD or chronic renal failure (CRF)
is defined as a condition where the kidneys decreased function by a slow,
progressive, irreversible, and vague (insidius) where the ability of the body fails to
maintain metabolism, fluid and electrolyte balance, resulting in uremia or
azotemia (Smeltzer, 2009). Chronic renal failure is a progressive impairment of
renal function and irreversible, which causes the body's ability failed to maintain
metabolism and fluid and electrolyte balance, causing symptoms of uremia
(retention of urea and other nitrogen garbage in the blood).
Etiology
The cause of CRF including glomerulonephritis, chronic infections, vascular
disease (Nephrosclerosis), the obstruction (calculi), collagen disease (luris
sutemik), nephrotic agent (amino glycosides), endocrine diseases (diabetes).
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
According to Brunner & Suddart (2014) each body system in chronic renal failure
uremia affected by the condition, the patient will show a number of signs and
symptoms. The severity of signs and symptoms depending on the part and the
degree of renal impairment, the patient's age and underlying condition. Signs and
symptoms of patients with chronic renal failure are as follows:
a. cardiovascular manifestations
Include hypertension (due to fluid retention and sodium from the activation of
the renin-angiotensin-aldosterone system), pitting edema (feet, hands, sacrum),
periorbital edema, Friction rub, pericardial, enlargement of the neck veins.
b. manifestations of dermatology
Gray skin color, shiny, dry skin, scaling, pruritus, ecchymosis, thin and brittle
nails, thin and coarse hair.
c. pulmonary manifestations
Krekels, thick sputum and clay, shallow breaths, breathing Kussmaul
d. Gastrointestinal manifestations
Breath smelled of ammonia, ulceration and bleeding at the mouth, anorexia,
nausea, vomiting, constipation and diarrhea, gastrointestinal tract bleeding
e. manifestations Neurology
Weakness and fatigue, confusion, disorientation, seizures, weakness of the legs,
the heat in the feet, changes in behavior. Diseguilibrium syndrome: Nausea,
vomiting, fatigue and headache
f. Musculoskeletal manifestations
Muscle cramps, muscle strength is lost, bone fracture, foot drop
g. Reproductive manifestations
Amenorrhea and testicular atrophy

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
As with other chronic diseases and old, patients with CKD will experience
few complications. Complications of CKD according to Smeltzer and Bare (2014)
and Suwitra (2014) among others are:
1. Hiperkalemi due to reduced secretion of metabolic acidosis, catabolism, and
excessive dietary input.
2. Pericarditis, pericardial effusion, and cardiac tamponad due to retention of
uremic waste products and inadequate dialysis.
3. Hypertension due to sodium and fluid retention and renin-angiotensin-
aldosterone system malfunctions.
4. Anemia due to decreased eritropoitin.
5. Metabolic bone disease and classification due to the retention of phosphate,
serum calcium levels are low, abnormal vitamin D metabolism and elevated
levels of aluminum due to increased nitrogen and inorganic ions.
6. Uream uremia due to increased levels in the body.
7. Malnutrition due to anorexia, nausea, and vomiting.
8. Hyperparathyroidism, hyperkalemia, and hyperphosphatemia.
9. Stomach or intestinal bleeding
10. Changes in blood sugar
11. Damage to the nerves of the feet and hands (peripheral neuropathy)
12. Dementia
13. A buildup of fluid around the lungs (pleural effusion)
14. Complications of the heart and blood vessels (Congestive heart failure,
coronary artery disease, high blood pressure, pericarditis, stroke)

F. Classification
The classification is based on the degree of chronic renal failure (stage)
GFR (glomerulus Filtration rate) where the normal value is 125 ml / min / 1,73m2
with Kockroft formula - Gault as follows:
Stage Definition eGFR
Stage 1 Kidney disease with normal or increased eGFR >90 mL/min/1.73 m2
 Stage 2 Kidney disease with a mild decrease in eGFR 60-89 mL/min/1.73 m2

Stage 3a Kidney disease with mild to moderate eGFR 45-59 mL/min/1.73 m2

Stage 3b Kidney disease with moderate-severe eGFR 30-44 mL/min/1.73 m2

reduction

Stage 4 Kidney disease with eGFR weight loss 15-29 mL/min/1.73 m2

Stage 5 Kidney failure <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

H. MEDICAL MANAGEMENT
Management of nursing in patients with CKD is divided into three, namely:
a) Conservative
- Lab.darah and urine examination
- Observation fluid balance
- Observe for edema
- Limit fluid intake

b) dialysis
- Peritoneal dialysis is usually done on a case - the case of emergency. While
dialysis can be done anywhere that is not acute is CAPD (Continues
Ambulatory Dialysis Peritonial)
- hemodialysis
Namely dialysis done through invasive action in the vein by using
machines. At first hemodiliasis performed through the femoral region, but
to simplify it is done:

- AV fistule: combining veins and arteries

- Double lumen: directly at the heart of the area (vascularization to the heart)
c) Operation
- decision-stone
- kidney transplant
 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
3. Activity intolerance is related to oxygen supply imbalance

C. Nursing Intervention
no Diagnose NOC NIC
1 Excess fluid in the After taking nursing - Maintaining the
body is related to action for 2x24 hours, its electrolyte balance
unbalance intake and expected that excess 1. Assessment of the
outflow characterized fluid volume can be electrolyte status: -
by edema extremity overcome with the serum level of
expected results: electrolytes - daily
1. intake and changes in body weight
outtake balance 2. indication of fluid
2. electrolyte intake and loss
balance 3. Identification of
the patients is not edema 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 Ineffective breath After the 1x24-hour respiratory Monitoring

pattern associated nursing care for adequate 1. Monitor the average -
with a buildup of breathing patterns. average, depth, rhythm
fluid in the lungs Criteria Results: and respiration effort
characterize by NOC: Respiratory 2. Record the chest
shortness of breath Status movement, observe the
 Increased ventilation symmetry, the use of
and adequate additional muscle,
oxygenation supraclavicular and
 Free of signs of intercostal muscle
respiratory distress retraction
 Clean breath sounds, 3. Monitor breathing
no cyanosis and patterns: bradipena,
dyspnea (capable of takipenia, Kussmaul,
removing sputum, hyperventilation,
able to breathe easily, Cheyne Stokes
no pursed lips) 4. Auscultation of breath
Vital signs within normal sounds, noting areas of
 range decreased / absence of
ventilation and
additional sound
oxygen Therapy
1. Auscultation of breath
sounds, record their
crakles
2. Teach the patient
breath
3. Adjust the position as
comfortable as
possible
4. Restrict to move
Collaboration of oxygen
3 Activity intolerance After taking nursing energy management
is related to oxygen actions for 2x24 hours, 1. observation of the
supply imbalance clients can perform daily patient's level of
life activities fatigue after activity
independently with the 2. help the patient
expected outcome identify the choice of
criteria: activities to be carried
1. oxygen saturation out
when on the 3. encourage the patient
move can be to choose activities that
controlled build resilience
2. respiratory rate 4. monitor the patient's
when active oxygen response
within normal 5. collaborate with family
limits to monitor patient
activity
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