prepared by d. chaplin chronic kidney disease. prepared by d. chaplin chronic kidney disease...
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Chronic Kidney Disease
Chronic Kidney Disease
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Chronic Kidney Disease
Progressive, irreversible damage to the nephrons and glomeruli
Progressive, irreversible damage to the nephrons and glomeruli
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Major causes are
Diabetes and high blood pressure Type 1 and type 2 diabetes mellitus High blood pressure (hypertension) Glomerulonephritis Polycystic kidney disease Use of analgesics - acetaminophen(Tylenol) and ibuprofen (Motrin,
Advil Clogging and hardening of the arteries(atherosclerosis) Obstruction of the flow of urine by stones, an enlarged prostate,
strictures (narrowings), or cancers. HIV infection, sickle cell disease, heroin abuse, amyloidosis, kidney
stones, chronic kidney infections, and certain cancers.
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Kidney functions - monitored regularly
Diabetes mellitus type 1 or 2 High blood pressure High cholesterol Heart disease Liver disease Amyloidosis Sickle cell disease Systemic Lupus erythematosus Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia Vesicoureteral reflux (a urinary tract problem in which urine travels the
wrong way back toward the kidney) Require regular use of anti-inflammatory medications A family history of kidney disease
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Chronic Renal FailureEnd Stage Renal Disease (ESRD)
Protein and waste metabolism accumulates in the blood (azotemia)
90% of kidney function is lost (kidney cannot adequately function)
Hypothesis: Nephrons remains intact, others progressively destroyed.
Adaptive response maintains function until ¾ are destroyed
Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately
Protein and waste metabolism accumulates in the blood (azotemia)
90% of kidney function is lost (kidney cannot adequately function)
Hypothesis: Nephrons remains intact, others progressively destroyed.
Adaptive response maintains function until ¾ are destroyed
Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately
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Stage DescriptionGFR*
mL/min/1.73m2
1Slight kidney damage with normal or increased filtration
More than 90
2 Mild decrease in kidney function 60-89
3Moderate decrease in kidney function
30-59
4Severe decrease in kidney function
15-29
5 Kidney failureLess than 15 (or dialysis)
Table 1. Stages of Chronic Kidney Disease*GFR is glomerular filtration rate, a measure of the kidney's function.
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Modifiable Factors
-Diabetic Mellitus-Hypertension-Increase Protein and Cholesterol Intake-Smoking-Use of analgesics
Non-Modifiable Factors-Hereditary-Age greater than 60 years old-Gender-Race
Decreased renal blood flowPrimary kidney disease
Damage from other diseases
Urine outflow obstruction
Decreased glomerular
filtration
Serum Creatinine
BUN
Hypertrophy of remaining nephrons
Inability to concentrate urine
Dilute Polyuria
Dehydration
Further loss of nephron function
Loss of nonexcretory renal
function
Failure to convert inactive forms of
calcium
Calcium absorption
1
Failure to produce
eryhtropoietin
AnemiaPallor
Impaired insulin action
Erratic blood glucose levels
Production of lipids
Advanced atherosclerosis
Immune disturbance
s
Delayed wound healing
Infection
Disturbances in reproduction
Libido Infertility
2a
Loss of Sodium in Urine
Hyponatremia
Chro
nic
Kid
ney
Dis
ease
-
Pat
hop
hys
iolo
gy
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Hypocalcemia Osteodystrophy
Excretion of nitrogenous
waste
Uremia
BUN,CreatinineUric Acid
Proteniuria
Peripheral nerve
changes
Pericarditis
CNS changes
Altered Taste
Bleeding Tendencies
Decreased sodium
reabsorption in tubule
Water Retention
HypertensionHeart Failure
Edema
Decreased potassium excretion
Hyperkalemia
Decreased phosphateexcretion
Hyperphosphatemia
Decreased calcium
absorption
Hypocalcemia
Hyperparathyroidism
Decreased potassium excretion
Increased potassium
Decreased hydrogen excretion
Metabolic acidosis
12a
Loss of excretory renal function
Pruritus
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Weakness and tiredness/ fatigue.
