Pathophysiology of Chronic Kidney Disease - Coursework Example

Chronic Kidney Disease Chronic Kidney Disease Chronic kidney disease (CKD) is a chronic derangement of the kidney that progresses insidiously for months and years (Graf, Ryan & Green, 2009). The kidney is dominantly involved in the removal of body waste product including nitrogenous waste from the body. It does this through various mechanisms that include filtration and secretion. In CKD, the filtration capacity of the kidney is gradually derailed leading to an impairment in the homeostatic functions carried out by the kidney (Bullock & Hales, 2012). The disease progresses through five stages that include stages one to five with each stage presenting with a lower "estimated glomerular filtration rate (eGFR)" towards stage five (Arora, 2015). In stage one of the disease, kidney damage has already begun but with high eGFR of more than 90ml/min/1.73m2 (Arora, 2015; Lopez-Novoa, Martinez-Salgado, Rodriguez-Pena, Lopez-Hernandez, 2010). The second stage is characterised by a decreased eGFR ranging from 60-89 ml/min/1.73m2 (Lopez-Novoa et al., 2010). In the third stage, the eGFR is about 30-59ml/min/1.73m2. In stage four the eGFR has severely reduced to a range of 15-29ml/min/1.73m2 while in stage five it goes as low as less than 15ml/min/1.73m2 (Arora, 2015). As the disease advances, the clinical symptoms of the diseases begin manifesting commonly in stages four and five of the disease. The following discussion shall entail a discussion on the self-management of the condition by the patient, the legal and ethical implication associated with the disease, the significance of the interprofessional team and the psychological and social aspects of care related to the disease. Self-Management in CKD CKD management requires the active participation of the patient to effectively delay the progression of the disease and initiation of dialysis (Chen et al., 2011). In stage five of the disease or end-stage-kidney-disease (ESKD) self-management by the patient is greatly required due to the increased demand for care resulting from the disease. Self-management is based on the self-management theory that postulates that CKD patients need to be central in the management of their condition such that problems that are significant as perceived by the patient should be addressed in conjunction with the patient (Chen et al., 2011). Maximal function among patients with CKD can be achieved through self-regulation that forms part of self-management process (Lin, Tsai, Lin, Hwang & Chen, 2013). Self-regulation encompasses self-reaction, self-judgement, and self-monitoring. Under self-regulation, the centrality of the patient is emphasised. Patients take time to analyse and judge their environmental problems and behaviour and use their analysis to come up with individualised strategies that support the management of their conditions (Lin et al., 2013). Therefore, a patient with CKD shall have to be supported do personal and environmental analysis to identify strategies that can assist in coping and living positively with the disease to prevent its rapid deterioration. Among the components of self-management identified as significant from patients’ point of view include self-advocacy, partnership in care, treatment or medication adherence, communication and self-care activities (Curtin et al., 2008). Communication is significant because patients have to avail and be open with information regarding the symptoms or signs they might have concerning the disease, to enhance their problem solving independently, and to enable them to receive information and guidance from healthcare workers attending to them to enhance their management (Curtin et al., 2008). During self-management, the patients with CKD are also expected to work in partnership with healthcare workers. This interlinked with efficient communication since the partnership cannot be optimised with poor communication networks between the two groups. The CKD patients are expected to seek information regarding their condition and its management from all relevant sources including books, articles and health websites most of which can be recommended by relevant healthcare workers (Curtin et al., 2008). Self-care is active involvement of CKD patients in their care. This includes performing physical care elements and behavioural activities such as symptoms monitoring, side-effects monitoring, tracking the progress of treatment, and engagement in behaviours that promote positive wellbeing such as regular exercise and health diet (Curtin et al., 2008). Self-advocacy entails positive actions by CKD patients in focussing on their interest and desires so that decisions can be made by them, can negotiate with their cares or healthcare workers, and can exhibit control on treatment and care (Curtin et al., 2008). Behaviours that encompass self-advocacy include substituting doctors, obtaining second opinion, and offering care and treatment