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CHAPTER 1

INTRODUCTION

1.1 Backgrounds

Kidney is a vital organ that plays a very important very important in maintaining the

stability of the environment in the body. The kidneys regulate the body's fluid and electrolyte

balance and acid base by filtering blood through the kidneys, selective reabsorption of water,

electrolytes and non-electrolytes, as well as urinary excrete the excess. The primary function of

the kidneys is to maintain the volume and composition of extracellular fluid within normal

limits. Composition and extracellular fluid volume is controlled by glomerular filtration, tubular

reabsorption and secretion.Kidney traversed about 1,200 ml of blood per minute, a volume equal

to 20 to 25 percent of cardiac output (5,000 ml per minute).

In developed countries, non-communicable chronic diseases (cronic non-communicable

diseases), especially cardiovascular disease, hypertension, diabetes mellitus, and chronic kidney

disease, has replaced infectious diseases (communicable diseases) as a major public health

problem. Impaired renal function can describe the condition of the vascular system so it can be

very helpful in preventing the disease early before patients experience more severe complicationssuch as stroke, coronary heart disease, kidney failure, and peripheral vascular disease. On

chronic kidney disease decreased kidney function requiring replacement therapy is expensive.

Chronic kidney disease is usually followed various complications such as cardiovascular disease,

respiratory disease, gastrointestinal disease, abnormalities in bone and muscle as well as anemia.

During this time, the management of chronic kidney disease prefer the diagnosis and treatment

of specific renal disease is a cause of chronic kidney disease and dialysis or kidney transplant if

you have kidney failure. Scientific evidence suggests that the complications of chronic kidney

disease, irrespective of etiology, can be prevented or inhibited if done early treatment. Therefore,

efforts should be undertaken is early diagnosis and effective prevention of chronic kidney

disease, and this is possible due to a variety of risk factors for chronic kidney disease can be

controlled.

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1.2 Purposes

This assigment have a several purpose first in future we hope student can explain about

anatomy and physiology Kidney, Twice Student can explain about sign and medical tests

detect kidney disease . Third student can explain about etiology of chronic kidney disease,

And the last but not least Student know how to deal with chronic kidney disease and also

student can writing scientific writing like English in nursing.

1.3 Benefits

The benefits of this assigment are students will know how to make a good assigment and

students will explore more about their vocabulary and their tenses skill writing scientific

paper in English also students can develop their knowledge about many disease likeChronic Kidney Disease.

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CHAPTER 2

REVIEW

2.1 Anatomy and physiology

Understanding how the urinary system helps maintain homeostasis by removing harmful

substances from the blood and regulating water balance in the body is an important part of

physiology. The kidneys, which are the main part of the urinary system, are made up of millions

of nephrons that act as individual filtering units and are complex structures themselves. The

ureters, urethra, and urinary bladder complete this intricate system.

The urinary system helps maintain homeostasis by regulating water balance and by removing

harmful substances from the blood. The blood is filtered by two kidneys, which produce urine, a

fluid containing toxic substances and waste products. From each kidney, the urine flows through

a tube, the ureter, to the urinary bladder, where it is stored until it is expelled from the body

through another tube, the urethra.

Figure 1

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Figure 2

Nephrons

The kidney consists of over a million individual filtering units called nephrons. Each nephron

consists of a filtering body, the renal corpuscle, and a urine-collecting and concentrating tube,

the renal tubule, shown in Figure 2.

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a. The renal tubule consists of three sections:

1. The first section, the proximal convoluted tubule (PCT), exits the

glomerular capsule as a winding tube in the renal cortex. The high-energy

yield and large surface area of these cells support their functions of

reabsorption and secretion.

2. The middle of the tubule, the nephron loop, is shaped like a hairpin and

consists of a descending limb that drops into the renal medulla and an

ascending limb that rises back into the renal cortex.

3. The final section, the distal convoluted tubule (DCT), coils within the

renal cortex and empties into the collecting duct. Cells here are cuboidal

with few microvilli.

