Regarding Chronic Kidney Failure

Chronic kidney failure (CRF) or late-stage kidney disease is a chronic impairment of kidney function that is progressive and irreversible. Where the body’s ability to fail to maintain metabolism and fluid and electrolyte balance, causes uremia (urea retention and other nitrogenous waste in the blood) (KMB, Vol. 2 p. 1448).


Causes of chronic kidney
The causes of chronic kidney failure are:
• High blood pressure (hypertension)
• Urinary tract blockage
• Glomerulonephritis
• Kidney abnormalities, such as polycystic kidney disease
• Diabetes mellitus (diabetes)
• Autoimmune disorders, such as systemic lupus erythematosus.
Two theoretical methods are usually proposed to explain impaired renal function in chronic kidney failure:
1. Traditional viewpoint
Saying that all nephron units have been attacked by disease but in different stages, and specific parts of nephrons related to particular functions can be wholly damaged or changed in structure, for example, organic lesions in the medulla will damage the anatomic arrangement of the curved henle .
2. Approach the bricker hypothesis or the complete nephron hypothesis
Argued that if the nephron was attacked by disease, the entire unit would be destroyed, but the remaining intact nephrons would still work normally. Uremia will arise if the number of nephrons that have been so reduced that the fluid and electrolyte balance can’t be maintained anymore.
Important adaptation is carried out by the kidneys in response to threats of fluid and electrolyte imbalances. The remaining nephrons are hypertrophy to carry out the entire workload of the kidney, and there is an increase in filtration acceleration, the solute load and tubular reabsorption in each nephron contained in the kidneys decrease normally.
This mechanism of adaptation is quite successful in maintaining the body’s fluid and electrolyte balance to a low level of kidney function. However, finally, if 75% of the mass of the nephron is destroyed, then the filtration speed and solute load for each nephron are so high that the glomerular-tubular balance can no longer be maintained. Flexibility in both the excretion process and solute concentration and water becomes reduced.
Clinical trip
The general course of progressive kidney failure can be divided into 3 stadiums
Stage I
Decreased renal reserve (kidney function between 40% -75%). This stage is the lightest, where kidney function is still good. At this stage, the sufferer has not yet felt the symptoms, and the physiological laboratory examination of the kidney is still within normal limits. During this stage serum, creatinine and levels of BUN (Blood Urea Nitrogen) are within normal limits and asymptomatic patients. Impaired kidney function may only be known by giving a heavy workload, along with urine concentration test form or by conducting a careful GFR test.
Stage II
Renal insufficiency (renal function between 20% -50%). At this stage, the sufferer can carry out the usual task while the power and concentration of the kidney decrease. At this stage, the treatment must be fast in things to overcome the lack of fluids, lack of salt, heart problems, and prevention of drug administration that is disturbing kidney function. If this step is carried out as soon as possible, it can prevent the patient from entering a more severe stage. At this stage, more than 75% of the functioning networks have been damaged. The new BUN level starts to rise above the normal limit. Increasing the concentration of BUN differs depending on the level of protein in the diet. At this stage, serum creatinine levels begin to increase beyond the normal level.

