1.1 Kidneys consists of outer cortex and of inner medulla, located on either side of spinal cord at T12-L3 vertebrae. Twenty-five percent of cardiac output is received by two kidneys. In retroperitoneal space, kidneys are protected by muscle, overlying ribs and renal fat. Nephron is called functional unit of kidneys, consisting of renal corpuscle, renal tubule, glomerular capsule and glomerulus (Chalouhy,2017). Blood is filtered resulting in urine being formed by kidneys. Filtrate passes through glomerulus, entering renal tubules consisting of proximal and distal convoluted tubule along with the loop of Henle. Capillaries surrounding tubules absorbs water and solutes that are send back into blood via reabsorption. About 90% of water is reabsorbed, secreting wastes that did not pass into the filtrate at the glomerulus into the tubule lumen. When fluid leaves the renal tubule via the collecting system it drains to the minor calyx to form urine. Urine is defecated from the body via urethra (AMBOSS,2019).
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1.2 PATHOPHYSIOLOGY: As Melanie feeling nausea which may be due to the accumulation of uremic toxins as declining kidney function to excrete metabolic waste. (National Kidney Foundation,2013). Melanie reported of being feeling very tired and the reason behind tiredness are decreased RBC and anaemia. Melanie also complaint of severe headaches and palpations which are the symptoms of kidney failure. (Better health,2018). Melanie ignored the symptoms for a very long period and delayed treatment has progressed to End-stage chronic kidney failure which is diagnosed after her blood test reports.
RESPIRATORY PROBLEMS: Melanie is at risk of developing tuberculosis and other respiratory infections because of her depressed immune system. Factors which effects immunity in patient suffering from chronic kidney disease are uremic toxin, malnutrition, chronic inflammation, alternation of vitamin D and Parathyroid hormone, and therapeutic dialysis. Primary pulmonary oedema can be another health issue in Melanie. Fibrosis can occur following visceral calcification, as excess calcium can deposit into alveolar septae in the lungs. Kussmaul respirations may occur because of metabolic acidosis (Rajmaria,2026).
HEMATOLOGIC SYSTEM: Melanie is at risk of anaemia, as patient suffering from ESKD is highly suspected to get anaemic because of the reduced production of Erythropoietin (EPO). Healthy kidneys produce EPO, a hormone responsible to produce red blood cells by the bone marrow. Renal failure decreases erythropoietin secretion, as a result body do not produce enough red blood cells and haemoglobin level start dropping in the suspect and result in anaemia. Melanie because of CKD is at risk of haematological changes such as decrease of HCT, MCV and RBC and platelet counts (Rajmaria,2016).
PRURITUS: Melanie is experiencing Pruritus. Pruritus or itchy skin is a common symptom that often occurs in patient with chronic kidney disease and continues after dialysis. Pruritus is believed to happen because of the formation of a calcium phosphate precipitate in subcutaneous tissues and result in inflammatory response in the skin. (Mettang, 2014).
Gastrointestinal System: Decline Kidney function result in kidney’s inability to excrete toxins, because of which Melanie can experience disturbance in gastrointestinal (GI) tract. Anorexia, nausea and vomiting are common risk factors for patient suffering from ESKD. Poor appetite and weight loss because of metabolic acidosis are common in CKD patient (Kidney health,2016).
NERVOUS SYSTEM: Melanie may have trouble in concentration along with some symptoms of apathy, lethargy, lability, and insomnia. Delusions, depression, mania, and euphoria are the risk factors of ESKD. At the beginning of dialysis treatment, sixty-five percent of patient have peripheral neuropathy. Suspect may experience sensory loss in the lower extremities and muscle atrophy (Rao&Juneja,2018).
RENAL OSTEODYSTROPHY: Pathological changes in the bones may occur in patient suffering from ESKD and result in renal osteodystrophy. Minimal stress may result in spontaneous ruptures of tendons, especially. Metastatic calcification and vascular calcification deposits also may found in the conjunctiva of the eye, around the joints and in the synovial fluid of joints in Melanie (Kidney health,2016).
