Understanding Chronic Kidney Disease Stages

Hey everyone, it's Sarah for EdsternurseRN.com and in this video I'm going to be going over chronic kidney disease, also known as chronic renal failure. And this video is part of an NCLEX review series over the renal system. And as always, don't forget to take the free quiz that you can access at the end of this video. So let's get started. First, let's start out talking about what is chronic kidney disease. It is where you have a significant decrease in renal function. And this happens over a long period of time and it is irreversible. Now that is the complete opposite of whenever we talked about in the previous lecture about acute kidney injury. Remember that was a sudden decrease in renal function and it tends to be reversible if they can figure out the cause and treat it appropriately. Now let's look at our kidney. And we're going to look specifically at the nephron because whenever we're talking about a decrease in renal function, we're really talking about this glomerulus and how it is filtering, specifically the glomerular filtration rate or GFR. So we'll be using that term a lot, GFR, because if you can understand the GFR, everything else tends to make sense. Okay, so the kidney, the functional unit of your kidney that actually produces urine are the nephrons. And in each kidney you have millions of these nephrons and their whole goal is to filter our blood that it receives from the heart and the glomerulus is the structure that does that. So it filters all these substances such as water, ions, which are like your electrolytes, bicarb, things like that, urea and creatinine, which are waste products. And remember urea? is a waste product from protein breakdown in the liver and creatinine is a waste product from the breakdown of muscle so it filters that now the glomerulus does not filter proteins and blood cells you should not find that in your filtrate unless your glomerulus is messed up and here your glomerulus is messed up so we can probably expect to find that and it drips down into Bowman's capsule and then it's going to go down through the renal tubules And the renal tubules are, in a sense, what they're going to do is they're just going to tweak that filtrate because the filtrate was created by the glomerulus and it's going to take what the body needs to maintain homeostasis. So it's going to reabsorb the amounts of water you need. It's going to reabsorb a little bit of urea and it's going to reabsorb our electrolytes that we need. However, it is not going to reabsorb creatinine. So let's talk about creatinine for a second. So creatinine It's that waste product and it's solely filtered by that glomerulus from the bloodstream. And it's not going to be reabsorbed in that renal tubule. So that's why we care so much about creatinine when we measure it in the urine and in the blood because it gives us a good indicator of how well that glomerulus is filtering that blood. So, whenever we measure our glomerular filtration rate, we take a lot of things into calculation, such as their creatinine clearance level. the patient's gender, their age, their race, and their weight. And that helps us determine that. Now what is a GFR specifically? It is the rate that the glomerulus filters waste, ions, and water in the blood. So it tells us how well the kidneys are performing, specifically that nephron, in helping our body maintain that beautiful homeostasis environment. Now we want a normal GFR in our patients and a normal GFR is greater than 90 milliliters per minute so 90 milliliters per minute or higher is a normal GFR so in chronic kidney disease what happens is that that GFR progressively decreases and there's various stages of CKD and for exams I would be familiar with the GFR for each stage Especially stage 4 and 5 because that's when you have severe loss of renal function because sometimes tests like to ask questions about that. So let's go over this. Okay, stage 1 is where you have kidney damage with normal renal function. So their GFR is going to be normal, greater than 90 milliliters per minute, but there's going to be proteinuria, protein in the urine that has presented for 3 months or more. Then they can progress to stage 2, which is kidney damage with mild loss of renal function. function with a GFR between 60 to 89 milliliters per minute and they'll have proteinuria that's been present for three months or more. Then stage three is mild to severe loss of renal function with a GFR between 60 to 89 milliliters per minute and they'll have proteinuria that's Between 30 to 59 milliliters per minute and then we go into the really severe stages. Stage four is severe loss of renal function with a GFR between 15 to 29 milliliters per minute and then the very last stage, which is the worst stage of all, is stage five and this is end stage renal disease and this is where the GFR. less than 15 milliliters per minute and this is where the patient's going to be getting dialysis regularly and will be a candidate for a kidney transplant and these stages are sourced from the National Institute of Diabetes and Digestive and Kidney Disease Health Statistics Therefore, as that GFR is decreasing, the patient is going to have issues. They're going to have issues with waste, with electrolyte imbalances, and fluid overload. And as you've seen in those stages, as they go from 1 to 5, that GFR is progressively decreasing. So the patient who's in the early stages of chronic kidney disease, they're going to probably be asymptomatic because that GFR is normal. Compared to that patient in stage 4, or five where the GFR is really low so this is really what we're going to be concentrating on or those patients who are in the last stages of chronic kidney disease especially when we're talking about our nursing interventions and things like that okay so when we have a decreased GFR our glomerulus is not filtering the way it should so think of it this way everything that should be filtered is just staying in the blood and it's just building up because it's not going through here to be dripped down into Bowman's capsule go through the tubules and the tubule will pick and choose what it wants. So what is going to happen to our waist levels in our body specifically the BUN which we measure it which is urea and creatinine it's going to increase in our body so those waist levels are going to be high and this is going to lead to problems such as azotemia, uremia, you're going to see neurological changes and itching things like that which which we'll talk in more in depth in our nursing interventions. Then what's gonna happen to our fluid status issues? Again, the glomerulus is not removing the water it