25/09/2017

ASUHAN KEPERAWATAN PADA PASIEN

DENGAN CHRONIC KIDNEY DISEASES

Titis Kurniawan, MNS

Capaian Pembelajaran
Mahasiswa mampu menjelaskan:
1. CKD konsep umum
2. Pathophysiology (etiology, pato-mechanism,
clinical manifestation)
3. Nursing care; pengkajian, masalah
keperawatan, & intervensi keperawatan

1
 25/09/2017

CKD

Progressive & Irreversible
loss of kidney function

Leading causes:

Disbetes

Hipertension

Irreversible = GFR <

60ml/min for 3 months or
longer

Result in; retained

substances; urea,
creatinine, electrolytes,
water, & others

2
 25/09/2017

Pato-mechanism

Pato-Mechanism

3
 25/09/2017

.Pato-mechanism
Other causes:
Systemic diseases; Lupus &
rheumatoid arthritis
Infection
Medication
Toxins

Clinical manifestations

Water
retention

4
 25/09/2017

..Clinical manifestation

..Clinical manifestation

5
 25/09/2017

Pato-Mechanism
https://www.youtube.com/watch?v=bwwQd7
xkHNc
https://www.youtube.com/watch?v=JjcqY95H
R1o

Modifiable Factors
Non-Modifiable Factors -Diabetic Mellitus
-Hereditary -Hypertension
-Age greater than 60 years old -Increase Protein and
-Gender Cholesterol Intake
-Race -Smoking
-Use of analgesics

Decreased renal blood flow

Primary kidney disease
Damage from other diseases
Urine outflow obstruction

BUN Decreased glomerular Serum

filtration Creatinine

Hypertrophy of
remaining nephrons
Dilute
Polyuria
Inability to Loss of Sodium in
Hyponatremia
concentrate urine Urine
Dehydration

Further loss of
nephron function

Loss of nonexcretory 2
renal function a

Failure to convert Failure to Impaired Production of Immune Disturbances in

inactive forms of produce insulin action lipids disturbances reproduction
calcium eryhtropoietin

Advanced
Calcium Erratic blood
Anemia atherosclerosis Delayed Infection Libido Infertility
absorption glucose
Pallor levels wound
healing
1

6
 25/09/2017

2
Hypocalcemia 1 a
Osteodystrophy
Loss of excretory renal
function

Excretion of Decreased Decreased Decreased Decreased

nitrogenous sodium potassium phosphate hydrogen
waste reabsorption in excretion excretion excretion
tubule
Uremia
Water Retention Hyperkalemia Hyperphosphatemia Metabolic
acidosis
BUN,
Creatinine Decreased
Uric Acid calcium
Hypertension absorption
Heart Failure
Edema
Proteniuria
Hypocalcemia

Hyperparathyroidism
Peripheral
nerve
Decreased potassium
changes
excretion

Pericarditis
Increased
potassium

CNS
changes

Pruritus

Altered Taste

Bleeding
Tendencies

Nursing Care
Assessment:
Chief complain; PQRST
Health History;
Reason admitted to Hospital
Adherence; diet, fluid intake, dyalisis,
etc

7
 25/09/2017

Assessment:
 Physical Exam;
 General ;
consciousness,
edema,
 IDWG
 Vital signs,
 Breathing sound
 Calculate I O

Collaborative Care
Conservative therapy
Correction of extracellular fluid volume
overload or deficit
Nutritional therapy
Erythropoietin therapy
Calcium supplementation, phosphate binders

8
 25/09/2017

Collaborative Care (Contd)

Drug Therapy
Hyperkalemia
IV insulin
IV glucose to manage hypoglycemia
IV 10% calcium gluconate
Sodium bicarbonate
Shift potassium into cells
Correct acidosis

Collaborative Care
Drug Therapy (contd)
Hyperkalemia (contd)
Sodium polystyrene sulfonate (Kayexalate)
Cation-exchange resin
Resin in bowel exchanges potassium for sodium

9
 25/09/2017

Collaborative Care
Drug Therapy (contd)
Hyperkalemia (contd)
Sodium polystyrene sulfonate (Kayexalate) (contd)
Evacuates potassium-rich stool from body
Educate patient that diarrhea may occur due to laxative
in preparation

Collaborative Care (Contd)

Drug Therapy
Hypertension
Weight loss
Lifestyle changes
Diet recommendations
Sodium and fluid restriction

10
 25/09/2017

Collaborative Care
Drug Therapy (contd)
Hypertension (contd)
Antihypertensive drugs
Diuretics
-Adrenergic blockers
Calcium channel blockers

Collaborative Care
Drug Therapy (contd)
Hypertension (contd)
Antihypertensive drugs (contd)
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin receptor blocker agents

11
 25/09/2017

Collaborative Care
Drug Therapy (contd)
Renal osteodystrophy
Phosphate intake restricted to
<1000 mg/day