CARDIOVASCULAR RISKS: High blood pressure is another risk factor of chronic kidney failure. Narrowing of Blood vessels and damaging of small blood vessels are associated with high blood pressure. Kidneys play important role in maintaining electrolytes balance in the body. In CKD, level of electrolytes such as calcium, potassium and phosphorous rises and over time increases the risk of cardiovascular disease such abnormal heart rhythms and atherosclerosis (Kidney health,2016)
- Anti-hypertensive medication such as Valsartan. (Mayo clinic, 2019)
- Cholesterol lowering medication (Mayo clinic, 2019).
- Medication to maintain ideal Haemoglobin level and prevent anaemia such as Eprex (Mayo clinic, 2019).
- Medications, special diet and regular exercise to prevent fluid overload and oedema (Mayo clinic, 2019).
- Haemodialysis or kidney transplantation. (MedlinePlus,2019).
- Special diet: choose diet with limited salt, potassium, calcium and less protein. (MedlinePlus,2019)
- Limit your fluid intakes. (Mayo clinic, 2019).
- Acute kidney disease occurs suddenly, and longer time period is required for someone to be diagnosed with CKD. (Alberta,2019).
- Usual reason of Acute Kidney disease is disease, dehydration, surgery or injury with severe blood loss, drugs or infection, on the other hand diabetes or hypertension are considered the most common causes of chronic renal disease. (Alberta,2019).
- Acute Kidney disease is curable if treated in time while Chronic Kidney disease cannot be reversed. (Mullins et al,2016).
- Duration of Acute Kidney injury is short while for chronic is indefinite. (Mullins et al,2016).
- Diagnosis for AKI are often accurate while for CKD is often uncertain. (Mullins et al,2016).
- Diagnostic test for AKI is usually decisive while for CKD is of limited value. (Mullins et al,2016).
Melanie is diagnosed with Chronic kidney disease, and treatment option for her is permanent dialysis and kidney transplant. Doctor suggested her haemodialysis creating AV fistula. AV fistula is a surgical procedure, in which an artery is connected to vein most commonly in the arm. AV fistula makes the vein wider and thicker and helps the blood to flow out and into the body faster. During haemodialysis, blood goes into the filter caller “dialyzer” also known as artificial kidney. Blood returns to the body when pumped through filter. Blood pressure is checked continuously by the machine and keep the speed of the blood flow through the filter as well as the fluid removed from the body, during the process. Most commonly people have three session a week and each session lasting for 4-5 hours. Melanie can choose have dialysis done at home, because it will give her flexibility to fit the treatment into her lifestyle rather than trying to fit around fixed dialysis schedules at a satellite or hospital. Moreover, it can save her travelling time and expenses. Melanie need to take care of her AV carefully: by keeping the vascular access clean at all the times, looking for signs of infections such as pain, redness, fewer and swallowing (Sofocleous,2015).
Administration of valsartan is used to control circadian rhythm and protect the kidneys and heart in CKD patients. The negative effects of renin-angiotensin-aldosterone system can damage target organs, so the medication that suppress this system are useful in patients with hypertension. Valsartan is an Angiotensin II antagonist that produces anti-hypertensive effects. Valsartan inhibits the binding of angiotensin II with AT1 receptor that results in vasodilation, reduction of blood pressure and increase in sodium and water reception (Derg, 2014). Main side effects of Valsartan include constipation, dry mouth, dyspepsia, muscle cramps, drowsiness, insomnia, anxiety and upper respiratory infection (Healthline,2018).
Nurses need to monitor the vital signs regularly with patient is initially commenced on Valsartan and after that periodic checks-ups required during treatment. In case of hypotension, dose of diuretics and associated antihypertensive agents can be reduced or ceased temporarily.
Nurses need to monitor for fluid overload through various set of daily assessments and observations such as peripheral oedema, dyspnoea, drastic weight gain in short period and jugular venous distention (Hombar,2014).
Nurses need to give their patient information and education on medication and its side effects and how side effects can be managed to ensure medication adherence.
If signs of angioedema or orofacial swelling occurs. Immediately cease medication, ensure supportive treatment and monitor for airway compromise. (unbound medicine, 2019).
People with chronic kidney disease(CKD), commonly suffer from anaemia because of the kidney inability to producer enough natural erythropoietin, a hormone which promotes the red blood cell production by stimulating the bone marrow. Eprex, is a synthetic erythropoietin hormone which increases the production of red blood cells and decreases the need for blood transfusions to treat anaemia. Melanie blood result shows that her haemoglobin level is very low and require Eprex. (Healthdirect,2019).