should. So what's gonna happen to that water? It's gonna stay in the blood. So we're gonna get fluid overload. So we're gonna be hypo or hypervolemic. We're gonna be hypervolemic. Now, what's gonna happen with that? Think about when there's too much water in the blood, we have a lot of pressure in there. Our blood pressure. is going to be high hypertension this can cause a lot of pressure on the heart which can cause it to become weak which can lead to fluid backing up into the lungs so pulmonary edema cardiac issues things like that how do you expect their urinary output to be if this glomerulus is not filtering the way it should will the urinary output be high or will it be low it will be low it'll be decreased okay so let's go over some terms if their urinary output was less than 400 milliliters per day what's that term it's term aug luria okay if the urinary output was less than a hundred milliliters per day what would that be that would be in urea so you'll be seeing some really low urinary output in these patients okay let's go over to fluid and electrolytes okay so glomerulus is not removed the ions it should so what's it going to do is those ions electrolytes are going to stay in the blood so which electrolytes are going to be high number one our potassium and we really care about potassium because it can cause cardiac issues so we're going to have hyperkalemia how's our phosphate levels going to be they're also going to be high as well along with our magnesium levels now What about calcium levels? Well, remember in our fluid and electrolyte series if you haven't checked it out I recommend you do because it'll help you when you're studying this material Phosphate and calcium have a relationship and they are always the opposite of each other So whenever you have high phosphate levels, you're gonna have low calcium levels. Now, why is that? Okay Calcium binds to phosphate. So if we have all this phosphate in our blood It's going to take the calcium and bind it to itself which is going to remove the calcium from our blood so we'll have hypocalcemia now let's take it a step further what's going to happen with that well whenever your parathyroid gland senses high phosphate levels it causes the parathyroid gland to release PTH parathyroid Parathyroid hormone. What does parathyroid hormone do? Well, we learned from our endocrine series, it stimulates the bones to release calcium from within itself to go into the blood to increase the blood serum of calcium. Well, what is that do to our bones? It makes them weak and brittle. So keep that in mind for whenever we're talking about nursing interventions. So we're going to have hyperkalemia, we're going to have hyperphosphatemia, we're going to have hypocalcemia, and we're going to have hypermagnesemia. Now let's look at this, our protein and blood. Our glomerulus, remember, should not filter proteins and blood cells. Well here in chronic kidney disease, the whole structure is being affected. Not only is our nephron going to be affected, but here in a second you're going to see that this whole kidney, the cells within it that secrete hormones and activate vitamin D are going to be affected. So what's getting through? protein so the patient will probably have some protein in the urine and they're probably going to have blood in the urine as well so think what's going to happen when we're losing all this protein in our urine well we know that albumin one of those proteins regulates oncotic pressure whenever you have decreased oncotic pressure it allows fluid within that capillary to leak into that interstitial tissue so we're going to get even more swelling and edema Then, with the hematuria, we're losing red blood cells in our urine. We're going to get anemia because we're losing blood into the urine. Now let's talk about our kidneys producing hormones. In a lot of patients, if you've ever worked on a dialysis floor, renal floor, you're going to notice these patients have very similar electrolyte imbalances and will have these issues because of what's going on. The kidneys produce hormones. hormone called EPO which is short for erythropoietin. What does EPO do? It helps create red blood cells in the bone marrow. In CKD, EPO is not being produced like it should. It's going to be decreased. So we're not producing red blood cells. What are we at risk for? We're at risk for anemia. So the patient can have that. Another hormone the kidneys produce is called RANIN, cells within the kidney. produce that and what does renin do it plays a role in increasing our blood pressure it maintains our blood pressure for us so what's happening with the glomerulus how much water is it filtering it's not really filtering a lot of water so those cells sense that and they say uh oh the kidneys aren't filtering a lot of water that means our blood pressure must be low so we need to release some renin to increase that blood pressure which is not a good thing because remember we're already in a a hypervolemic state, we already have hypertension going on. So we're going to release more renin, which is going to increase our blood pressure even more. Here in a second, when we talk about the causes of this condition, hypertension is one of them. So we're causing even more damage to our kidneys. Another thing that the kidneys do is kidneys activate vitamin D. What does vitamin D do? It plays a crucial role in helping our body reabsorb calcium from the food we take in. But with CKD, it's not as effective as it sounds. KD you're not really activating that vitamin D so guess what you're not really going to be reabsorbing that calcium taken from food because we need that vitamin D to help us do that so they're going to be they're going to experience even more hyper hypo calcine EMEA which remember with the high phosphate levels they're gonna even have even lower calcium levels so that's gonna be a double whammy with our calcium now let's look at the causes of chronic kidney disease okay one cause is diabetes mellitus and how does this cause this condition well when the patient has uncontrolled hyperglycemia so they have a lot of glucose in that blood their blood sugars are running very very high this causes glucose to stick to the artery wall and remember sugar is sticky so it sticks to the artery wall and that causes damage to the arteries that supply the kidneys so they can develop chronic kidney disease because your kidneys are being deprived of the new nutrients it needs to function. Another thing that can cause it is high blood pressure. So the patient has uncontrolled hypertension and we learned from our hypertension video that hypertension is one of those things that happen that causes really no signs