Collaborative Care
Drug Therapy (contd)
Renal osteodystrophy (contd)
Phosphate binders
Calcium carbonate (Tums)
Bind phosphate in bowel and excreted
Sevelamer hydrochloride (Renagel)
Lowers cholesterol and LDLs

12
 25/09/2017

Collaborative Care
Drug Therapy (contd)
Renal osteodystrophy (contd)
Phosphate binders (contd)
Should be administered with each meal
Side effect: Constipation

Collaborative Care
Drug Therapy (contd)
Renal osteodystrophy (contd)
Supplementing vitamin D
Calcitriol (Rocaltrol)
Serum phosphate level must be lowered before
administering calcium or vitamin D

13
 25/09/2017

Collaborative Care
Drug Therapy (contd)
Renal osteodystrophy (contd)
Controlling secondary hyperparathyroidism
Calcimimetic agents
Cinacalcet (Sensipar)
SensiNvity of calcium receptors in parathyroid glands
Subtotal parathyroidectomy

Collaborative Care (Contd)

Drug Therapy
Anemia
Erythropoietin
Epoetin alfa (Epogen, Procrit)
Administered IV or subcutaneously
Increased hemoglobin and hematocrit in 2 to 3 weeks
Side effect: Hypertension

14
 25/09/2017

Collaborative Care
Drug Therapy (contd)
Anemia (contd)
Iron supplements
If plasma ferritin <100 ng/ml
Side effect: Gastric irritation,
constipation
May make stool dark in color

Collaborative Care
Drug Therapy (contd)
Anemia (contd)
Folic acid supplements
Needed for RBC formation
Removed by dialysis
Avoid blood transfusions

15
 25/09/2017

Collaborative Care (Contd)

Drug Therapy
Dyslipidemia
Goal
Lowering LDL below 100 mg/dl
Triglyceride level below 200 mg/dl
Statins
HMG-CoA reductase inhibitors
Most effective for lowering LDL

Collaborative Care
Drug Therapy (contd)
Dyslipidemia (contd)
Fibrates
Fibric acid derivatives
Most effective for lowering triglycerides
Can also decrease HDLs

16
 25/09/2017

Collaborative Care (Contd)

Drug Therapy
Complications
Drug toxicity
Digitalis
Antibiotics
Pain medication (Demerol, NSAIDs)

Collaborative Care (Contd)

Nutritional Therapy
Protein restriction
0.6 to 0.8 g/kg body weight/day
Water restriction
Intake depends on daily urine output

17
 25/09/2017

Collaborative Care (Contd)

Nutritional Therapy
Sodium restriction
Diets vary from 2 to 4 g depending on
degree of edema and hypertension
Sodium and salt should not be equated
Patient should be instructed to avoid
high-sodium foods
Salt substitutes should not be used because they
contain potassium chloride

Collaborative Care
Nutritional Therapy (contd)
Potassium restriction
2 to 4 g
High-potassium foods should be avoided
Oranges
Bananas
Tomatoes
Green vegetables

18
 25/09/2017

Collaborative Care
Nutritional Therapy (contd)
Phosphate restriction
1000 mg/day
Foods high in phosphate
Dairy products
Most foods high in phosphate are also high in
calcium

Collaborative
Dyalisis; HD/PD
https://www.youtube.com/watch?v=mi34xCfmL
hw

19
 25/09/2017

Nursing Management
Nursing Assessment
Complete history of any existing renal disease,
family history
Long-term health problems
Dietary habits

Nursing Management
Nursing Diagnoses
Excess fluid volume
Risk for injury
Imbalanced nutrition: Less than body
requirements
Grieving
Risk for infection

20
 25/09/2017

Nursing Management
Planning
Overall goals
Demonstrate knowledge and ability to comply
with therapeutic regimen
Participate in decision making
Demonstrate effective coping strategies

Nursing Management
Planning
Overall goals (contd)
Continue with activities of daily living within
psychologic limitations

21
 25/09/2017

Nursing Management
Nursing Implementation
Health promotion
Identify individuals at risk for CKD
History of renal disease
Hypertension
Diabetes mellitus
Repeated urinary tract infection
Regular checkups and changes in urinary
appearance, frequency, and volume should be
reported

Nursing Management
Nursing Implementation (Contd)
Acute intervention
Daily weight
Daily BPs
Identify signs and symptoms of fluid overload
Identify signs and symptoms of hyperkalemia
Strict dietary adherence

22
 25/09/2017

Nursing Management
Nursing Implementation (Contd)
Acute intervention (contd)
Medication education
Motivate patients in management of their disease

Nursing Management
Nursing Implementation (Contd)
Ambulatory and home care
When conservative therapy is no longer effective,
HD, PD, and transplantation are treatment options
Patient/family need clear explanation of dialysis
and transplantation

23
 25/09/2017

Nursing Management
Evaluation
Maintenance of ideal body weight
Acceptance of chronic disease
No infections
No edema
Hematocrit, hemoglobin, and serum albumin
levels in acceptable range

24