Side effects include diarrhea, Oedema, Flu-like symptoms, hypertension and infection. (WebMD,2019)
● Haemodialysis patient having EPREX frequently require an increase in heparin dose because of an increase in packed cell volume to prevent coagulation. Risk of occlusion of dialysis system is involved, if heparinisation is not ideal for a patient (C. Health,2019).
● Female receiving EPREX therapy have chances of resuming menses, so nurses should discuss the possibility of potential pregnancy and need for contraception with Melanie the patient (C. Health,2019).
● In chronic kidney failure, electrolytes imbalance may occur, so electrolyte level should be monitored. If high serum potassium level is detected, then along with treatment of the hyperkalaemia, ceasing of EPREX administration should be considered until normal serum potassium level is achieved (C. Health,2019).
● Nurses need to measure the haemoglobin level in patient receiving EPREX therapy on a regular basis, 10g/L per month is an optimal increase in haemoglobin level in patients with chronic renal failure. Nurses need to ensure that haemoglobin level must not surpass 20 g/L per month, as it involves the risk of an increase in hypertension. When haemoglobin approaches 120 g/L, cessation of eprex should be considered. (C. Health,2019).
● Education and information on medication and its side effects to patient and family members. (C. Health,2019).
Glomerular filtration rate (GFR) – a value use to evaluate level of kidney function. Normal Kidney function are indicated if GFR value is 100-140 mls/min, while < 90 mls/min indicates mild Kidney failure and < 60mls/min moderate. When this value remains < 30 mls/min, it means kidney function has declined severely and < 15mls/min value refers to End-stage Kidney Failure and this situation is incompatible with life, without dialysis or transplantation. Melanie GFR value (15mls/min) indicates that she is suffering from ESKD and require haemodialysis (National Kidney Foundation,2019).
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HAEMOGLOBIN: Melanie blood result show that she is anaemic, which is a common risk factor of CKD. Erythropoietin (EPO), is a hormone produced by kidneys which induces the production of red blood cells from bone marrow. In ESKD, kidneys are unable to produce enough natural EPO to stimulate red blood cell production from bone marrow resulting in anaemia. In case of low haemoglobin level, body do not receive the oxygen it needs, and as a result patient feel easy tired, lethargic, short of breath and irregular heartbeat (Roger,2012).
TEACH BACK METHOD: Teach-back is a very effective communication technique for ensuring health literacy and information to patient and their families to eliminate any risks out of misunderstanding. It is also, an effective method to assist patient to practice autonomy and make their own independent health decisions. It is a technique to empower patients to better engage in their care. It also enhances health safety and yield positive outcomes by ensuring that the patients have correctly understood their conditions, treatment options and any other important information regarding their health. (Cindy,2015).
According to the teach-back method, provide Melanie all important information on available treatment options explaining all the advantages and risk-factors associated with each option. Ensure Melanie has easy access to the supportive health care -services. Ensure Melanie has access to education program and encourage her to participate in it to empower self -care and autonomy (Wong, et al., 2018).
According to teach back method explanation on haemodialysis therapy and why it is important to limit the fluid intake as well as the strategies Melanie can adopt to limit her fluid intake like: Choose diet with limited sodium and spicy food. Educate patient about the hidden fluid content of some foods such as watermelon, ice-creams, soup and gravy. Cold drinks are recommended over hot. Educate patient to keep themselves cool, as it helps to reduce thirst and need for drinks. Sipping is recommenced, as patient can enjoy the small liquid over longer period. Suggestion on using small glasses or cups for your drink and wisely distributing fluid limits over the day (DaVita,2019). Educate patient to record all fluid intake including treats such as ice. During summer, suggest patients to prefer ice over water. Juice can also be freeze and consumed to satisfy thirst. Tell Melanie importance of Using mouthwash or brushing teeth to battle dry mouth. Keep lips moist by using lip balm (RACGP,2019).
Tips to manage with your CKD:
Aim for a healthy weight and control your blood pressure. Always ask for information to monitor your kidney health and participate actively in treatment. Remain complained with medications and discuss any concerns with your health team. Seek dietitian advice to develop a diet plan. Choose health lifestyle and do physical exercise routinely. Keep healthy sleep pattern. Manage your stress and depression in healthy ways. (RACGP,2019).
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