and symptoms until it's too late. It's like the silent killer. So a lot of times the patient is unaware that they even have high blood pressure. So there's this constant high pressure hitting those artery walls to the kidneys and and it becomes damage which Whenever the artery that's feeding the kidney becomes damaged, that's less blood that's going to go to the kidneys and go to that nephron and cause kidney damage. So these two diseases, these two issues are the most common causes for developing chronic kidney disease. Other causes can include acute kidney injury, acute renal failure, which is what we talked about in the previous video. Maybe they don't progress to the recovery stage of that disease and they progress to chronic kidney disease instead. Polycystic kidney disease, they can develop this and this is a genetic condition where cysts develop in the kidneys causing issues with renal function, infection, or nephrotoxic drugs. Those drugs that are very, very toxic to the kidneys like NSAIDs, aminoglycosides, chemotherapy drugs, or contrast dye for testing procedures. Okay, so what is the... treatment for chronic kidney disease. Remember, we have various stages. In those early stages where that GFR is normal, what is usually ordered is for the patient to control their blood pressure and to control their blood glucose level to prevent any further damage to that kidney so they can hopefully preserve that current GFR and not have it decrease anymore. Also, they may prescribe, the physician may prescribe blood pressure medicine to keep that blood pressure low and to help protect the kidneys because there's two groups of medications that they have found that actually provide a protective mechanism to the kidneys and they include ace inhibitors which are those angiotensin converting enzyme inhibitors and those are your drugs that end in pril like lisinopril or the arbs the angiotensin receptor blockers and these are the drugs that end in sartan s-a-r-t-a in like low sartan. And in addition to that, they'll be monitoring their GFR regularly, making sure it's not getting progressively worse and having the patient monitor their blood pressure and making sure it's staying within a normal range. Now, when they progress or in those advanced stages, like stages three, four, and five, especially that last stage, stage five, Where the GFR is abnormal, the patient may need dialysis on a regular schedule. A lot of patients have dialysis on Monday, Wednesday, Friday, or Tuesday, Thursday. And what is dialysis again? This is really... What it is, is it's a machine that's going to take the blood and filter it like how the nephron of the kidney should have. It's going to remove the excessive water, the waste, and regulate those electrolyte levels. the end stage renal disease, they, if they're a candidate, they can be a candidate for a kidney transplant. Now let's look at our nursing interventions. Okay, what are we going to be doing for this patient as the nurse? Well, let's ask yourself, what is going on with this patient with those late stages of chronic kidney disease? Well, they're going to have a buildup of waste in the blood. They're going to have anemia, electrolyte imbalances, low urinary output, and fluid overloads. So we want to tailor our nursing interventions based on what is going on with the patient. So first let's talk about the buildup of waste in the blood. Patients going to have what's called uremia and whenever they have this, they will have some specific signs and symptoms because remember our glomerular filtration rate has decreased. So it's not filtering all that waste out it should. So that waste is trying to go somewhere. One thing they can have is itching and this is due to the fact that the blood is going due to deposits of urea crystals on the skin and it's being secreted through the sweat glands and it has a unique look to it it'll actually look like this white frost on the skin and this is known as uremic frost another thing the patient can have because of those because of those levels really high in the blood they can have confusion and you need to be assessing their neuro status and they're at risk for injury falls so you want to be thinking of say safety issues. And diet. What type of diet would we want them to follow? We want them to follow a low protein diet because remember urea is the breakdown of protein in the liver. So we want them to have some protein to prevent muscle wasting, but we don't want them to have high amounts because it's just going to be broken down into more urea, more waste that our kidneys can not get rid of. And our blood is going to become really acidic from all this. this waste in there. So the blood pH can be less than 7. 3-5 and they can enter into the two conditions known as metabolic acidosis and whenever that happens you may see what's called cosmo breathing and these are deep rapid breaths and it's the respiratory system of trying to blow off carbon dioxide because carbon dioxide is an acid and it's trying to increase The blood pH, so make sure you're watching the respiratory status, counting those respirations, is it labored, is it rapid, what's going on. Now another thing is anemia. What's anemia again? It's low red blood cells. And what do red blood cells do? Because they're really important in our body. They help transport oxygen to our tissues, to our body, so it can function properly. Now why are we seeing anemia again? Just a recap because we have low production of EPO. Remember EPO? Arithropoietin helps stimulate our bone marrow to produce red blood cells. So we're not getting that. Another thing is we can be losing blood through our urine so that can decrease it even more along with being deficient in other minerals such as iron, folic acid, and vitamin b12 because those substances play a role in helping us produce hemoglobin which helps transport red blood cells throughout the system. Now your patient when you look at them they will be pale, they'll be very tired, they can be short of breath just getting up from the bed to the bedside chair, they get really winded and they can be confused. So what are some treatments for this that the physician may order? Supplements of iron to help replenish those levels to help produce more red blood cells if they're low in that. Also, erythropoietin shots, EPO shots, and these are given sub-Q and this will help stimulate that bone marrow to produce red blood cells where your kidneys are not able to stimulate them to do that anymore. Or a blood transfusion to replace them with some more fresh red blood cells. Okay, another thing we had going on was low urinary output and fluid overload. So anytime we're dealing with fluid