suggestions. Another self-management component is adherence to treatment and medication (Curtin et al., 2008). Medications or treatment interventions are only prescribed by clinicians, but it is the responsibility of the patient to ensure that the prescribed pharmacological and non-pharmacological interventions are complied and adhered to. The adherence part is dependant on other components of self-management such as partnership and communication. Since the patient may be on a number of medication and treatment interventions such as diet control, exercise, dialysis especially in the late stage of the disease, it is paramount that communication of the interventions and contribution required by the patient is done succinctly and appropriately. For patients to self-manage their CKD effectively, they need to be educated on the presentation and progress of the diseases with the significance of each stage and its symptoms been explained in a simplified language understandable by the patients. Danger signs or symptoms should be known to the patient. The patient should also be careful with other medications they may use such as over-the-counter medications such as NSAIDs that may aggravate the condition (Constantini et al., 2008; British Columbia Medical Association [BCMA], 2008). Besides, since most drugs are eliminated form the body or excreted via the kidney, decreased filtration capacity of the kidney associated with late stages of the disease may impair elimination of some drugs posing toxicity risks to the patient (Arora, 2015). The latter has the potential to aggravate CKD. Therefore, non-prescription medication that may be used by the CKD patient should be presented to health professionals, and guidance should be given to the patients regarding the drugs' safety. CKD commonly occurs with other diseases such as hypertension, diabetes mellitus and conditions such as anaemia (Zadrazil & Horak, 2015; Fraser et al., 2015; Dyck, Hayward & Harris, 2012). In cases where the CKD patient has comorbidities, the management of these other conditions is also significant to the overall wellbeing of the patient. Some of these conditions such as diabetes have the potential to aggravate CKD making it progress to ESKD faster (Dyck, Hayward & Harris, 2012). Therefore, self-management of these conditions is significant including measures such diet modification, medication adherence and lifestyle modification are salient in preventing the deterioration of CKD (Thomas, 2009). Legal and Ethical Issues Associated with CKD Management The management of patients suffering from CKD should be as per the ethical guidelines provided for in each profession in addition to the four basic ethical principles. The four primary ethical principles include the principle of justice, autonomy, non-maleficence and beneficence (Page, 2012; Bhanji, 2013). The autonomy principle allows the patient to have obligations and rights regarding the forms of treatment that the patient is to receive (Bhanji, 2013). For patients’ autonomy to be met, the patients should be competent enough to make decisions regarding their care and be able to make care related decisions without coercion. For patients to be competent to make their independent decisions, the patients need to be of sound mind and should understand the relevant details related to the decisions they are supposed to make. This means that their decisions should be from an informed perspective. Therefore, healthcare workers need to make sure that the patients are well educated on the pertinent care issues to enable them make informed decisions (Byrd & Winkelstein, 2014; Bhanji, 2013). Thus, patients with CKD are expected to understand the stage of the disease they are in and the clinical implications for the stage, the management measures and implications of the same before they make decisions concerning the condition’s care. The explanations given to the patient regarding care interventions should be impartial incorporating both the negative and positive effects of the interventions. The second principle is that of beneficence that requires healthcare providers working with patients with CKD not only to refrain from perpetrating any harm to the patient but also to make sure that they are driven by altruism to do good for the patients (Bhanji, 2013). In this case, the health care providers should always design and implement CKD care related interventions that are meant to support, sustain or improve the wellbeing of the patient and limit the deterioration of the condition. The need to prolong the CKD patient’s life should be among the prioritised aims as per the principle of beneficence. This principle is closely related to that of non-maleficence. Non-maleficence requires healthcare providers to avoid doing any harm to the patient or to forestall the occurrence of any harm (Page, 2012). This means that CKD-related care interventions should have their efficacy and safety ascertained to be safe for the patient or the negative