Nocturia is often an early symptom
Itchiness of the skin which can progressively worsen
Pale skin which is easily bruised
Muscular twitches, cramps and pain
Pins and needles in the hands and feet
Nausea
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As the condition worsens the symptoms progress to:
Oedema (swelling of the face, limbs and abdomen) Oliguria (greatly reduced volume of urine) Dyspnoea (breathlessness) Vomiting Confusion Seizures Severe lethargy Very itchy skin Breath that smells of ammonia
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Associated complications of chronic Kidney Disease would be:
Anaemia, mostly due to deficiency of
erythropoietin
Bleeding which is caused by impairment of platelet
function
Metabolic Bone Disease (known as Renal
Osteodystrophy)
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Cardiovascular Disease
- hypertension, (which may further exacerbate
the renal failure)
-accelerated atherosclerosis
-pericarditis. 80% of those with chronic renal
failure develop hypertension which must be
treated
Associated complications of chronic Kidney Disease would be:
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Nervous system – neuropathy caused by the loss of myelin from nerve fibres – may improve when dialysis is established
Gastrointestinal complications - anorexia, nausea and vomiting, and a higher incidence of peptic ulcer disease
Associated complications of chronic Kidney Disease would be:
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Skin disease – itching, which is attributed to the retention of metabolic waste products. It often improves with dialysis. Dry skin can also occur
Muscle dysfunction - myopathy leading to muscle cramps and the “restless leg” syndrome
Associated complications of chronic Kidney Disease would be:
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Metabolic dysfunction - involving lipids, insulin and uric acid (gout). Metabolic acidosis is also associated
Associated complications of chronic Kidney Disease would be:
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Diagnosis
Urine Tests Urinalysis Twenty-four hour urine
tests Glomerular filtration
rate (GFR) Blood Tests Creatinine and urea
(BUN) in the blood
Estimated GFR (eGFR) Electrolyte levels and
acid-base balance Blood cell counts Other tests Ultrasound: Biopsy
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Treatment Modalities
Decrease fluid 1000ml/day
Decrease protein (.5-1kg body weight)
Decrease sodium (1-4gm variable)
Decrease potassium
Decrease phosphorous (<1000mg/day)
Dialysis (periotoneal, hemodialysis)
RBC, Vitamin D (calcitrol replacement) etc.
Decrease fluid 1000ml/day
Decrease protein (.5-1kg body weight)
Decrease sodium (1-4gm variable)
Decrease potassium
Decrease phosphorous (<1000mg/day)
Dialysis (periotoneal, hemodialysis)
RBC, Vitamin D (calcitrol replacement) etc.
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Dialysis Hemodialyis(Hemo)Peritoneal (PD)
General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another
Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)
Peritoneal – Peritoneal membrane is the semi permeable membrane
General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another
Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)
Peritoneal – Peritoneal membrane is the semi permeable membrane
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Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through
Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment
Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through
Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment
Osmosis - movement fluid from an area of < to > concentration of solutes (particles)
Osmosis - movement fluid from an area of < to > concentration of solutes (particles)
Osmosis-Diffusion-Ultrafiltration
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Peritoneal Dialysis
Catheter placement – anterior abdominal wallTenckoff (25cm length with cuff anchor and
migration)Dialysis solution (1-2 liters sometimes smaller)Three phases of PD
Inflow (fill) approximately 10 minutes, could be in cycles)
Dwell (equilibration) (approximately 20-30 min or 8 hours+)
Drain (approximately 15 minutes) These 3 phases are called Exchanges
Catheter placement – anterior abdominal wallTenckoff (25cm length with cuff anchor and
migration)Dialysis solution (1-2 liters sometimes smaller)Three phases of PD
Inflow (fill) approximately 10 minutes, could be in cycles)
Dwell (equilibration) (approximately 20-30 min or 8 hours+)
Drain (approximately 15 minutes) These 3 phases are called Exchanges
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Peritoneal Dialysis
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Hemodialysis
Vascular access for high blood flow
Shunts, (teflon, external)
Arteriovenous fistulas and grafts (AV)
Anastomosis between an artery and vein
Fistulas are native vessels (4-6 wks maturity)