issues, what are we always going to do in any type of patient, we're going to monitor their intake and output very, very closely. We're also going to perform daily weights because weighing patients and looking at their weight is a good indicator of fluid retention. So we'll be using the same scale every day in the morning and we'll be looking at those weights. their weight today compared to their weight yesterday are they gaining any are they losing any we're going to assess the swelling status in their extremities in their legs and their arms and their belly and in their face is it going down or is it getting worse lung sounds we're going to be listening to that because when you hear crackles that can indicate pulmonary edema so if they're in fluid overload the heart may be becoming weak and so it's allowing fluid to stay into the lungs or flow over into the lungs. We're going to monitor the blood pressure because we want to keep their blood pressure at a normal range because remember high blood pressure is really hard on those kidneys and assessing the respiratory status again that goes back to the fluid overload. Another thing that may be ordered by the physician is a fluid restriction because we want to watch their urinary output really closely and make sure that we're not just giving them or allowing them to have so much fluids compared to what their kidneys can actually put out. So it'll be based on what the physician orders with that and a low sodium diet because sodium loves water. So the more sodium they have in their system because they're not really excreting the sodium as they should, that draws more water into the vascular system, which can increase the blood pressure even more along with other diet restrictions, which we're going to talk about whenever we go over our fluid and electrolyte problems. And again, one of those electrolyte imbalances the patient can have is called hyperkalemia where you have a high potassium level and the potassium level can be higher than 5.1 milliequivalents per liter and what is a normal potassium level? 3.5 to 5.1 milliequivalents per liter that's where we want them now the reason potassium is so important is because it plays a role in muscle contraction and what's happened is that there has been a decrease ability on the nephrons part to filter and excrete potassium. So the patient is at risk for a cardiac event. So we really want to monitor their EKG, have them on a bedside monitor, and we're looking at that EKG specifically for any tall peaked T waves like this one right here. Also the QRS complex can widen as you can see right here and your PR interval can get long. So You're looking at that, but most tests they like to ask about this T wave. Remember it's going to be tall and peaked. Okay, on the nurse's part you'll want to be restricting those foods that are rich in potassium and that includes foods like potatoes, avocado, strawberries, bananas, spinach. and oranges and in my fluid electrolyte videos if you're wanting to know foods that are really rich in the certain substances go to that series or on the website because I have mnemonics on how to remember those foods so check that out and the physician may order k-exolate which will you can give it orally or rectally and it will take that potassium and excrete it out of the body Another thing that electrolyte imbalance they can have is remember that hyperphosphatemia where they have a high phosphate level and that's greater than 4.5 milligrams per deciliter and normal false level is 2.7 to 4.5 milligrams per deciliter and what is that going to do to our calcium level when phosphate's high because remember phosphate likes to bind with calcium it's going to decrease our calcium level so we're going to get hypocalcemia and that is a level less than 8.6 milligrams per deciliter and you usually want your calcium levels between 8.6 to 10 milligrams per deciliter and again this is because that nephron is damaged so that phosphate has increased in the blood and it's bonded with calcium and bringing that level down and what's another reason why we're having low calcium levels because of that decrease ability of activating vitamin d by the kidneys because we're not going to be reabsorbing as much calcium as we should So, what happens? This patient is definitely at risk for some bone issues because again, just to recap, that high phosphate level stimulates the parathyroid gland to produce PTH, parathyroid hormone. Parathyroid hormone stimulates the bones to release calcium into the blood to increase the serum calcium level. Well, doing that, it hurts bone health, so they're at risk for injury and so you want to prevent that. So what do physicians order? to help bring those phosphate levels down because we want those normal so it doesn't deplete our calcium levels anymore. Phosphate binders and this will help decrease phosphate and some drugs are calcium carbonate or calcium acetate also known as Foslo and what these drugs do is they bind with the phosphate in the foods and it excretes the phosphate in the stool. So ask yourself when is the best time to give a patient their calcium carbonate. or Foslo right with meals like five minutes before meals or immediately after because we want them to take it with food because it's working on the food that they're taking that has phosphate in it so it can excrete it out of the stool so you want to give it with that and they want to follow a low phosphate diet so this will be to restrict foods like poultry fish dairy products nuts especially your canned sodas that have phosphate in them and oatmeal next patient is at risk for hypermagnesemia and this is a high magnesium level and the level can be greater than 2.6 milligrams per deciliter and we like our mag levels in between 1.6 to 2.6 milligrams per deciliter and when you have a high magnesium level it's usually because you have a low calcium level because those go hand in hand as we learn in our fluid and electrolyte series and with this the patient's tendon reflexes will be diminished or completely absent depending on how high that magnesium level is and they can be lethargic. So what you want to remember with this is you want to not give them any magnesium-based antacid or laxatives because you're just giving them more magnesium and you want to Make sure you're restricting those foods high in magnesium. Also, the physician may order IV calcium to help decrease this level because as we replenish the calcium level, our mag level will come back down to normal. Okay, so that wraps up this video on chronic kidney disease. Thank you so much for watching. Don't forget to take the free quiz and to subscribe to our channel for more videos.