effects associated with the interventions should not outweigh the interventions' benefits. The last among the four ethical principles is that of justice that requires fairness ad equality to prevail in the provision of care to the patient (Bhanji, 2013). Justice in healthcare greatly borders on the rights of the CKD. For instance, if a CKD patient were to receive information regarding a complication that has occurred or a poor prognosis regarding the condition, if such information is withheld from the patient then that would be injustice perpetrated towards the patient. In addition to these ethical principles, there are specific codes of professional standards that govern the practice of each profession in healthcare including nursing and medicine. These should also be adhered to when carrying out responsibilities they are qualified to perform in their profession including in the management of patients with CKD. The legal implications of caring for a patient with CKD come in when the patient understands that the disease is a chronic one that may render the patient unable to make decisions independently (Sabatino, 2010; R Ekore, Bolatito, J Ekore & Ajayi, 2012). Some of the legal devices through which the patient may address the issue is through the use of advanced care directives (ACD) (Sabatino, 2010). ACD are protected by law, and they include directives such as decision not resuscitate (NFR). The latter prohibits a care provider from attempting to resuscitate the patient in case the patient goes into cardiac arrest (Rhaghunathan, 2013). The patient is allowed to grant another individual, that may be a family member, ‘power of attorney’ to decide on pertinent issues regarding patient care on the patient’s behalf, especially for issues not specified in an ACD (Ekore et al., 2012). Interprofessional team Members and their Roles Interprofessional team members attending to a CKD patient collaborate in ensuring that the care offered to the patient is optimal. The members that form the team caring for a patient with CKD include nephrologists, general practitioners (GP), renal nurses, vascular and transplant surgeons, psychologists, dietician, pharmacist, and social workers (Bayliss, Bhardwaja, Ross, Beck & Lanese, 2011). GPs are the physicians that are responsible for the primary care of the CKD patient. Their roles include supporting and management and monitoring of the condition in addition to other comorbidities that may arise. GPs can aid in the identification of the disease early enough and delay its progress by up to 50% (Renal Disease Health Network [RDHN], 2008). As the disease progresses to the extend of requiring renal replacement therapy (RRT), nephrologists are particularly significant in assessing the patient for RRT suitability. The dialysis sessions are followed up by the nephrologists. Dieticians are significant in informing on the correct diet limiting on salt and protein intake due to impaired kidney excretion capacity (Bayliss et al., 2011). Renal nurses, meet the continuous and follow-up needs of the patient including basic assessments such as weight, blood pressure, medication list, and patient education. Social workers are also salient to the care of CKD patients. The social worker is responsible for easing the patient’s pathway towards ESKD by following up on financial and insurance issues, providing emotional, social and cultural support where necessary (James et al., 2008). Pharmacists serve the role of reviewing medication prescribed for safety and efficacy and provide advice to the patient regarding other medications including advice against the use of some over-the-counter drugs (RDHA, 2008). Patient with CKD may experience stress and depression resulting from the disease's demands. Therefore, a psychologist is significant in offering counselling services and prescribe interventions to relieve the patient of elements such as stress and depression (James et al., 2008). All these members of the interprofessional are interdependent on each other but with a single goal of ensuring the wellbeing of the patient is sustained. Psychological and Social Care CKD patients may suffer from anxiety and even depression related to the uncertainty of the condition especially when they are not well informed. Anxiety can occur because the patient may be worried for his life and those of his close ones or may be as a result of mistaking the disease for an imminent source of death. To manage the anxiety, the patient is made aware that feeling anxiety over the same is not uncommon and shall be educated and reassured of a manageable life ahead despite the disease (Arora, 2015). Anxiety relieving techniques such as positive visualization, reassuring self-statements, and deep breathing shall be utilised to enhance the patient’s personal mastery and self-confidence (Thomas, 2009). Depression among CKD patients may arise from mal-adaptive coping and may even result in self-injury. Caring for CKD patients with depression