Takeaways:

• Millions of adults in the United States have or are at risk for developing chronic kidney disease (CKD); incidence continues to rise and CKD impacts many aspects of health.
• Nurses practicing in a variety of inpatient and outpatient settings encounter patients at all stages of CKD.
• The three main nursing care goals are preventing and/or slowing disease progression, promoting physical and psychosocial well-being, and monitoring disease and related processes.

Approximately 30 million American adults have chronic kidney disease (CKD), an additional 20 million are at risk for developing it, and a variety of factors (such as the pervasiveness of obesity and chronic health conditions) may increase its incidence. Nurses will continue to encounter patients with CKD in all practice settings, where they will help manage the disease and prevent progression. This article provides an overview of CKD in adults and care goals for nurses who want to ensure that they can help meet the needs of patients with CKD. (Visit the American Nurse website for an overview of kidney function.)

Overview

CKD is a structural and/or functional abnormality of the kidney that lasts 3 months or longer. It’s a progressive and chronic condition that affects many aspects of the patient’s health.

Common causes and risk factors

The top three causes of CKD (in order of incidence) are diabetes, hypertension, and glomerulonephritis. Diabetes and hypertension cause approximately 70% of CKD cases. Other risk factors include:

• congenital abnormalities (for example, poly­cystic kidney disease, Alport syndrome, sickle cell disease)
• urinary tract or systemic infections
• family history of CKD
• urinary or kidney stones
• history of acute kidney injury or failure
• urinary tract obstruction
• autoimmune disease (for example, scleroderma, systemic lupus erythematosus)
• nephrotoxin exposure from sources such as over-the-counter pain medications (for example, aspirin or ibuprofen), prescribed pain relievers (for example, oxycodone or naproxen), other medications (for example, antibiotics or antineoplastics), pesticides, and heavy metals (for example, lead, mercury, or arsenic)
• age 60 or older and ethnicity (African American, American Indian, Asian, Pacific Islander, or Hispanic).

Early-stage CKD can be asymptomatic, so recognizing risk factors and alerting patients and providers to them is crucial for prevention, early diagnosis, and optimal disease management.

Diagnosis

In the past, CKD diagnosis was based on serum creatinine results. However, recent evidence suggests that’s not an accurate measure because of variations in patients’ body size, weight, and muscle mass. Now, CKD is diagnosed based on glom­erular filtration rate (GFR), which is a calculated value that takes into account body size, weight, and muscle mass and includes modifications for ethnicity. GFR is automatically calculated and reported by laboratories as part of serum results (for example, as part of a comprehensive metabolic panel). Labs calculate the rate using the Modification of Diet in Renal Disease or the Chronic Kidney Disease Epidemiology

Collaboration formulas. Other tests, such as urinalysis and serum results, also are important in CKD diagnosis and management. For example, a provider may find that a patient has decreased serum hemoglobin and hematocrit values that require prescribing a synthetic erythropoietin, such as epoetin alfa. (Visit the American Nurse website to view a list of CKD diagnostic tests.)

Staging and symptoms

As with many chronic diseases, trended data (or data collections over time) can be used to help manage CKD. Typically, interventions are planned based on CKD stage and how a patient feels physically and mentally. Stage is determined mainly based on GFR and the presence of kidney damage. (See CKD staging.)

Due to the kidneys’ compensatory abilities, symptoms occur gradually and may not become obvious until CKD is advanced. In earlier stages (1 to 3), patients may be asymptomatic or have subtle, nonspecific symptoms that are attributed to other conditions. By the time patients experience overt symptoms (stages 3 to 5), typically 80% to 90% of kidney function has been destroyed. (Stage 3 CKD may be considered early or late depending on many factors, including diagnostic test results and how a patient feels.) (See CKD symptoms.)

Complications

CKD complications include heart failure, hypertension, hypervolemia, arrhythmias, anemia, pulmonary edema, anorexia, seizures, stroke, convulsions, coma, renal osteodystrophy, amenorrhea, and erectile dysfunction. CKD also can advance to end-stage renal disease (ESRD). Patients with ESRD may die from complications of their disease, typically from cardiovascular-related events.

Nursing care goals

Nurses care for adults with various stages of CKD in a variety of inpatient and outpatient settings. Regardless of CKD stage, the three main nursing care goals are:

• prevent or slow disease progression
• promote physical and psychosocial well-being
• monitor disease and treatment complications.

Prevent or slow disease progression

Identifying and managing risk factors is the best way to prevent or slow CKD progression. Collaborate with patients and providers to target modifiable risk factors, specifically focusing on diabetes and hypertension management to keep glucose levels and blood pressure readings within appropriate target ranges. A combination of self-management techniques and medication therapies guide management of these chronic comorbidities.

Promote physical and psychosocial well-being

Provide patient-specific education to help patients take charge of their condition and promote well-being. Focus education on a broad overview of CKD, treatment, and self-management techniques. Specific educational needs will depend on the patient’s baseline knowledge, CKD stage, and current and/or future treatment plans. Conclude all education with an evaluation to gauge the patient’s understanding. Be particularly sensitive to patients’ psychological needs.

Overview. Your overview of CKD should include information about normal kidney function, common causes and risk factors, diagnostic testing, staging, symptoms, and complications. To identify specific areas of educational need, start with questions such as, “What do you know about your illness?” “What would you like to know about your illness?” and “What would you like to know about treating your illness?”

Treatment. Early-stage CKD treatment includes medications, appointments, and many lifestyle changes. Late-stage treatment also may include renal replacement therapies (RRTs), which require a strong support system.

Treatment education should occur regularly. In early-stage CKD, focus on engaging patients in self-management and care plans to slow progression. As CKD progresses, patients will need education about RRTs—hemodialysis, peritoneal dialysis, or kidney transplant. Many choices exist within each therapy. For example, hemodialysis can be provided at home or at a dialysis center, at night or during the day. Peritoneal dialysis can be continuous or intermittent. Transplants can come from a living or deceased donor. Several considerations go into deciding which RRT is best for the patient, including patient preference, which best suits the patient’s daily life (including social, home, body image, activities, and employment considerations), options available in the patient’s area, clinical contraindications, social support systems, and skill or ability to complete therapy requirements. Provide patients with information about these topics and welcome questions, concerns, and comments. (See RRT patient education tips.)

Throughout disease progression, ask patients about their future treatment plans (“Have you thought about what treatments you may or may not want in the future?”). Share patients’ answers with providers to help develop care plans.

Self-management. Maintaining a healthy weight is key to CKD self-management. Talk to patients about healthy eating and activity habits. Some patients may require specific dietary modifications because of kidney function changes. For example, depending on individual patient requirements, some electrolytes (such as potassium, sodium, and phosphorus) may need to be limited. Review any provider-prescribed restrictions with patients and verify their understanding, including what foods to eat and avoid. In general, encourage patients to eat a variety of foods that are fresh, lean, low-fat, low-sugar, and low-cholesterol.

Explain to patients that avoiding alcohol and nephrotoxins will help slow CKD progression. If a patient smokes, work with him or her to develop an individualized cessation plan. In addition, educate patients about how to protect themselves from injury and infection. For example, explain that they should wash their hands frequently, avoid ill family and friends, and remove safety hazards (for example, throw rugs and exposed power cords) from the home. Teach patients how to recognize signs and symptoms of infection and to report them to healthcare providers.

Care plans developed collaboratively between engaged patients and the care team can improve outcomes. Even if you’re not involved in treatment decisions, you can support patients by sharing information to help them understand their treatment. Explain treatment options and what each involves (including benefits, adverse events, and how to manage complications); discuss how treatment may impact their daily lives; and provide information about treatment locations in the area, transportation, and other support services. Talk to patients about the importance of adhering to medications and other prescribed treatments, and encourage them to ask questions and voice concerns.