So let's get started. First, let's start out talking about what is chronic kidney disease. It is where you have a significant decrease in renal function. And this happens over a long period of time and it is irreversible. Now that is the complete opposite of whenever we talked about in the previous lecture about acute kidney injury.

Remember that was a sudden decrease in renal function and it tends to be reversible if they can figure out the cause and treat it appropriately. Now let's look at our kidney. And we're going to look specifically at the nephron because whenever we're talking about a decrease in renal function, we're really talking about this glomerulus and how it is filtering, specifically the glomerular filtration rate or GFR.

So we'll be using that term a lot, GFR, because if you can understand the GFR, everything else tends to make sense. Okay, so the kidney, the functional unit of your kidney that actually produces urine are the nephrons. And in each kidney you have millions of these nephrons and their whole goal is to filter our blood that it receives from the heart and the glomerulus is the structure that does that. So it filters all these substances such as water, ions, which are like your electrolytes, bicarb, things like that, urea and creatinine, which are waste products.

And remember urea? is a waste product from protein breakdown in the liver and creatinine is a waste product from the breakdown of muscle so it filters that now the glomerulus does not filter proteins and blood cells you should not find that in your filtrate unless your glomerulus is messed up and here your glomerulus is messed up so we can probably expect to find that and it drips down into Bowman's capsule and then it's going to go down through the renal tubules And the renal tubules are, in a sense, what they're going to do is they're just going to tweak that filtrate because the filtrate was created by the glomerulus and it's going to take what the body needs to maintain homeostasis. So it's going to reabsorb the amounts of water you need. It's going to reabsorb a little bit of urea and it's going to reabsorb our electrolytes that we need.

However, it is not going to reabsorb creatinine. So let's talk about creatinine for a second. So creatinine It's that waste product and it's solely filtered by that glomerulus from the bloodstream.

And it's not going to be reabsorbed in that renal tubule. So that's why we care so much about creatinine when we measure it in the urine and in the blood because it gives us a good indicator of how well that glomerulus is filtering that blood. So, whenever we measure our glomerular filtration rate, we take a lot of things into calculation, such as their creatinine clearance level.

the patient's gender, their age, their race, and their weight. And that helps us determine that. Now what is a GFR specifically?

It is the rate that the glomerulus filters waste, ions, and water in the blood. So it tells us how well the kidneys are performing, specifically that nephron, in helping our body maintain that beautiful homeostasis environment. Now we want a normal GFR in our patients and a normal GFR is greater than 90 milliliters per minute so 90 milliliters per minute or higher is a normal GFR so in chronic kidney disease what happens is that that GFR progressively decreases and there's various stages of CKD and for exams I would be familiar with the GFR for each stage Especially stage 4 and 5 because that's when you have severe loss of renal function because sometimes tests like to ask questions about that. So let's go over this.

Okay, stage 1 is where you have kidney damage with normal renal function. So their GFR is going to be normal, greater than 90 milliliters per minute, but there's going to be proteinuria, protein in the urine that has presented for 3 months or more. Then they can progress to stage 2, which is kidney damage with mild loss of renal function.

function with a GFR between 60 to 89 milliliters per minute and they'll have proteinuria that's been present for three months or more. Then stage three is mild to severe loss of renal function with a GFR between 60 to 89 milliliters per minute and they'll have proteinuria that's Between 30 to 59 milliliters per minute and then we go into the really severe stages. Stage four is severe loss of renal function with a GFR between 15 to 29 milliliters per minute and then the very last stage, which is the worst stage of all, is stage five and this is end stage renal disease and this is where the GFR.

less than 15 milliliters per minute and this is where the patient's going to be getting dialysis regularly and will be a candidate for a kidney transplant and these stages are sourced from the National Institute of Diabetes and Digestive and Kidney Disease Health Statistics Therefore, as that GFR is decreasing, the patient is going to have issues. They're going to have issues with waste, with electrolyte imbalances, and fluid overload. And as you've seen in those stages, as they go from 1 to 5, that GFR is progressively decreasing.

So the patient who's in the early stages of chronic kidney disease, they're going to probably be asymptomatic because that GFR is normal. Compared to that patient in stage 4, or five where the GFR is really low so this is really what we're going to be concentrating on or those patients who are in the last stages of chronic kidney disease especially when we're talking about our nursing interventions and things like that okay so when we have a decreased GFR our glomerulus is not filtering the way it should so think of it this way everything that should be filtered is just staying in the blood and it's just building up because it's not going through here to be dripped down into Bowman's capsule go through the tubules and the tubule will pick and choose what it wants. So what is going to happen to our waist levels in our body specifically the BUN which we measure it which is urea and creatinine it's going to increase in our body so those waist levels are going to be high and this is going to lead to problems such as azotemia, uremia, you're going to see neurological changes and itching things like that which which we'll talk in more in depth in our nursing interventions. Then what's gonna happen to our fluid status issues?

Again, the glomerulus is not removing the water it should. So what's gonna happen to that water? It's gonna stay in the blood. So we're gonna get fluid overload.