The operation of the human nephron consists of three processes:

a) Glomerular filtration

b) Tubular reabsorption

c) Tubular secretion

In summary, three processes occurring in successive portions of the nephron accomplish the

function of urine formation:1. Filtration of water and dissolved substances out of the blood in the glomeruli and into

Bowman's capsule;

2. Reabsorption occurs in the proximal tubules of the nephron. Reabsorption of water and

dissolved substances out of the kidney tubules back into the blood (note that this process

prevents substances needed by the body from being lost in the urine);3. Secretion occurs around the distal and collecting tubules into those tubules. Secretion of

hydrogen ions (H+), potassium ions (K+), ammonia (NH3), and certain drugs out of the

blood and into the kidney tubules, where they are eventually eliminated in the urine.

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1.2 Types and Clasification of Chronic Kidney Disease

Definition

Chronic kidney disease is a decrease of kidney function to maintain metabolic,

fluid and electrolyte balance consequent from destruction of kidney structure that

progressive with manifestations residual buildup of metabolites (toxic uremic) in the

blood.

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2.3 Sign and medical tests detect kidney disease

2.3.1 Sign the Chronic Kidney Disease

People in the early stages of chronic kidney disease usually do not feel sick at all.

People whose kidney disease has gotten worse may:

1. need to urinate more often or less often

2. feel tired

3. lose their appetite or experience nausea and vomiting

4. have swelling in their hands or feet

5. feel itchy or numb

6. get drowsy or have trouble concentrating

7. have darkened skin

8. have muscle cramps

2.3.2 Medical tests detect kidney disease

Because a person can have kidney disease without any symptoms, a doctor may first

detect the condition through routine blood and urine tests. The National Kidney Foundation

recommends three simple tests to screen for kidney disease: a blood pressure measurement, a

spot check for protein or albumin in the urine, and a calculation of glomerular filtration rate

(GFR) based on a serum creatinine measurement. Measuring urea nitrogen in the blood provides

additional information.

2.3.2.1 Blood Pressure Measurement

. A person's blood pressure is considered normal if it stays below 120/80, stated as "120

over 80." Recommends that people with kidney disease use whatever therapy is necessary,

including lifestyle changes and medicines, to keep their blood pressure below 130/80.

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2.3.2.2 Microalbuminuria and Proteinuria

Healthy kidneys take wastes out of the blood but leave protein. Impaired kidneys may fail

to separate a blood protein called albumin from the wastes. At first, only small amounts of

albumin may leak into the urine, a condition known as microalbuminuria, a sign of deteriorating

kidney function. As kidney function worsens, the amount of albumin and other proteins in the

urine increases, and the condition is called proteinuria. A doctor may test for protein using a

dipstick in a small sample of a person's urine taken in the doctor's office. The color of the

dipstick indicates the presence or absence of proteinuria.

A more sensitive test for protein or albumin in the urine involves laboratory measurement

and calculation of the protein-to-creatinine or albumin-to-creatinine ratio. Creatinine is a waste

product in the blood created by the normal breakdown of muscle cells during activity. Healthy

kidneys take creatinine out of the blood and put it into the urine to leave the body. When the

kidneys are not working well, creatinine builds up in the blood.

The albumin-to-creatinine measurement should be used to detect kidney disease in people at high

risk, especially those with diabetes or high blood pressure. If a person's first laboratory test

shows high levels of protein, another test should be done 1 to 2 weeks later. If the second test

also shows high levels of protein, the person has persistent proteinuria and should haveadditional tests to evaluate kidney function.

2.3.2.3 Glomerular Filtration Rate (GFR) Based on Creatinine Measurement

GFR is a calculation of how efficiently the kidneys are filtering wastes from the blood. A

traditional GFR calculation requires an injection into the bloodstream of a substance that is later

measured in a 24-hour urine collection. Recently, scientists found they could calculate GFR

without an injection or urine collection. The new calculation-the eGFR-requires only a

measurement of the creatinine in a blood sample.