Grafts are artificial/synthetic material
Vascular access for high blood flow
Shunts, (teflon, external)
Arteriovenous fistulas and grafts (AV)
Anastomosis between an artery and vein
Fistulas are native vessels (4-6 wks maturity)
Grafts are artificial/synthetic material
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Hemodialysis
AV Fistula CommunicationAV Fistula Communication
AV Graph AccessAV Graph Access
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Hemodialysis
Hemodialysis MachineHemodialysis MachineHemodialysis CircuitHemodialysis Circuit
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PD Advantages and Disadvantages
Immediate initiation
Less complicated
Portable (CAPD)
Fewer dietary restrictions
Short training time
Less cardio stress
Choice for diabetics
Immediate initiation
Less complicated
Portable (CAPD)
Fewer dietary restrictions
Short training time
Less cardio stress
Choice for diabetics
Bacterial/chemical peritonitis
Protein lossExit site of catheterSelf imageHyperglycemiaSurgical placement of
catheterMultiple abdominal
surgery
Bacterial/chemical peritonitis
Protein lossExit site of catheterSelf imageHyperglycemiaSurgical placement of
catheterMultiple abdominal
surgery
AdvantagesAdvantages DisadvantagesDisadvantages
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Hemo Advantages & Disadvantages
Rapid fluid removalRapid removal of urea
& creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at
the bedside
Rapid fluid removalRapid removal of urea
& creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at
the bedside
Vascular access problems
Dietary & fluid restrictions
HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist
Vascular access problems
Dietary & fluid restrictions
HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist
AdvantagesAdvantages DisadvantagesDisadvantages
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Disequalibrium SyndromeFluid removal and decrease in BUN during
hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures
Treatment: Hypertonic saline, Normal saline
Fluid removal and decrease in BUN during hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures
Treatment: Hypertonic saline, Normal saline
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The following are general dietary guidelines:
Protein restriction: Salt restriction Fluid intake: Potassium restriction: Phosphorus restriction: Control blood pressure and/or diabetes; Stop smoking; and Lose Excess Weight
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Avoided or used with caution:
Certain analgesics: Aspirin; ibuprofen Fleets or phosphosoda enemas because of their high
content of phosphorus Laxatives and antacids containing magnesium and
aluminum such as magnesium hydroxide Ulcer medication H2-receptor
antagonists: cimetidine, ranitidine Decongestants such as pseudoephedrine especially if
they have high blood pressure Herbal medications
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Nursing Care Pre, Post Dialysis
Weigh before & after
Assess site before & after (bruit, thrill, infection, bleeding etc.)
Medications (precautions before & after)
Vital signs before and after etc.
Weigh before & after
Assess site before & after (bruit, thrill, infection, bleeding etc.)
Medications (precautions before & after)
Vital signs before and after etc.
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Renal Transplant
Living and Cadaveric donors
Predialysis: obtain a dry weight free of excess fluids and toxins
More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement
Delay may increase ATN
Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)
Living and Cadaveric donors
Predialysis: obtain a dry weight free of excess fluids and toxins
More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement
Delay may increase ATN
Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)
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Complications Post Transplant
Rejection is a major problem
Hyperacute rejection: occurs within minutes to hours after transplantation
Renal vessels thrombosis occurs and the kidney dies
There is no treatment and the transplanted kidney is removed
Rejection is a major problem
Hyperacute rejection: occurs within minutes to hours after transplantation
Renal vessels thrombosis occurs and the kidney dies
There is no treatment and the transplanted kidney is removed
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Immunological Compatibility of Donor and Recipient
Done to minimize the destruction (rejection) of the transplanted kidney
HUMAN LEUKOCYTE ANTIGEN (HLA)
This gives you your genetic identity (twins share identical HLA)
HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.
Done to minimize the destruction (rejection) of the transplanted kidney
HUMAN LEUKOCYTE ANTIGEN (HLA)
This gives you your genetic identity (twins share identical HLA)
HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.