So we're gonna be hypo or hypervolemic. We're gonna be hypervolemic. Now, what's gonna happen with that? Think about when there's too much water in the blood, we have a lot of pressure in there. Our blood pressure.

is going to be high hypertension this can cause a lot of pressure on the heart which can cause it to become weak which can lead to fluid backing up into the lungs so pulmonary edema cardiac issues things like that how do you expect their urinary output to be if this glomerulus is not filtering the way it should will the urinary output be high or will it be low it will be low it'll be decreased okay so let's go over some terms if their urinary output was less than 400 milliliters per day what's that term it's term aug luria okay if the urinary output was less than a hundred milliliters per day what would that be that would be in urea so you'll be seeing some really low urinary output in these patients okay let's go over to fluid and electrolytes okay so glomerulus is not removed the ions it should so what's it going to do is those ions electrolytes are going to stay in the blood so which electrolytes are going to be high number one our potassium and we really care about potassium because it can cause cardiac issues so we're going to have hyperkalemia how's our phosphate levels going to be they're also going to be high as well along with our magnesium levels now What about calcium levels? Well, remember in our fluid and electrolyte series if you haven't checked it out I recommend you do because it'll help you when you're studying this material Phosphate and calcium have a relationship and they are always the opposite of each other So whenever you have high phosphate levels, you're gonna have low calcium levels. Now, why is that?

Okay Calcium binds to phosphate. So if we have all this phosphate in our blood It's going to take the calcium and bind it to itself which is going to remove the calcium from our blood so we'll have hypocalcemia now let's take it a step further what's going to happen with that well whenever your parathyroid gland senses high phosphate levels it causes the parathyroid gland to release PTH parathyroid Parathyroid hormone. What does parathyroid hormone do? Well, we learned from our endocrine series, it stimulates the bones to release calcium from within itself to go into the blood to increase the blood serum of calcium.

Well, what is that do to our bones? It makes them weak and brittle. So keep that in mind for whenever we're talking about nursing interventions.

So we're going to have hyperkalemia, we're going to have hyperphosphatemia, we're going to have hypocalcemia, and we're going to have hypermagnesemia. Now let's look at this, our protein and blood. Our glomerulus, remember, should not filter proteins and blood cells.

Well here in chronic kidney disease, the whole structure is being affected. Not only is our nephron going to be affected, but here in a second you're going to see that this whole kidney, the cells within it that secrete hormones and activate vitamin D are going to be affected. So what's getting through?

protein so the patient will probably have some protein in the urine and they're probably going to have blood in the urine as well so think what's going to happen when we're losing all this protein in our urine well we know that albumin one of those proteins regulates oncotic pressure whenever you have decreased oncotic pressure it allows fluid within that capillary to leak into that interstitial tissue so we're going to get even more swelling and edema Then, with the hematuria, we're losing red blood cells in our urine. We're going to get anemia because we're losing blood into the urine. Now let's talk about our kidneys producing hormones.

In a lot of patients, if you've ever worked on a dialysis floor, renal floor, you're going to notice these patients have very similar electrolyte imbalances and will have these issues because of what's going on. The kidneys produce hormones. hormone called EPO which is short for erythropoietin.

What does EPO do? It helps create red blood cells in the bone marrow. In CKD, EPO is not being produced like it should. It's going to be decreased. So we're not producing red blood cells.

What are we at risk for? We're at risk for anemia. So the patient can have that.

Another hormone the kidneys produce is called RANIN, cells within the kidney. produce that and what does renin do it plays a role in increasing our blood pressure it maintains our blood pressure for us so what's happening with the glomerulus how much water is it filtering it's not really filtering a lot of water so those cells sense that and they say uh oh the kidneys aren't filtering a lot of water that means our blood pressure must be low so we need to release some renin to increase that blood pressure which is not a good thing because remember we're already in a a hypervolemic state, we already have hypertension going on. So we're going to release more renin, which is going to increase our blood pressure even more. Here in a second, when we talk about the causes of this condition, hypertension is one of them.

So we're causing even more damage to our kidneys. Another thing that the kidneys do is kidneys activate vitamin D. What does vitamin D do?

It plays a crucial role in helping our body reabsorb calcium from the food we take in. But with CKD, it's not as effective as it sounds. KD you're not really activating that vitamin D so guess what you're not really going to be reabsorbing that calcium taken from food because we need that vitamin D to help us do that so they're going to be they're going to experience even more hyper hypo calcine EMEA which remember with the high phosphate levels they're gonna even have even lower calcium levels so that's gonna be a double whammy with our calcium now let's look at the causes of chronic kidney disease okay one cause is diabetes mellitus and how does this cause this condition well when the patient has uncontrolled hyperglycemia so they have a lot of glucose in that blood their blood sugars are running very very high this causes glucose to stick to the artery wall and remember sugar is sticky so it sticks to the artery wall and that causes damage to the arteries that supply the kidneys so they can develop chronic kidney disease because your kidneys are being deprived of the new nutrients it needs to function. Another thing that can cause it is high blood pressure.