In a laboratory, a person's blood is tested to see how many milligrams of creatinine are in one

deciliter of blood (mg/dL). Creatinine levels in the blood can vary, and each laboratory has its

own normal range, usually 0.6 to 1.2 mg/dL. A person whose creatinine level is only slightly

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above this range will probably not feel sick, but the elevation is a sign that the kidneys are not

working at full strength. One formula for estimating kidney function equates a creatinine level of

1.7 mg/dL for most men and 1.4 mg/dL for most women to 50 percent of normal kidney

function. But because creatinine values are so variable and can be affected by diet, a GFR

calculation is more accurate for determining whether a person has reduced kidney function.

2.3.2.4 Blood Urea Nitrogen (BUN)

Blood carries protein to cells throughout the body. After the cells use the protein, the remaining

waste product is returned to the blood as urea, a compound that contains nitrogen. Healthy

kidneys take urea out of the blood and put it in the urine. If a person's kidneys are not working

well, the urea will stay in the blood.

A deciliter of normal blood contains 7 to 20 milligrams of urea. If a person's BUN is more than

20 mg/dL, the kidneys may not be working at full strength. Other possible causes of an elevated

BUN include dehydration and heart failure.

Medical Test for CKD Normal range

1. Kreatinin Male : 0,6-1,3 mg/dl. Female : 0,5-1,0 mg/dl

2. BUN 5 25 mg/dl

3. GFR Male : 120+25 ml/mnt Female :95/20 ml/mnt

2.5 Chronic Kidney Disease clinical assessment.

1. History.

Taking a thorough and accurate history is an essential part of the assessment process the

patients history provides the foundation and direction for the rest of the assessment. The

overall goal of the patient interview is to expose key clinical manifestations that will

facilitate the identification of the underlying cause of the illness. A review of the patients

current illness and symptoms, including presence weight changes, B/P changes, increased

pulse, increased respirations, neck vein distention, dependent, peripheral edema,

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increased fluid intake, increased sodium intake, decreased fluid volume . This

information then assist in the development of an appropriate management or plan.

2. Clinical assessment.

Four techniques are used in the physical assessment, there are, inspection, palpation,

percussion, and auscultation.

a. Inspection should focus on the skin, moist skin ,and vaskuler.

b. Palpation should focus on oedema in foot and skin turgor .

c. Percussion should focus on underlying kidney structure.

d. Auscultation should focus on the presence or absence of normal breath sounds, and

the kidney.

3. Treatment

Controlling blood pressure will slow further kidney damage.

a) Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers

(ARBs) are used most often.

b) The goal is to keep blood pressure at or below 130/80 mmHg

Other tips for protecting the kidneys and preventing heart disease and stroke:

a) Do not smoke.

b) Eat meals that are low in fat and cholesterol.

c) Get regular exercise (talk to your doctor or nurse before starting to exercise).

d) Take drugs to lower your cholesterol, if needed.

e) Keep your blood sugar under control.

f) Avoid eating too much salt or potassium.

Always talk to your kidney doctor before taking any over-the-counter medicine, vitamin, or

herbal supplement. Make sure all of the doctors you visit know you have chronic kidney disease.

Other treatments may include:

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1. Special medicines called phosphate binders, to help prevent phosphorous levels from

becoming too high

2. Treatment for anemia, such as extra iron in the diet, iron pills, iron through a vein

(intravenous iron) special shots of a medicine called erythropoietin, and blood

transfusions

3. Extra calcium and vitamin D (always talk to your doctor before taking)

You may need to make changes in your diet. You may need to limit fluids.

1. Your health care provider may recommend a low-protein diet.

2. You may have to restrict salt, potassium, phosphorous, and other electrolytes.

3. It is important to get enough calories when you are losing weight.

Nursing care in chronic kidney disease

Definition

Chronic kidney disease is a decrease of kidney function to maintain metabolic, fluid and

electrolyte balance consequent from destruction of kidney structure that progressive with

manifestations residual buildup of metabolites (toxic uremic) in the blood.