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Immunological Analysis
WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney
A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation
WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney
A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation
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Immulogical AnalysisMIXED LYMPHOCYTE CULTURE
The donor and recipient lymphocytes are mixed. Result = HIGH SENTIVITY, this is
contraindicated for renal transplantation.
ABO BLOOD GROUPING
ABO blood group must be compatible
MIXED LYMPHOCYTE CULTURE
The donor and recipient lymphocytes are mixed. Result = HIGH SENTIVITY, this is
contraindicated for renal transplantation.
ABO BLOOD GROUPING
ABO blood group must be compatible
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Surgery
LLQ of the abdomen outside of the peritoneal cavity
Renal artery and vein anastomosed to the corresponding iliac vessels
Donor ureters are tunneled into the recipients’ bladder.
LLQ of the abdomen outside of the peritoneal cavity
Renal artery and vein anastomosed to the corresponding iliac vessels
Donor ureters are tunneled into the recipients’ bladder.
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Complications Post Transplant
Acute Rejection: occurs 4 days to 4 months after transplantation
It is not uncommon to have at least one rejection episode
Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)
Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys
Acute Rejection: occurs 4 days to 4 months after transplantation
It is not uncommon to have at least one rejection episode
Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)
Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys
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Complications Post Transplant
Chronic Rejection: occurs over months or years and is irreversible.
The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum creatinine levels
Supportive treatment, difficult to manage
Replace on transplant list
Chronic Rejection: occurs over months or years and is irreversible.
The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum creatinine levels
Supportive treatment, difficult to manage
Replace on transplant list
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Complications Post TransplantInfectionHypertensionMalignancies (lip, skin,
lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage
InfectionHypertensionMalignancies (lip, skin,
lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage
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100 patients with eGFR < 60
(Tuesday morning in Outpatients)
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Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)
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Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD
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The majority of patients with CKD 1-3 do not progress to ESRF.
Their risk of cardiovascular death is higher than their risk of progression.
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Optimise risk factors
Cardiovascular disease Proteinuria Hypertension Diabetes Smoking Obesity Exercise tolerance
TAKE HOME MESSAGE
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Nursing Care Plan of a Patient With ESRD
• Nursing diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.• Goal: Maintenance of ideal body weight without excess fluid.
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Assess fluid status (Daily weight, intake and output balance, skin turgor and presence of edema, distention of neck veins, blood pressure, pulse rate, and rhythm, respiratory rate and effort).
Limit fluid intake to prescribed volume. Identify potential sources of fluid (medications and fluids
used to take medications; oral and intravenous, foods).
Explain to patient and family rationale for restriction.
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Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea, vomiting, and dietary restrictions.
• Goal: Maintenance of adequate nutritional intake.
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• Interventions: The nurse should: Assess nutritional status (weight changes, serum electrolyte,
BUN, creatinine, protein, transferrin, and iron levels). Assess patient’s nutritional dietary patterns (diet history, food
preferences, calorie counts). Assess for factors contributing to altered nutritional intake
(Anorexia, nausea, or vomiting, diet unpalatable to patient, depression, lack of understanding of dietary restrictions, stomatitis).
Provide patient’s food preferences within dietary restrictions. Promote intake of high biologic value protein foods
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Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Deficient knowledge regarding condition and treatment.• Goal: Increased knowledge about condition and related treatment.
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• Interventions: The nurse should: Assess understanding of cause of renal failure, its meaning
and consequences, and its treatment. Provide explanation of renal function and consequences of
renal failure at patient’s level of understanding and guided by patient’s readiness to learn.
Provide oral and written information as appropriate about renal function and failure, fluid and dietary restrictions, medications, reportable problems, signs, and symptoms, follow-up schedule, community resources, and treatment options.
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Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure.• Goal: Participation in activity within tolerance.• Interventions: The nurse should: Assess factors contributing to fatigue (anemia, fluid and electrolyte imbalances, retention of waste products, depression) Promote independence in self-care activities as tolerated; assist if fatigued. Encourage alternating activity with rest. Encourage patient to rest after dialysis treatments.
52TAKE HOME MESSAGE
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THANK YOU
Have a check on your blood pressureSugar & Salt / year