So the patient has uncontrolled hypertension and we learned from our hypertension video that hypertension is one of those things that happen that causes really no signs and symptoms until it's too late. It's like the silent killer. So a lot of times the patient is unaware that they even have high blood pressure. So there's this constant high pressure hitting those artery walls to the kidneys and and it becomes damage which Whenever the artery that's feeding the kidney becomes damaged, that's less blood that's going to go to the kidneys and go to that nephron and cause kidney damage. So these two diseases, these two issues are the most common causes for developing chronic kidney disease.

Other causes can include acute kidney injury, acute renal failure, which is what we talked about in the previous video. Maybe they don't progress to the recovery stage of that disease and they progress to chronic kidney disease instead. Polycystic kidney disease, they can develop this and this is a genetic condition where cysts develop in the kidneys causing issues with renal function, infection, or nephrotoxic drugs.

Those drugs that are very, very toxic to the kidneys like NSAIDs, aminoglycosides, chemotherapy drugs, or contrast dye for testing procedures. Okay, so what is the... treatment for chronic kidney disease. Remember, we have various stages.

In those early stages where that GFR is normal, what is usually ordered is for the patient to control their blood pressure and to control their blood glucose level to prevent any further damage to that kidney so they can hopefully preserve that current GFR and not have it decrease anymore. Also, they may prescribe, the physician may prescribe blood pressure medicine to keep that blood pressure low and to help protect the kidneys because there's two groups of medications that they have found that actually provide a protective mechanism to the kidneys and they include ace inhibitors which are those angiotensin converting enzyme inhibitors and those are your drugs that end in pril like lisinopril or the arbs the angiotensin receptor blockers and these are the drugs that end in sartan s-a-r-t-a in like low sartan. And in addition to that, they'll be monitoring their GFR regularly, making sure it's not getting progressively worse and having the patient monitor their blood pressure and making sure it's staying within a normal range. Now, when they progress or in those advanced stages, like stages three, four, and five, especially that last stage, stage five, Where the GFR is abnormal, the patient may need dialysis on a regular schedule. A lot of patients have dialysis on Monday, Wednesday, Friday, or Tuesday, Thursday.

And what is dialysis again? This is really... What it is, is it's a machine that's going to take the blood and filter it like how the nephron of the kidney should have.

It's going to remove the excessive water, the waste, and regulate those electrolyte levels. the end stage renal disease, they, if they're a candidate, they can be a candidate for a kidney transplant. Now let's look at our nursing interventions.

Okay, what are we going to be doing for this patient as the nurse? Well, let's ask yourself, what is going on with this patient with those late stages of chronic kidney disease? Well, they're going to have a buildup of waste in the blood. They're going to have anemia, electrolyte imbalances, low urinary output, and fluid overloads.

So we want to tailor our nursing interventions based on what is going on with the patient. So first let's talk about the buildup of waste in the blood. Patients going to have what's called uremia and whenever they have this, they will have some specific signs and symptoms because remember our glomerular filtration rate has decreased.

So it's not filtering all that waste out it should. So that waste is trying to go somewhere. One thing they can have is itching and this is due to the fact that the blood is going due to deposits of urea crystals on the skin and it's being secreted through the sweat glands and it has a unique look to it it'll actually look like this white frost on the skin and this is known as uremic frost another thing the patient can have because of those because of those levels really high in the blood they can have confusion and you need to be assessing their neuro status and they're at risk for injury falls so you want to be thinking of say safety issues. And diet.

What type of diet would we want them to follow? We want them to follow a low protein diet because remember urea is the breakdown of protein in the liver. So we want them to have some protein to prevent muscle wasting, but we don't want them to have high amounts because it's just going to be broken down into more urea, more waste that our kidneys can not get rid of.

And our blood is going to become really acidic from all this. this waste in there. So the blood pH can be less than 7. 3-5 and they can enter into the two conditions known as metabolic acidosis and whenever that happens you may see what's called cosmo breathing and these are deep rapid breaths and it's the respiratory system of trying to blow off carbon dioxide because carbon dioxide is an acid and it's trying to increase The blood pH, so make sure you're watching the respiratory status, counting those respirations, is it labored, is it rapid, what's going on.

Now another thing is anemia. What's anemia again? It's low red blood cells. And what do red blood cells do?

Because they're really important in our body. They help transport oxygen to our tissues, to our body, so it can function properly. Now why are we seeing anemia again?

Just a recap because we have low production of EPO. Remember EPO? Arithropoietin helps stimulate our bone marrow to produce red blood cells. So we're not getting that.

Another thing is we can be losing blood through our urine so that can decrease it even more along with being deficient in other minerals such as iron, folic acid, and vitamin b12 because those substances play a role in helping us produce hemoglobin which helps transport red blood cells throughout the system. Now your patient when you look at them they will be pale, they'll be very tired, they can be short of breath just getting up from the bed to the bedside chair, they get really winded and they can be confused. So what are some treatments for this that the physician may order?

Supplements of iron to help replenish those levels to help produce more red blood cells if they're low in that. Also, erythropoietin shots, EPO shots, and these are given sub-Q and this will help stimulate that bone marrow to produce red blood cells where your kidneys are not able to stimulate them to do that anymore. Or a blood transfusion to replace them with some more fresh red blood cells.