Etiology

Response that occurs is a decrease of kidney function that progressive . Clinical condition allows

can lead to chronic renal failure can be caused from the kidney itself and outside the kidney.

Diseases from kidney

1. Diseases on the kidney filter (glomerulus) called glomerulonephritis

2. Germ infection: pyelonephritis, ureteritis

3. Kidney stones: neftrolitiasis

4. Cysts in the kidney: kidney polcystis

5. Direct trauma of the kidney

6. Malignancy on the kidney

7. There obstruction such as stones, tumors, narrowing / stricture

Common disease in the outside kidney

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a) Systemic diseases such as diabetes mellitus, hypertension, and high cholesterol

b) Dyslipidemia

c) Infection in the body such as pulmonary tuberculosis, syphilis, malaria, and hepatitis

d) Preeclampsia

e) Drugs

f) A lot of liquid that lost with sudden (burns)

Chronic kidney disease may result from any cause of renal dysfunction of sufficient

magnitude .The most common cause is diabetic nephropathy followed by hypertensive

nephroangiosclerosis and various primary and secondary glomerulopathies. Metabolic syndrome,

in which hypertension and type 2 diabetes are present, is a large and growing cause of renal

damage. Diabetes and high blood pressure are the two most common causes and account formost cases.

Many other diseases and conditions can damage the kidneys, including:

a) Autoimmune disorders (such as systemic lupus erythematosus and scleroderma)

b) Birth defects of the kidneys (such as polycystic kidney disease)

c) Certain toxic chemicals

d) Glomerulonephritise) Injury or trauma

f) Kidney stones and infection

g) Problems with the arteries leading to or inside the kidneys

h) Some pain medications and other drugs (such as cancer drugs)

i) Reflux nephropathy (in which the kidneys are damaged by the backward flow of urine

into the kidneys)

j) Other kidney diseases

Chronic kidney disease leads to a buildup of fluid and waste products in the body. This condition

affects most body systems and functions, including:

Blood pressure control

Red blood cell production

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Vitamin D and bone health

Pathophysiology

Pathophysiology of chronic kidney disease began in the early phase the disorder of fluid

balance, salt handling, and the accumulation of residual substances still vary and depend on the

side of kidney that ill. This process untill the kidney function is less than 25% of normal, the

clinical manifestations of chronic renal failure may be minimal, because the nephron-nephron

which healthy takes over the function of damaged nephrons. The remaining nephrons increase

the speed of filtration, reabsorption, secretion and hypertrophy.

Along with the increasing number of nephrons is dead, then the remaining nephrons

facing an increasingly tough task so that the nephron-nephron were damaged and eventually die.

Sebgian from the cycle of death is apparently due to the demands on existing nephron-nephron toincrease protein reabsorption. By the time a progressive nephron-nephron, the formation of scar

tissue and renal blood flow is reduced. Renin release will increase along with fluid overload that

can cause hypertension. Hypertension will worsen the condition of kidney failure, with the aim

of increased filtration of plasma proteins. Conditions will get worse with more and more scar

tissue formed in response to the progressive destruction of nephrons and renal function declined

rapidly with the accumulation of metabolites manifestation that should be excluded from the

circulation and causes a severe uremia syndrome which gives many manifestations in any organ

of the body.