Polyuria due to kidney failure is regularly greater in diseases that primarily attack the tubules, although polyuria is common and rarely more than 3 liters/day. Anemia is generally found in kidney failure with kidney function between 5% -25%. The kidney problems are very decreased, and symptoms of a lack of blood appear, blood pressure will rise, the patient’s activities begin to be disrupted.
Stage III
Urinary renal failure (kidney function of less than 10%)
All symptoms are clear and patients are entering in a state where they cannot do their daily tasks as they should. Symptoms of symptoms that arise include nausea, vomiting, decreased appetite, shortness of breath, dizziness, headache, reduced urine, lack of sleep, seizures and eventually decreased consciousness to come. The final city arises in about 90% of the mass of the nephron has been destroyed. The GFR value is 10% from normal, and creatinine levels may be 5-10 ml/minute or less.
In this conditioning serum, creatinine and BUN levels will increase very markedly as a decrease. In the late stages of kidney failure, patients begin to feel symptoms that are quite severe because the kidneys are no longer can maintain the homeostatic liquid and electrolytes in the body. Patients usually become oliguri (urinary discharge) less than 500 / day due to glomerular failure even though the initial disease process attacks the kidney tubules,
complex attacks on the tubules of the gums, complex biochemical changes, and characteristic symptoms called the uremic syndrome to affect every system in the body. In the late stages of kidney failure, the patient will suffer unless he gets treatment in the form of a kidney transplant or dialysis.
Treatment of chronic kidney
1. Dialysis
Dialysis can be done to prevent complications of acute, acute kidney failure, such as hyperkalemia, pericarditis, and seizures. Pericarditis improves biochemical abnormalities; cause liquid, protein, and sodium can be consumed freely; eliminate the tendency of bleeding, and helps wound healing.
2. Handling of hyperkalemia
Fluid and electrolyte balance is a major problem in acute renal failure; hyperkalemia is the most life-threatening condition in this disorder. Therefore the patient is observed for hyperkalemia through a series of serum electrolyte levels (potassium value> 5.5 mEq / L; SI: 5.5 mmol / L), ECG changes (low or very high T wave peaks), and changes in clinical status. Increased potassium levels can be reduced by administering resin replacement ions (sodium polystriren sulfonate [Kayexalatel]), orally or through retention of enemas.
3. Maintaining fluid balance
Management of fluid balance is based on daily weight, measurement of central venous pressure, urine and serum concentration, fluid loss, blood pressure and the patient’s clinical status. Enter and oral and parental output of urine, gastric drainage, feces, wound drainage and perspiration are calculated and used as a basis for fluid replacement therapy.
Case study
Hj client name. H
85 years old.
Entered Hospital on April 30, 2005 with complaints Can’t urinate and right waist pain .. This complaint lasted 3 days at home. Initially the client could not defecate? 2 days ago the client used dulcolax suppository for 2 consecutive days and the client was able to defecate.
A day later the client had difficulty urinating, although pushing the urine could not come out, then the family took him to the hospital. When we arrived at the hospital a catheter was placed and the urine flowed out and came out slightly red and then it came out slightly brown like tea.
When the client assessment has been treated for 3 days the focus data obtained:
The client’s general state is rather weak, the lower limbs are weak, not powerful, wrinkled skin is not elastic. pretibial odema. Less muscle tone. always lying in bed, daily activities, a day assisted by his child, installed a brown urine catheter such as tea water, wet and smelly lazy cloth.
TD 160/90 mmHg. Pulse is 82 x / minute, body temperature is 36.2O C, sclera appears pale, eye secret (+). Ammonia smells, speaking softly is sometimes unclear,
Laboratory examination results
Date; 2/5 2005
Ureum: 202.32
Creatinine: 3, 93
SGOT: 19
SGPT: 30
WBC: 5.5 x 103 /? L
RBC: 3.90
HGB: 10.7
HCT: 32.5%
GDS: 161
Supporting investigation
USG Results:
• Kidney: It appears that both kidneys shrink with unclear echodifference (right kidney 5.9 x 3.1 cm; left kidney 5.8 x 2.5 cm).
• Impression: bilateral PNC.
Medical Therapy
Drugs:
• IVFD NaCl 0.9% 20 tts / minute
• Allopurinol 300mg 1-0-0
• Zonidip 10mg 0-0-1
• 300mg Fiber 0-0-1
• Inj. Neurosanbe 1 amp / day / drips
Based on the assessment, nursing diagnoses obtained:
1. Excess fluid volume is associated with decreased urine output, fluid and sodium retention.
2. Disorders of ADL fulfillment are related to physical weakness.
3. Changes in the oral mucous membrane associated with chemical irritation.
4. Risk of damage to the integrity of the skin associated with decreased activity, impaired metabolic status.
Action plan
1. Excess fluid volume is associated with decreased urine output, fluid and sodium retention.
1. Assess fluid status:
• Daily weight
• The balance of input and output
• Skin turgor and edema
• Blood pressure, pulse, and pulse rate.
2. Limit fluid input
3. Identify potential sources of fluid
• Medications and fluids used for treatment, oral and intravenous.
• Food
4. Explain the rational limitation of fluid
5. help clients deal with discomfort due to fluid restrictions.
6. Increase and encourage oral hygiene.
2. Disorders of ADL fulfillment are related to physical weakness.
• Determine the client’s ability to participate in self-care activities. (scale 0–4).
• Give help with activities that are needed
• Encourage the family to help fulfill ADL clients in bed.
• Help the family care for clients in bed.
• Encourage the family to replace the buttocks if they are wet.
• Help and motivate the family to maintain the cleanliness of the client’s body,
3. Changes in the oral mucous membrane associated with chemical irritation.
1. Inspection of the oral cavity pays attention to moisture, the character of saliva, the presence of inflammation, ulceration.
2. Give fluids as long as 24 hours within the specified limit.
3. Give frequent oral care.
4. Advise oral hygiene after eating and before going to bed.
5. Encourage the client to avoid lemon dessert/ingredients containing alcohol.
4. Risk of damage to the integrity of the skin associated with decreased activity, impaired metabolic status.
1. Inspection of the skin for changes in color, skin moisture, vascular.
2. Change position frequently, the client’s movements slowly, give a soft cloth cushion on the bone protrusion.
3. Maintain dry linen free from wrinkles.
4. Keep nails short.

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