Okay, another thing we had going on was low urinary output and fluid overload. So anytime we're dealing with fluid issues, what are we always going to do in any type of patient, we're going to monitor their intake and output very, very closely. We're also going to perform daily weights because weighing patients and looking at their weight is a good indicator of fluid retention. So we'll be using the same scale every day in the morning and we'll be looking at those weights. their weight today compared to their weight yesterday are they gaining any are they losing any we're going to assess the swelling status in their extremities in their legs and their arms and their belly and in their face is it going down or is it getting worse lung sounds we're going to be listening to that because when you hear crackles that can indicate pulmonary edema so if they're in fluid overload the heart may be becoming weak and so it's allowing fluid to stay into the lungs or flow over into the lungs.

We're going to monitor the blood pressure because we want to keep their blood pressure at a normal range because remember high blood pressure is really hard on those kidneys and assessing the respiratory status again that goes back to the fluid overload. Another thing that may be ordered by the physician is a fluid restriction because we want to watch their urinary output really closely and make sure that we're not just giving them or allowing them to have so much fluids compared to what their kidneys can actually put out. So it'll be based on what the physician orders with that and a low sodium diet because sodium loves water.

So the more sodium they have in their system because they're not really excreting the sodium as they should, that draws more water into the vascular system, which can increase the blood pressure even more along with other diet restrictions, which we're going to talk about whenever we go over our fluid and electrolyte problems. And again, one of those electrolyte imbalances the patient can have is called hyperkalemia where you have a high potassium level and the potassium level can be higher than 5.1 milliequivalents per liter and what is a normal potassium level? 3.5 to 5.1 milliequivalents per liter that's where we want them now the reason potassium is so important is because it plays a role in muscle contraction and what's happened is that there has been a decrease ability on the nephrons part to filter and excrete potassium.

So the patient is at risk for a cardiac event. So we really want to monitor their EKG, have them on a bedside monitor, and we're looking at that EKG specifically for any tall peaked T waves like this one right here. Also the QRS complex can widen as you can see right here and your PR interval can get long.

So You're looking at that, but most tests they like to ask about this T wave. Remember it's going to be tall and peaked. Okay, on the nurse's part you'll want to be restricting those foods that are rich in potassium and that includes foods like potatoes, avocado, strawberries, bananas, spinach.

and oranges and in my fluid electrolyte videos if you're wanting to know foods that are really rich in the certain substances go to that series or on the website because I have mnemonics on how to remember those foods so check that out and the physician may order k-exolate which will you can give it orally or rectally and it will take that potassium and excrete it out of the body Another thing that electrolyte imbalance they can have is remember that hyperphosphatemia where they have a high phosphate level and that's greater than 4.5 milligrams per deciliter and normal false level is 2.7 to 4.5 milligrams per deciliter and what is that going to do to our calcium level when phosphate's high because remember phosphate likes to bind with calcium it's going to decrease our calcium level so we're going to get hypocalcemia and that is a level less than 8.6 milligrams per deciliter and you usually want your calcium levels between 8.6 to 10 milligrams per deciliter and again this is because that nephron is damaged so that phosphate has increased in the blood and it's bonded with calcium and bringing that level down and what's another reason why we're having low calcium levels because of that decrease ability of activating vitamin d by the kidneys because we're not going to be reabsorbing as much calcium as we should So, what happens? This patient is definitely at risk for some bone issues because again, just to recap, that high phosphate level stimulates the parathyroid gland to produce PTH, parathyroid hormone. Parathyroid hormone stimulates the bones to release calcium into the blood to increase the serum calcium level.

Well, doing that, it hurts bone health, so they're at risk for injury and so you want to prevent that. So what do physicians order? to help bring those phosphate levels down because we want those normal so it doesn't deplete our calcium levels anymore. Phosphate binders and this will help decrease phosphate and some drugs are calcium carbonate or calcium acetate also known as Foslo and what these drugs do is they bind with the phosphate in the foods and it excretes the phosphate in the stool.

So ask yourself when is the best time to give a patient their calcium carbonate. or Foslo right with meals like five minutes before meals or immediately after because we want them to take it with food because it's working on the food that they're taking that has phosphate in it so it can excrete it out of the stool so you want to give it with that and they want to follow a low phosphate diet so this will be to restrict foods like poultry fish dairy products nuts especially your canned sodas that have phosphate in them and oatmeal next patient is at risk for hypermagnesemia and this is a high magnesium level and the level can be greater than 2.6 milligrams per deciliter and we like our mag levels in between 1.6 to 2.6 milligrams per deciliter and when you have a high magnesium level it's usually because you have a low calcium level because those go hand in hand as we learn in our fluid and electrolyte series and with this the patient's tendon reflexes will be diminished or completely absent depending on how high that magnesium level is and they can be lethargic. So what you want to remember with this is you want to not give them any magnesium-based antacid or laxatives because you're just giving them more magnesium and you want to Make sure you're restricting those foods high in magnesium. Also, the physician may order IV calcium to help decrease this level because as we replenish the calcium level, our mag level will come back down to normal. Okay, so that wraps up this video on chronic kidney disease.

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Transcript for:Understanding Chronic Kidney Disease Stages

Transcript for:
Understanding Chronic Kidney Disease Stages