Impact of chronic kidney failure provide a variety of nursing issues. Mechanisms of the

emergence of nursing problems. Here's the picture:

13

Fluid volume increaseshypernatremia

hyperkalemia

Ph decreases

Hiperpospatemia andhypocalcemia

Response hyperkalemiaDamage to nerve impulses

conduction disturbances

Electrical ventricularmuscle

Arhythmia

High risk ofseizures

Decrease in

cerebral perfusion

Response to hypocalcemia

PTH increases

Decreased bone calciumdeposits

Activation SRAA

metabolic acidosis

Systemic hypertension

Excess

fluidvolume

Increased cardiac

workload

Decreased cardiac output

Decreased cardiac output

Decrease in tissue

perfusion

Osteodystrophy ginjal

Uremic syndrom

Response to metacidosis and u

syndrome on the ne

and respiratory system1. Kussmaul breathing

2. Lethargy, dec

awareness3. Edemas increased

cell

4. Cerebral dysfunctio5. Peripheral neuropat

Breathipattern diso

Process changemindset

neurologic deficit

Ketikkan teks atau alamat situs web atau terjemahkan dokumen.

Batal

Contoh penggunaan "":diterjemahkan oleh Google secara otomatis

GFR decreased metabolism and cause failure to maintain fluid and

electrolyte balanceUremic toxic buildup in the blood

Fluid and electrolyte imbalance.

Various conditions that cause decreased

nephron function

Compensation mechanism and adaptation of nephrons causing increased mortalitynephron forming scar tissue and decreased renal blood flow

Progressive destruction of kidney structure

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Picture 6.3 Pathophysiology GKK to nursing problems in the respiratory system, cardiovascular

system, and nervous system

Stadium

Chronic renal failure is always associated with a progressive decline in GFR. Stages of chronic

renal failure is based on the remaining level of GFR and include the following.

1. Decrease renal reserve, which occurs when the GFR decreased 50% from normal.

2. Renal insufficiency, which occurs when the GFR decreased to 20-35% of normal. Nephron-

nephron remains highly vulnerable to damage themselves because of the weight they receive.

3. Kidney failure, which occurs when the GFR is less than 20% of normal. The more nephrons

are dead.

4. Terminal renal failure, which occurs when the GFR to less than 5% of normal. Only a few

remaining functional nephrons. On the whole kidney was found scarring and tubular atrophy.

Response of disorders on the Chronic Kidney Disease

1) Fluid imbalance

Early loss of kidney function and is unable to concentrate urine (hipothenuria) and

excessive fluid loss (polyuria). Hipothenuria not caused by or associated with a reduced

number of nephrons, but by increasing the load the substance of each nephron. This happens

because the integrity of nephrons that carry these substances and excess water for nephron-

nephron function can not be long. Occurs osmotic diuretic, causing a person to become

dehydrated.

If the number of nephrons are not functioning increases, the kidneys are unable to

filter urine (isothenuria). At this tahp glomerular plasma becomes stiff and can not be

filtered easily through the tubules, there will be excess liquid with water and sodium

retention.

2) Sodium imbalance

Sodium imbalance is a serious problem in which the kidneys can remove at least 20-

30 mEq of sodium per day or can be increased to 200 mEq per day. Variations in sodium

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loss associated with intact nephron theory. In other words, if there is damage to the

nephrons, then there is no exchange of sodium.

Nephrons with excess sodium that causes decreased GFR and dehydration. Increased

loss of sodium in gastrointestinal disorders, especially vomiting and diarrhea. This situation

worsen hyponatremia and dehydration.

GGK heavy on sodium balance can be maintained despite the loss in the value of

flexible sodium. Healthy people can also rise above 500 mEq / day. When the GFR falls

below 25-30 ml / min, the excretion of sodium less than 25 mEq / day, the maximum

excretion of 150-200 mEq / day. At this state of the sodium in the diet is limited at around 1-

1.5 grams / day.

3) Potassium imbalance

If the balance of fluid and controlled metabolic acidosis, hyperkalemia rarely occurs

before the stadium IV. Potassium balance associated with aldosterone secretion. During

urine output was maintained, potassium levels are usually maintained. Hiperkaliemia occurs

due to excessive potassium intake, the effect of treatment, hiperkatabolik (infection), or

hyponatremia. Hyperkalemia is also a characteristic of the stage uremia.

Hypokalemia occurred in the state of severe vomiting or diarrhea, the renal tubular

disease, and kidney disease nephrons, where this condition will lead to increased excretion

of potassium. If persistent hypokalemia, the possibility of decreased GFR and increased

NH3 production; HCO3 decreased and sodium survive.