Assess patients’ self-management abilities before and after educational sessions. Ask questions, such as: “How is your physical and/or emotional health?” “What are your worries or what concerns you most?” “What’s important for you to achieve?” “What are your priorities?” “What would improve your quality of life and well-being?” and “How are you and your loved ones handling your illness?” Based on the answers, provide education and resources to help patients improve their self-management skills.

Psychological needs. Keep in mind that patients with CKD are at risk for many psychosocial issues, such as anxiety, depression, and stress. For example, Casey and colleagues’ systematic review of patients beginning hemodialysis found that they felt vulnerable because of their access site and related procedures, disfigured by their therapy access site, their body image was altered, and their life had been encroached on. They also felt anxious because they had to confront decisions they wanted to avoid. Patients who undergo transplants may feel guilty, especially if they received a deceased-donor transplant.

The complex and lifelong nature of the CKD diagnosis will present many challenges and concerns. For example, many patients take several medications, conform to dietary and other restrictions, travel to appointments and treatments, experience employment effects, may feel they’re a burden on their loved ones, and pay for expensive medications and therapies. In addition, their self-image may be altered as a result of their disease and treatments. Assess patients’ psychosocial status and coping mechanisms, and help them identify strategies, resources, and interventions to support their well-being.

Monitor disease and treatment complications

CKD can result in several complications (such as fluid overload, electrolyte imbalances, and anemia) that will require treatment. In collaboration with patients and pro­viders, nurses help deliver treatment by assessing, planning, implementing, and evaluating care plans. For example, if your patient is experiencing fluid overload, you may need to carry out provider orders that include applying fluid restrictions and/or administering diuretic medications. Electrolyte imbalances may require dietary changes and/or medication administration. Use the nursing process when performing these treatments, and frequently and promptly com­municate with patients and providers to help improve outcomes. Your accurate and thorough nursing assessment data will help in revising treatment plans to ensure that patients meet goals. These data should include vital signs, including pain and pulse oximetry levels, intake and output, weight, mental status, energy level, reflexes, skin color and integrity, presence of blood in sputum and stools, heart and lung sounds, psychological status and needs, and the patient’s ability to accomplish activities of daily living.

For patients with late-stage CKD who are receiving hemodialysis or peritoneal dialysis, assess access sites for any issues (for example, signs and symptoms of occlusion and/or infection), keep sites clean and dry to prevent infection, and promptly report concerns to providers. Place an identification band on the access extremity so other healthcare professionals know not to use it for any other procedures.

Promptly report signs and symptoms (changes in blood pressure, nausea, vomiting, chest pain, back pain, cramping, and fever with or without chills) of RRT adverse events and infection to providers. Signs and symptoms of local infection at the access site include redness, warmth, tenderness, purulent drainage, sores, and swelling. Signs and symptoms of systemic infection include fever, chills, blood pressure changes, nausea, and vomiting. If a patient has a hemodialysis arteriovenous graft or fistula, assess for patency and signs that the access site may fail by palpating for a thrill (vibration); auscultating for a bruit (swishing); and assessing capillary refill time, pulses, and for alterations in sensation, color, temperature, and shape (abnormalities such as blebs, ballooning, and bulging).

For patients who have undergone transplantation, report any signs of acute organ rejection (for example, flulike symptoms, pain at the transplant site, sudden weight gain or swelling, feeling generally unwell). Work with the transplant team to meet patients’ care and educational needs.

Patients always have the right to refuse treatment or choose palliative care. Help patients make the best choice for themselves and respect their wishes. Collaborate with and involve providers in these discussions and decisions. (See Resources.)

Build confidence, improve care

Nurses encounter adults with CKD in all settings and at all stages of the disease. When you can identify the risk factors for CKD, understand how to prevent or slow disease progression, and are skilled at providing patient education and monitoring the disease and its treatment, your confidence in caring for these patients will increase. With that confidence and knowledge, you can promote patient physical and psychosocial well-being to help ensure quality of life.

Jennifer Chicca is a PhD candidate and graduate assistant at the Indiana University of Pennsylvania in Indiana.

References

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