shall require the patient to express their feelings and psychological interventions geared at relieving depression such as cognitive behavioural therapy may be advised and be provided during routine patient visits for sessions such dialysis (Arora, 2015). Pharmacological therapy for depression may also be significant for cases not responsive to non-pharmacological therapy. In such a case, antidepressant may be of significance. The social aspects that me be associated with CKD patients include an interruption of the patient’s family process especially in an advanced stage of the disease requiring dialysis. The family members or friends are expected to accompany the patient for appointment and dialysis session as a form of social support. The burden of accompanying the patient may interfere with the social aspect of the lifestyle of family members (Thomas, 2009). The family may be assisted to seek the services of a carer who can support the patient during dialysis sessions. Nevertheless, the family members are integral to the management of the patient as they form part of the patient’s social support system (Arora, 2015). Conclusion CKD can be debilitating to the patient especially in its late stages. Management of the condition requires the input of the patient concerning self-management and other healthcare providers that form the interprofessional team. The collaborative input of all the involved parties in patient management is instrumental to the delayed progression of the disease. Besides, in the management of the CKD patient, the patient needs including the spiritual, psychological, social and emotional needs should be addressed comprehensively as they affect the general wellbeing of the patient. References Arora, P. (2015). Chronic Kidney Disease. Retrieved April 30, 2016, from http://emedicine.medscape.com/article/238798-overview Bayliss, E.A., Bhardwaja, B., Ross, C., Beck, A. & Lanes, D.M. (2011). Multidisciplinary team care may slow the rate of decline in renal function. Clinical Journal of American Sociology and Nephrology, 6 (4), 704-710. Bhanji, S.M. (2013). Health care ethics. Clinical Research and Bioethics, 4 (1), 1-3. British Columbia Medical Association. (2008). Chronic kidney disease. Vancouver, BC.: Ministry of Health Services BC. Bullock, S. & Hales, M. (2012). Principle of pathophysiology. Frenchs Forest, NSW: Pearson Education. Byrd, G.D. & Winkelstein, P. (2014). A comparative analysis of moral principles and behavioral norms in eight ethical codes relevant to health sciences librarianship, medical informatics, and the heath professions. Journal of the Medical Library Association, 102 (4), 247-256. Chen, S., Tsai, Y., Sun, C., Wu, W., Lee, C. & Wu, M. (2011). The impact of self-management support on the progression of chronic kidney disease -a prospective randomized controlled trial. Nephrology Dialysis and Transplantation, 0, 1-7. Constantini, L., Beanlands, H., McCay, E.,Cattran, D., Hladunewich, M. & Francis, D. (2008). The self-management experience of people with mild to moderate chronic kidney disease. Nephrology Nursing Journal , 35 (2), 147-155. Curtin, R.B., Walter, B.A., Schatell, D., Pennell, P., Wise, M. & Klicko, K. (2008). Self-efficacy and self-management behaviours in patients with chronic kidney disease. Advances in Chronic Kidney Disease, 15 (2), 191-205. Dyck, R.F., Hayward, M.N. & Harris, S.B. (2012). Prevalence, determinants, and co-morbidities of chronic kidney disease among first nations adults with diabetes: Results from the CIRCLE study. BMC Nephrology, 13 (57), 1-6. Ekore, R.I., Bolatito, L., Ekore, J. & Ajayi, I. (2012). Paternalism and the utilization of advanced care directives. Palliative Care & Medicine, 2 (7), 1-4. Fraser, S.D., Roderick, P.J., May, C.R., McIntyre, N., McIntyre, C., Fluck, R.J., ... & Taai, M.W. (2015). The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study. BMC Nephrology, 16 (193), 1-7. Graf, J., Ryan, C & Green, F. (2009). An overview of chronic kidney diseases in Australia. Canberra: Australian Institute of Health and Welfare. James, A. Mitchell, G., Bissett, M., Zekrzewski, L., Wright, A. Balandin, S., ... Hughes, M. (2008). Role of the interdisciplinary/multidisciplinary team. In E. C. Johnson (Ed.), Chronic illness and disability: principles for nursing practice (1st ed., pp. 14-32). Sydney: Elsevier. Lin, C., Tsai, F., Lin, H., Hwang, S Chen, H. (2013). Effects of a self-management program on patients with early-stage chronic kidney disease: A pilot study. Applied Nursing Research, 26, 151-156. Lopez-Novoa, J.M., Martinez-Salgado, C., Rodriguez-Pena, A.B & Lopez-Hernandez, F.J. (2010). Common pathophysiological mechanisms of chronic kidney disease: therapeutic perspective. Pharmacology and Therapeutics, 128 (1), 61-81. Page, K. (2012). The four principles: Can they be measures and do they predict ethical decision making? BMC Medical Ethics, 13 (10), 1-5. Renal Disease Health Network. (2008). Chronic kidney disease model of care. