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Article Excerpt
Children with chronic kidney disease (CKD) present complex clinical challenges to nurses in inpatient and outpatient settings (Miller, Macdonald, Kolnacki, & Simek, 2004). CKD involves the irreversible loss of renal function to the extent that the kidneys are unable to meet the metabolic demands of the body. Typically, CKD progresses gradually over a period of months or years and is associated with a variety of complications, including electrolyte imbalances, malnutrition, metabolic acidosis, anemia, bone disease, and growth failure. The goals of treatment for CKD are to delay progression of the underlying disease and to minimize the impact of associated complications. These patients require lifelong disease management.
The complexity of the therapeutic regimen for CKD requires that nurses have a thorough knowledge of the disease for education and reassurance purposes. Nurses providing inpatient care for children with CKD play an important role in the treatment of acute complications as well as in the implementation of strategies for lifelong management of CKD and its comorbidities.
We present a case study that reflects many of the challenges encountered in the nursing management of CKD in children, highlighting the nurse's role in formulating an appropriate plan of care. Where possible, we provide guidelines for continuing care in the outpatient setting.
Chronic Kidney Disease: Background
The U.S. National Kidney Foundation (NKF) defines CKD as the presence of kidney damage or decreased kidney function for at least 3 months, irrespective of the underlying diagnosis (National Kidney Foundation Kidney Disease Outcomes Quality Initiative [NKF-K/DOQI], 2002a). Kidney damage includes any structural or functional abnormality of the kidney involving pathologic, laboratory, or imaging manifestations. Decreased kidney function is defined by a reduction in the glomerular filtration rate (GFR) to below 60 mL/min/1.73 [m.sup.2], the level at which at least half of normal adult kidney function is lost (National Kidney Foundation Kidney Disease Outcomes Quality Initiative [NKF-K/DOQI], 2002b). The NKF classification for CKD identifies 5 stages of severity, reflecting increasing degrees of kidney damage or dysfunction (see Table 1).
According to the U.S. Renal Data System (USRDS), the incidence of end-stage renal disease (CKD stage 5) in the pediatric population (aged to 19 years) has increased gradually since 1980; in 2002 the incidence and prevalence rates of ESRD were 1.5 and 8.2 per 100,000 children, respectively (USRDS, 2004). However, because the early stages of CKD are often asymptomatic, the precise incidence of CKD is unknown. Nevertheless, the prevalence of early stage CKD is believed to be higher than that associated with kidney failure (NKF-K/DOQI, 2002a, 2002b). This belief combined with the complications associated with CKD emphasizes the importance of early recognition and initiation of measures to slow the progression of CKD.
Accurate CKD staging may be useful in guiding the timing and type of therapeutic interventions initiated, given that complications often are related to the degree of renal dysfunction (see Table 1). CKD staging in children is best achieved by estimating the GFR. The most common method for estimating the GFR in children is the Schwartz formula, which incorporates body weight, height, and serum creatinine level (see Table 2) (Schwartz, Haycock, Edelmann, & Spitzer, 1976). Fortunately, this simple method does not require a 24-hour urine collection, which is nearly impossible in children who are not toilet trained. Research has shown that use of 24-hour or timed urine samples does not provide a substantial improvement in creatinine clearance estimates compared with estimates determined using the Schwartz formula (NKF-K/DOQ, 2002a, 2002b).
The primary etiology of CKD in children varies with age; however, the most common cause is structural abnormality, including obstructive uropathy (see Table 3) (North American Pediatric Renal Transplant Cooperative Study [NAPRTCS], 2004). The present case study describes a child with CKD resulting from posterior urethral valves (PUV), a congenital condition in which the lower urinary tract is obstructed. PUV affects 1 in 3,000 to 8,000 male infants (Yohannes & Hanna, 2002) and is the most common congenital obstructive uropathy (Hinds, 2004). Persistently high bladder pressure in these patients can lead to the development of secondary vesicoureteral reflux and renal damage (Hinds, 2004) and an increased incidence of urinary tract infection (UTI), which can further impair renal function (Strand, 2004). Approximately one third of patients with PUV develop CKD during childhood (Yohannes & Hanna, 2002).
Case Study
Summary of present illness. A 7-year-old boy was admitted to the hospital with a 2-day history of fever to 102 degrees F, abdominal pain, vomiting, lack of appetite, and foul-smelling urine. On admission, the patient underwent a nursing assessment. The child appeared dehydrated with sunken eyes and dry, warm skin. Auscultation of the chest revealed no cardiopulmonary abnormalities. Evaluation of the periorbital, pretibial, and sacral regions demonstrated no edema. Vital signs were stable except for a body temperature of 102.2 degrees F and mild tachycardia. Laboratory evaluation included a serum chemistry panel, blood cultures, and complete blood count with differential. A urine sample for culture and analysis was obtained by sterile catheterization. Height and weight were below the 5th percentile, consistent with growth impairment resulting from CKD.
Past medical history. The child's past medical history was significant for CKD secondary to PUV diagnosed at birth. Before this hospital admission, the patient's serum creatinine was stable at 2.0 mg/dL (stage 3 CKD). He was being seen as an outpatient every three months by a pediatric nephrologist and had a history of multiple hospital admissions for urologic surgeries (which included bilateral nephrostomies in the neonatal period and subsequent oblation of the posterior urethral valves, and bilateral reimplantation of the ureters) and multiple episodes of pyelonephritis.
Horne care. Routine home care is provided by the patient's mother and includes clean...
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