4) Bases Acid Imbalance

Metabolic acidosis occurs because the kidneys are unable to excrete hydrogen ions to

maintain normal blood pH. Renal tubular dysfunction resulting in the inability of H ions and

expenses generally decreased excretion of H + is proportional to the drop in GFR. The acid

is continuously formed by the metabolism in the body and is not filtered effectively, NH3

decreased and tubular cells are not functioning. Failure of bicarbonate formation aggravate

imbalances. Some of the excess hydrogen dibuffer by bone mineral. As a result of metabolic

acidosis allow osteodystrophy.

5) Magnesium imbalance

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Magnesium in the early stages of CRF was normal, but decreased progressively in

the excretion of urine, causing accumulation. Combination of decreased excretion and

excessive intake can lead hipermagnesiemia stopped breathing and heart.

6) Imbalance of Calcium and Phosphorus

In normal calcium and phosphorus retained by the parathyroid hormone that causes

the kidneys reabsorbing calcium, mobilization of calcium from bone, and depressed tubular

reabsorption of phosphorus. If renal function decreases 20-25% of normal,

hyperphosphatemia and hypocalcemia occurred causing secondary hiperparathyroidisme.

Impaired metabolism of vitamin D and when hiperparathyroidisme lasts for a long time

resulting in osteorenal dystrophy.

7) Anemia

Hb decline caused by the following things.

1. Damage erythropoietin production.

2. The life span of red blood cells due to changes in plasma short.

3. Increased red blood cell loss due to gastrointestinal ulceration, dialysis, and blood

sampling for laboratory examination.

4. Inadequate nutritional intake.

5. Folate deficiency.

6. Iron deficiency / iron.

7. Increase in parathyroid hormone stimulates fibrous tissue or osteitis fibrosis, causes the

production of blood cells in the marrow decreased.

8) Creatinine urea

The result of proteins metabolic is urea that increased (accumulated). The BUN

content (blood urea nitrogen) are not a right indicator from kidney disease because an

increase of BUN occurred in a decrease in GFR and an increase in protein intake.

Assessment of serum creatinine is a better indicator in renal failure because of creatinine

excretion equal to the amount produced by the body.

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Assessment

The main complaint

The main complaint is usually obtained varied, begin urine output a little until cant

urinate, restless until loss of awareness, no appetite (anorexia), nausea, vomiting, dry mouth,

fatigue, breath odor (urea), and itching on the skin.

Health History Now

Nurse assess the decrease in the quantity of urine output, decrease of awareness, changes

in breathing patterns, physical weakness, changes in skin turgor and skin colour, breath odor of

ammonia, and changes in nutrition needs. Nurse assess information about where are patients

need to solve the problem and what is patients get any treatment.

Health History Ago

Nurse assess the history of kidney disease of patient, urinary tract infections, heart failure,

use of nephrotoxic drugs, Benign prostatic hyperplasia, and prostatectomy. Nurse assess the

urinary tract stone disease, recurrent urinary tract infections, diabetes mellitus, and hypertension

in the past that predispose to disease. The important information to nurse assessment about the

history of using drug in the past time and the history of allergy to drugs. And then documented

by Nurse.

Psychosocial

A change in the function of the body structure and the dialysis will cause the patient to

experience disturbances in self-image. Long treatment time, costs a lot of care and treatment

causes patients to experience anxiety, impaired self-concept (self-image) and the role of family

disruption (self esteem).

Physical examination

General conditional and Vital sign

Patient's general condition is weak and looks so sick. Level of awareness is decrease according to

the level of uremia which can affect the central nervous system. Vital sign is often changed and

respiratory rate increased. changes the blood pressure from mild to severe hypertension.

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B1 (breathing)

In this phase is often obtained the clients breath odor such as urine (uremic fetor). Uremia

response is often obtained in the kussmaul breathing. Breath pattern is fast and deep is effort to

disposal of carbon dioxide that accumulates in circulation.

