Med-Surg - Renal System, part 7: Chronic Kidney Disease
by Cathy Parkes December 17, 2021 Updated: March 20, 2022 5 min read
Hi. I'm Cathy with Level Up RN. In this video, we are going to talk about chronic kidney disease, or CKD. At the end of the video, I'm going to give you guys a little knowledge check to test your understanding of some of the key facts I'll be covering in this video. So definitely, stay tuned for that. And if you have our Level Up RN medical-surgical flashcards, definitely, pull those out so you can follow along with me. Chronic kidney disease, or CKD, is the gradual, irreversible loss of kidney function. So this is differentiated from acute kidney injury, which is the sudden loss of kidney function that is often reversible. So risk factors associated with CKD include older age, dehydration, acute kidney injury, hypertension, diabetes. That is a key cause of CKD that I see all the time in the hospital. In addition, medications and autoimmune disorders such as lupus can lead to chronic kidney disease.
Signs and symptoms of CKD are typically related to the fact that we will have fluid volume overload. So the kidneys aren't working properly, and they're not getting rid of excess fluids. That fluid is backing up into the body, and it can cause jugular vein distension, hypertension, edema, crackles, dyspnea. Other signs and symptoms of CKD include pruritis, so it's like itchiness, as well as nausea and vomiting and something called uremic frost. So uremic frost is where we have crystallized urea deposits on the skin. So when we have protein that is broken down, so metabolized, we end up with urea. So that's a waste product of protein. And normally, that urea should be excreted in the urine. But when the kidneys aren't working properly, then that waste product can build up and cause that uremic frost. Chronic kidney disease also causes a number of electrolyte abnormalities.
So with CKD, we're going to have elevated potassium, phosphorus, and magnesium and decreased sodium and calcium. In addition, creatinine and BUN will be elevated. So those values are elevated anytime we have kidney dysfunction. And then hemoglobin and hematocrit will be decreased. This is because the kidneys normally make erythropoietin, which stimulates red blood cell production. But since the kidneys are messed up, they are not producing enough erythropoietin, which is why we have a decrease in blood levels. With a urinalysis, we may see hematuria, so blood in the urine, as well as proteinuria, so protein in the urine. In terms of the staging of CKD, we have stage 1, 2, 3, 4, and 5, and those stages depend on the patient's GFR, or glomerular filtration rate. So when we get to stage 5, that is the end-stage renal disease, GFR will be less than 15.
So in terms of treatment, medications that can be used in the treatment of CKD include diuretics to get rid of excess fluid, sodium polystyrene to help bring down those potassium levels. So elevated potassium can cause dysrhythmias, which can be life-threatening, so we need to bring down those levels. Epoetin alfa can be administered in order to boost up the red blood cells. Because again, the erythropoietin that the kidneys are supposed to produce, they're not producing that as much. In addition, we can provide a phosphorus binding agent to bring bring down levels of phosphorus and antihypertensive agents to help bring down the blood pressure and then vitamin and mineral supplements as well.
In terms of procedure, as a patient's CKD progresses, they will likely be needing dialysis. And eventually, they will need a kidney transplant. In terms of nursing care, we're going to want to monitor our patients eyes and nose and their daily weight. And we're going to need to restrict fluid, sodium, as well as potassium, phosphorus, and magnesium. And then protein restriction may be in place as well. But it really depends because if a patient is getting dialysis, then protein is lost with each exchange. So we don't want the protein to get too low, so the patient will need to work with a dietitian to figure out that exact right amount of protein that they should be consuming. And then because we have this fluid volume overload, we also need to protect the patient's skin from injury. Because any time we have all this extra fluid and edema, it really makes the skin very fragile, almost like tissue paper. So we want to handle our patient with care.
In terms of patient teaching for CKD, you want to advise your patient to avoid nephrotoxic medications such as NSAIDs. They should also avoid contrast dye, which is very difficult on the kidneys. And they should avoid magnesium-containing antacids. So with CKD, we already have issues with high levels of magnesium. So those antacids can make things worse. Like I mentioned before, the patient will need to work with a dietitian to understand their restrictions in terms of fluid intake, protein intake, and electrolytes. And then when the patient's CKD gets to the point where they're GFR is very low, so when they have end-stage renal disease, they will need dialysis.
So in order to get dialysis, they need an AV fistula. So an AV fistula is a surgically created connection between the artery and vein that allows for hemodialysis access. So when your patient has an AV fistula, we never want to take blood pressure or do a venipuncture on that arm, super important. So you need to alert your patient to that and also put a big sign above the patient's bed that says no blood pressure or blood draws on the left arm or the right arm, depending on where they have the AV fistula. And you also want to alert your team members to that as well. You want to advise your patient to not carry heavy items on that arm or sleep on that arm. And when your patient gets a new fistula, then they should perform hand exercises in order to mature that fistula.
All right. You guys ready for a quiz? For this quiz, I want you to tell me whether the following lab values are increased or decreased with CKD. You ready? First one is creatinine, increased. GFR, decreased. Potassium, increased. Phosphorus, increased. Fluid volume, increased. Red blood cells, decreased. Calcium, decreased. Magnesium, increased. All right. I hope you did well with that. I know it's a lot to remember. That's why the flashcards were my best friend in nursing school, because it really takes repetition for all of these different facts to sink in. Take care and good luck with studying.
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