Nursing Diagnoses and Interventions

5 Key Nursing Diagnoses

1. Decreased Cardiac Output 

2. Ineffective tissue perfusion (renal) 

3. Excess fluid volume related to kidney disease

4. Impaired Urinary Elimination r/t effects of disease, need for dialysis

5. Acute pain

There will be excess fluid volume of fluid overload related to decrease glomerular filtration rate and sodium retention due to kidney malfunction. The glomerular filtration rate will be very low creating a lot of pressure on the kidneys. This will make it difficult for the patient to excrete urine. Furthermore, with excess fluid can not leave, so it overloads the lymph system. This can cause the following in the interstitial spaces: edema, weight gain, pulmonary congestion, hypertension, shortness of breath, dyspnea on exertion, oliguria (low output of urine) and altered mental status. The kidneys are already under pressure, but it will get increasing worse. There will be a electrolyte unbalance especially in sodium and potassium. Electrolytes like sodium and potassium regulates blood pressure, blood volume, and cardiac contractions.  This can lead to decrease caridac output, or your heart unable to pump blood with oxygen throughout the body. The blood pressure will spike up because it is trying to compensate. This of course affects how well your blood is perfuse in the body if it still contains waste.  It will also lead to decrease urine output, and if the body can not filter and remove its waste, then it can lead to kidney failure and dialysis.

The plan is to monitor fluid status, and reduce the excess. First we will establish a baseline of the patient and make improvements from that point. Some nursing interventions will be the following: making note of input and output, vital signs, weight gain, any signs of edema, auscultation of lung sounds, lab value checks, and restricting sodium intake , 

Citations:
Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care(9th ed.). Maryland Heights, Mo.: Mosby.

Lewis, S. (2011). Medical-surgical nursing: Assessment and management of clinical problems. (8th ed.). St. Louis, Mo.: Elsevier/Mosby.

Nurse's Role to Educate!

Nurse's main role is educating the patient. Education is key for the patient especially after they leave the hospital/clinical setting. 

We want the patient to understand what is happening and what to expect. As we mentioned in previous blogs, we want to explain to the patient what is happening to the body and how to manage their condition before it gets potentially worse.  First, an explanation of how does diabetes affect the body and kidneys. We want them to know that if their glucose levels, and blood pressure levels are not well manage, it can cause further complications. This can further damage the kidney from filtering properly. 

Hence, there is a lot of emphasis of teaching the the patient to be healthy by staying active and eating a healthy low sodium diet. In addition, smoking must completely stop. Staying healthy will manage the glucose levels in the blood. Furthermore, the body can function better with weight loss and blood pressure is better maintained. 

Another important component is medication adherence and understanding their usages is very important. We do not want to create further complications for patients.  They need to understand what common over the counter drugs can be toxic. They must take only the prescribed medication and to talk to the provider about any drug drug interactions that may be harmful to their well-being. 

Below is a list and summary of what the nurse will have the following as interventions/goals for the patient:

Regular exercise program

Lose weight if obese

Stop smoking

Limited consumption of alcohol

Low Sodium Diet (perhaps speak to a dietitian)

Avoid NSAIDS and any nephrotoxins

Ideal blood pressure would be less than 130/80

Ideal Hemoglobic A1C (HgbA1C) would be less than 7% (check every 3 months)

Lower cholesterol

Assess medications for potential contraindication in CKD and any other drug interactions

Adjust medication dosing for level of eGFR

Please refer to the following sites for management

• https://www.kidney.org/atoz/content/diabetes
• http://www.mayoclinic.org/departments-centers/nephrology-hypertension/minnesota/overview/specialty-groups/diabetic-nephropathy-clinic
• http://www.mayoclinicproceedings.org/article/S0025-6196(11)60034-7/fulltext#cesec20

According to mayoclinic, we can determine how severe the kidney disease in based on GFR and albumin results. Furthermore, below is an approach to treat and manage diabetic nepphropathy. 

Citations:

Nephrology and Hypertension in Minnesota. (n.d.). Retrieved February 20, 2015, from http://www.mayoclinic.org/departments-centers/nephrology-hypertension/minnesota/overview/specialty-groups/diabetic-nephropathy-clinic

Cohen, L. (n.d.). Nurse to Nurse: Nursing Role in Diabetic Nephropathy Management. Retrieved February 20, 2015, from http://dx.doi.org/10.1007/978-1-4613-2287-0_12

Bakris, G. (n.d.). Recognition, Pathogenesis, and Treatment of Different Stages of Nephropathy in Patients With Type 2 Diabetes Mellitus. Mayo Clinic Proceedings, 444-456. Retrieved February 20, 2015, from http://www.mayoclinicproceedings.org/article/S0025-6196(11)60034-7/fulltext#cesec20

Treat yourself well!

The most frequent route of treatments are drugs, diet, tight blood glucose (sugar) levels and blood pressure levels.  Most importantly, self care is taking care of yourself and having healthy lifestyle. 

Blood pressure can make the kidneys work harder and worsen the disease. Drugs can be use to lower the blood pressure. Ask your doctor to see which one is right for you. You don't wanna take any type of blood pressure meds because it can hide symptoms of low blood sugar and it does not work with well with diabetics. Usually, the physician will prescribe ACE inhibitors for those with diabetes, kidney disease and high blood sugar. Even if your blood pressure is normal in the healthy range, controlling your blood pressure with medication can slow down kidney damage. (Remember that the pressure in the GLOMERULAR of the kidney  is undergoing lots of pressure to filter your blood). 

Blood glucose should be maintained with healthy food. Medication such as insulin may be provided by your health care provider depending on your situation. Most of all, checking blood sugars and maintaining it by keeping a record is recommended. That way, you will understand how the sugars are affected with exercise and diet. 

To lower blood glucose and your blood pressure include the following: losing weight, less sodium or sale in the diet, avoiding alcohol and tobacco, and regular exercise. This is all part of maintaining a healthy way of life so your kidneys can work to the best of is ability without added pressure. 

Last, but not least of all the self-cares is having regular check-ups. A microalbuminuria test of the urine is to assess how well the kidneys (As mention in previous posts). Further more, a diet of macroalbuminuria is a low-protein diet. Low protein is recommended because it can increase the workload on kidneys. Remember how we mentioned that albumin is a protein in the body that the kidneys try to retain. However, when the kidneys do not function properly, albumin leaks and becomes excreted in the urine. Therefore, a low protein diet can decrease protein loss and hopefully keep more protein in the blood. 

Again with any of the treatments above, it is important to speak to your health care provider and what steps are best for you. 

To recap on Diabetic nephropathy and treatments you can do, watch the link below.

Citations:

Gross, J., De Azevedo, M., Silveiro, S., Canani, L., Caramori, M., & Zelmanovitz, T. (2005). Diabetic Nephropathy: Diagnosis, Prevention, And Treatment. Diabetes Care, 164-176. Retrieved February 12, 2015, from http://care.diabetesjournals.org/content/28/1/164.full

Bakris, G. (n.d.). Recognition, Pathogenesis, and Treatment of Different Stages of Nephropathy in Patients With Type 2 Diabetes Mellitus. Mayo Clinic Proceedings, 444-456.

Diabetic nephropathy. (n.d.). Retrieved February 12, 2015, from http://www.mayoclinic.org/diseases-conditions/diabetic-nephropathy/care-at-mayo-clinic/tests-diagnosis/con-20035589

Signs and Symptoms!

Initially, there are no symptoms that can be detected in diabetic nephropathy. It can be as long as 5 to 10 years before symptoms show up. However, you can always go to the doctor and do check ups as a patient with type 1 or 2 diabetes. 

With diabetic nephopathy, the kidneys slowly work harder and harder to the point where it can not maintain its function. As the main filtering system, kidneys cannot withstand filtering at such high volume, which lead to a buildup of fluid. You can only push your kidneys so far without any consequences. Think of your capillaries in the kidneys running a marathon at much faster rate than it use to. At first, the kidneys are fine when it runs faster. The kidneys can handle a little pressure, but it usually likes to maintain it's "usual jogging pace". Then there's all this stress place upon the kidneys. The monsters are coming for you, pumping your blood pressure up, making the kidneys sprint for their lives. With that, you kidneys are just going to be so exhausted, it's going to slack and leak some albumin (a protein) into the urine. The urine may contain blood and become cloudy. There is going to discomfort as it gets worse. 

The main way to identify kidney problems is diabetes management and a urine micoralbumin test checkup. This test measures the amount of protein known as albumin in the urine. The kidneys job is to help blood filter out waste, and protein is helpful and vital in the blood. As we mentioned earlier, your kidneys are overworked and now leaky like a faucet that is under high volumes of pressure. At first, only small amounts of albumin are loss, and eventually, it will slowly increase. It will lead to the point where it excretes over 300 mg, making it a condition called microalbuminiuria.

Long term symptoms will of diabetic nephropathy (kidney disease) will lead to following: fatigue, dry/itchy skin, shortness for breath, high blood pressure, poor appetite, confusion, swelling of ankles/feet/hands (fluid buildup), headache, nausea, vomiting, upset stomach, difficulty concentrating, polyuria (needing to void often due to the high rate of excretion) and just feeling unwell.  You main refer the the diagram below, which show you common symptoms of kidney disease, and symptoms that lead to kidney failure. Furthermore, it gives some information about prevention. Tune into next week where we will discuss prevention and mainly treatments for kidney disease. 

Citations:

Gross, J., De Azevedo, M., Silveiro, S., Canani, L., Caramori, M., & Zelmanovitz, T. (2005). Diabetic Nephropathy: Diagnosis, Prevention, And Treatment. Diabetes Care, 164-176. Retrieved February 6, 2015, from http://care.diabetesjournals.org/content/28/1/164.full

Bakris, G. (n.d.). Recognition, Pathogenesis, and Treatment of Different Stages of Nephropathy in Patients With Type 2 Diabetes Mellitus. Mayo Clinic Proceedings, 444-456.

Diabetic nephropathy. (n.d.). Retrieved February 6, 2015, from http://www.mayoclinic.org/diseases-conditions/diabetic-nephropathy/care-at-mayo-clinic/tests-diagnosis/con-20035589

Kidney biopsy. (n.d.). Retrieved February 6, 2015, from http://www.mayoclinic.org/tests-procedures/kidney-biopsy/basics/definition/prc-20018979

Check and test if you suspect...diabetic nephropathy!

Generally, patients with either type 1 and 2 diabetes should be screen yearly for any complications. 

What you would check if you suspect diabetic nephropathy?
There are the following things you can do: blood tests, urinalysis, renal imaging, renal function testing, and a kidney biopsy. 
Blood test and urinalysis are commonly done on patients to check kidney function. However, since it is not sufficient enough to see the severity the kidney damage, serum creatinine and the glomerular filtration rate (GFR) is also measured in the renal function testing.

Blood test: It is a comprehensive panel that can checks if your kidneys are functioning within the normal range. 

Urinalysis: Urine samples is a good indicator of how the kidneys are filtering the body waste. If there are high levels of microalbuminia in your urine, this may indicated renal problems. Furthermore, a urinalysis is a good indicator, but it is not accurate. The urinary albumin excretion can change and 2-3 samples may be collected over a course of time. This is to avoid any false-positive results that may be caused by something else beside kidney disease. 

Renal imaging: Magnetic resonance imaging (MRI) or ultrasound imaging may be used to see how well the blood is perfusing in the kidneys. X-ray may also be used to see if the kidneys look abnormal. 

Renal function testing: The kidney's filtering function are determined using renal analysis testing. The glomerular filtration rate calculated, which is a accurate measure of how well the kidneys/renal system is functioning. 

**Remember the glomerular is the filtration function unit of the kidneys that help the body filter the blood and excretes the waste through urine. **

Kidney biopsy: The doctor will perform a procedure called percutaneous kidney biopsy that uses a needle to extract pieces of the kidney tissue. This sample will undergo lab tests to check for any signs of disease or damage. 

Depending on the severity of kidney damage, a few or all of the following tests may be done. 

Citations:

Gross, J., De Azevedo, M., Silveiro, S., Canani, L., Caramori, M., & Zelmanovitz, T. (2005). Diabetic Nephropathy: Diagnosis, Prevention, And Treatment. Diabetes Care, 164-176. Retrieved February 1, 2015, from http://care.diabetesjournals.org/content/28/1/164.full

Bakris, G. (n.d.). Recognition, Pathogenesis, and Treatment of Different Stages of Nephropathy in Patients With Type 2 Diabetes Mellitus. Mayo Clinic Proceedings, 444-456.

Diabetic nephropathy. (n.d.). Retrieved February 1, 2015, from http://www.mayoclinic.org/diseases-conditions/diabetic-nephropathy/care-at-mayo-clinic/tests-diagnosis/con-20035589

Kidney biopsy. (n.d.). Retrieved February 1, 2015, from http://www.mayoclinic.org/tests-procedures/kidney-biopsy/basics/definition/prc-20018979

Pathophysiology of Diabetic Nephropathy-What causes nephropathy!

As we know, diabetic nephropathy occurs when the kidneys do not function properly on a microvascular level. We already know it is caused by diabetes, but it is is due to a variety of factors on a microscopic level. Mainly, hypertension and hyperglycemia damages the glomerulus (a functional unit of the kidney) is under a lot of pressure to filter the blood. This is a hemodynamic change of the glomerular hyperperfusion and hyperfiltration, resulting in microalbuminuria. 

What do all theses words mean?

Hemodynamic is of or relating to the flow of blood within the body system. 

Hyperperfusion means an increase of blood flow. 

Hyperfiltration is an increase of an abnormal increase in filtration. 

Continuing on....

The glomerulus is under a lot of stress, and eventually leaks albumin from the capillaries. Albumin is a major protein found in the blood and we don't want lose it! It's important.  If that is excreted out of the body, instead of kept, it can lead to the glomerular basement membrane thickening. The thickening of the basement membrane slow down the filtration rate since there's less room for the blood to bypass. This will also increase the levels of albumin when excreted in the urine (microalbuminiuria). 

Below is a complicated image that gives you an image of increase hypertension to the glomerular, leads to mesangial expansion, thickening of the glomerular basement membrane (GBM), and podocyte injury (podocypathy). Podocyte is a fucntion unit of the kidney that helps filtrate the blood. The basement membrane is composed of mesangial cells, that make up bowman's capsule of the glomerulus. When all these various functional units are affected, it leads to dysfunction.

Image from Nature.com. Link below. http://www.nature.com/nrneph/journal/v10/n2/images_article/nrneph.2013.272-f1.jpg

Furthermore, the mesangial cells that hold the capillaries in the glomerulus together, respond to injury by releasing cytokines. Cytokines lead to inflammation and mesangial cell expansion. In diabetic nephropathy, mesangial cells respond with increased pressure and injury that is caused by high blood glucose. This later can cause kidney failure leading to ERSD (previous mentioned earlier posts). This is definitely not good so we will talk about how you can diagnose this disease!

Here's a video link for those who are interested!

Next week, we will discuss how you diagnose the disease!

Citations:

1. Bakris, G. (n.d.). Recognition, Pathogenesis, and Treatment of Different Stages of Nephropathy in Patients With Type 2 Diabetes Mellitus. Mayo Clinic Proceedings, 444-456. Retrieved January 25, 2015.

2. Schena, F. (2005). Pathogenetic Mechanisms of Diabetic Nephropathy.Journal of the American Society of Nephrology, S30-S33.

3. Diabetic Nephropathy. (2000, January 1). Retrieved January 25, 2015, from http://journal.diabetes.org/clinicaldiabetes/v18n12000/Pg7.htm

4. Lewis, S. (2014). Medical-surgical nursing: Assessment and management of clinical problems. (8th ed.). St. Louis, Mo.: Elsevier/Mosby.

5. Plasma. (n.d.). Retrieved January 25, 2015, from http://www.redcrossblood.org/learn-about-blood/blood-components/plasma

6. (n.d.). Retrieved January 25, 2015, from http://www.rjme.ro/RJME/resources/files/530112023027.pdf

(Epidemiology) Prevalence of Diabetic Nephropathy!

Diabetes nephropathy (Diabetic kidney disease) is the leading cause of chronic kidney disease (CKD) and end stage renal disease (ESRD) as mention in the earlier post.  According to the Centers for Disease Control and Prevention and the National Diabetes Statistic reports that adults with diabetes are 2-3 times as likely to have CKD and make up 44% of new ESRD cases.  Furthermore, the American Diabetes Association states about 20-30% of the patients with type 1 or type 2 diabetes will develop nephropathy. However, with type 2 diabetes, these people are more susceptible to ESRD.  Therefore, people with diabetics must monitor their blood sugar before it damages the kidneys.  An early start to taking care of oneself will decrease your risk of complications in the future.

Diabetic nephropathy varies by racial/ethnic background. Native Americans, Hispanics (especially Mexican Americans), and African Americans are at higher risk of developing ESRD with type 2 diabetes compared those to non-Hispanic whites. You can see it here according to this data from CDC (click on the pdf link to see http://www.cdc.gov/nchs/data/hus/2011/051.pdf ). This shows how diabetes is the leading cause of kidney ESRD. Hypertension is the second diagnosis in relation to ESRD.

Below is a kidney disease mortality from the CDC and National Vital Statistics System . In Washington state alone (2012), there were 482 deaths who suffered from kidney disease. There were a total of 45,622 deaths in the USA. 

 I couldn't find a chart with the morbidity of kidney disease so below is a summary of morbidity and mortality from the CDC. Please click on this link (http://www.cdc.gov/nchs/fastats/kidney-disease.htm) to see more information. As summarized below, about 1.7 percent of adults are diagnosed with kidney disease, which is the frequency of the disease. However, mortality is the number of deaths caused of kidney disease, which is 9 total from 2011.

Prevention and detection are key to avoid any complication with the kidney for those with diabetes. 

Tune in to next week for etiology and pathophysiology of the disease! Stay happy and healthy!  




Citations: 

1. Diabetes Care. (n.d.). Retrieved January 18, 2015, from http://care.diabetesjournals.org/content/25/suppl_1/s85.full

2. Van Buren, P., & Toto, R. (n.d.). Hypertension In Diabetic Nephropathy: Epidemiology, Mechanisms, And Management. Advances in Chronic Kidney Disease, 28-41.

3. (n.d.). Retrieved January 18, 2015, from http://www.cdc.gov/nchs/data/hus/2011/051.pdf 

4. (n.d.). Retrieved January 18, 2015, from http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf

5. (n.d.). Retrieved January 18, 2015, from http://www.cdc.gov/nchs/data/hpdata2020/hp2020_D_CKD_progress_review_presentation.pdf  

6. Kidney Disease. (2014, July 14). Retrieved January 18, 2015, from http://www.cdc.gov/nchs/fastats/kidney-disease.htm