B2 (blood)

Nurse auscultation action will find a friction rub which is a typical sign of pericardial effusion on

the condition of severe uremia. There are the sign and symptoms of congestive heart failure,

Blood pressure increased, the CRT value is more 3 seconds, palpitations, chest pain or angina

and shortness of breath, heart rhythm disturbances, edema decreased peripheral perfusion

secondary from decreased of cardiac output consequent from hyperkalemi, and electrical

conduction disturbances in ventricular muscle.

Anemia is often obtained on hematological system. Anemia as consequent from decreased

production of erythropoietin, uremic gastrointestinal lesions, red blood cell age is decreased, and

blood loss that usually from the GI tract, bleeding tendency secondary to thrombocytopenia.

B3 (brain)

Physical examination action in the brain, nurse get signs the level of awareness is decreased,

dysfunction of cerebral, such as changes in thought processes and disorientation. Clients often

get the seizures, the peripheral neuropathy, burning feet syndrome, restless leg syndrome, muscle

cramps and muscle aches.

B4 (bladder)

Decrease in urine output less than 400 ml per day until anuri, decreased of severe libido.

B5 (bowel)

There signs such as the nausea and vomiting, anorexia and diarrhea secondary to ammonia

breath, inflammation of the oral mucosa, and gastrointestinal ulcers so often found decreased

nutritional intake from normal needs.

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B6 (bone)

There signs such as the pelvic pain, headaches, muscle cramps, leg pain (worse at night), skin

gatel, existing or recurrent infections, pruritus, fever (sepsis, dehidrase), petechiae, akemosis area

of the skin, bone fractures, defosit phosphate calcium, skin, soft tissue, and joint motion

limitations.

There are general physical weakness secondary from anemia and decreased a peripheral

perfusion from hypertension.

Diagnostic Assessment

Laboratory

1. Erythrocyte sedimentation rate is rising and severe if anemia, hypoalbuminemia and count of

reticulocyte is low.

2. Urea and creatinine is rising, usually the comparisons of urea and creatinine of approximately

20:1. Comparisons are increased because of gastrointestinal bleeding, fever, extensive burns,

steroid treatment, and urinary tract obstruction. This comparison is decreased if count of urea

is more little than creatinine, in a diet low in protein, and decreased creatinine clearance test.

3. Hyponatremia: the generally due to excess fluid. Hyperkalemia: usually occurs in advanced

renal failure along with a decrease in diuresis.

4. Hypocalcemia and hyperphosphatemia: occurs because of decreased synthesis of vitamin D3

in the chronic kidney disease.

5. Increased alkaline phosphate due to impaired bone metabolism, especially bone leachate

phosphatase Isoenzymes.

6. Hypoalbuminemia and hipokolesterolemia; generally caused by metabolic disorders and low-

protein diet.

7. Elevation of blood sugar, because disorders of carbohydrate metabolism in condition renal

failure (resistance to the effects of insulin in peripheral tissues).

8. Hypertriglyceride, due to disorders of fat metabolism, caused elevation of the hormone insulin

and decrease lipoprotein lipase.

9. Metabolic acidosis with respiratory compensation suggests that decreased pH, BE decreased,

decreased HCO3, PCO2, all caused retention of organic acids in renal failure.

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Other Diagnostic Examination

1. Plain abdominal to assess the shape and large kidney (the stone or the existence of an

obstruction). Dehydration will make things worse kidney, therefore patients are not expected

to fast.

2. Intra Venous pielografi (IVP) to assess pelviokalises system and ureter. This examination has

a risk of kidney function decline in certain circumstances, for example: advanced age,

diabetes mellitus, and uric acid nephropathy.

3. Ultrasound to assess and shape of the kidney, thick renal parenchyma, renal parenchymal

density, pelviokalises system anatomy, proximal ureter, bladder, and prostate.

4. Renogram to assess renal function right and left, the location of the disturbance (vascular,

parenchymal, excretion), and residual renal function.

5. ECG to see the possibilities: left ventricular hypertrophy, signs of pericarditis, arrhythmias,

electrolyte disturbances (hyperkalemia).

Actual / high risk for excess fluid volume bd decrease in urine volume, fluid retention and

sodium

Objective: In a 1x24 time avoid excess systemic fluid volume.

Evaluation criteria:

- Clients no shortness of breath, reduced extremity edema, edema light socket (-), urine output>

600 ml / hr.

intervention Rational

Assess the extremity edema. Suspect failing congestive / excess fluid

volume.

Rest / advise client on bed rest when edema is

still going on.

Keeping clients in the state of bed rest for a

few days may be needed to increase diuresis

aimed at reducing edema.

Assess blood pressure. As one way to find an increase in the amountof fluid which can be determined by increasing

the workload of the heart that can be seen from

the increase in blood pressure.

measuring intake and output decrease in cardiac output, resulting in

impaired renal perfusion, sodium or water

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retention, and decreased urine output.

Weigh weight sudden changes of body weight showed

impaired fluid balance.

provide supplemental oxygen by nasal cannula

or mask according to indications.

increase the dosage of oxygen to the need to

counter the effects of myocardial hypoxia orischemia.

collaboration

given a diet without salt.

provide high protein low calorie diet.

give diuretics, eg, furosemide, spironolaktone,

hidronolaktone.

adenokortikosteroid, prednisone group.

do dialysis.

Sodium increases fluid retention and increased

plasma volume.

low-protein diet to lower renal insufficiency

and nitrogen retention which will increase

BUN. high calorie diet for energy reserves and

reduce protein catabolism.

diuretics aims to reduce plasma volume and

reduce fluid retention in the tissues thus

reducing the risk of pulmonary edema.

adenokortikosteroid, prednisone used to lower

class Proteinuri.

dialysis will reduce the volume of excessliquid.

Evaluation

Results are expected after chronic renal failure patients get the following interventions:

1. Ineffective breathing pattern back

2. Not a decrease in cardiac output

3. No arrhythmias

4. Avoid excess body fluid volume

5. Increase in cerebral perfusion

6. The patient did not experience any neurological deficit

7. Not suffered soft tissue injuries

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CONCLUSION

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Chronic kidney disease is a significant public health issue and challenge to healthcare

professionals. Many patients with stages 1 to 3 of chronic kidney disease are manage

effectively in community with minimal medical and nursing intervention and will rarely

reach the latter stages of chronic kidney disease. By identifying those patients at risk of

developing chronic kidney disease and having effective management strategies in place,

such as good glycaemic control, blood pressure and cholesterol control, it is likely that

the progress of chronic kidney disease will be delayed. Nurses in primary and secondary

care can help patients to understand chronic kidney disease, lifestyle modifications and

concordance with medications.

BIBLIOGRAPHY

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Anderson, S.P.(2006). Pathophysiology: Clinical concepts of diseasep processes (6thedition 2nd

volume). Jakarta: EGC.

National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease:

evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1. Diakses tanggal 27

April 2013 pukul 16.00.

Sloane, E.(2004).Anatomy and Physiology An Easy Learner. Jakarta: EGC.page 266-277

White, L., Duncan and Gena. (2002). Medical-Surgical Nursing: An Integrated Approach (2nd

Ed). United States: Columbia circle.

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http://www.uptodate.com/contents/epidemiology-etiology-and-course-of-chronic-kidney-disease-in-children/abstract/1http://www.uptodate.com/contents/epidemiology-etiology-and-course-of-chronic-kidney-disease-in-children/abstract/1http://www.uptodate.com/contents/epidemiology-etiology-and-course-of-chronic-kidney-disease-in-children/abstract/1http://www.uptodate.com/contents/epidemiology-etiology-and-course-of-chronic-kidney-disease-in-children/abstract/1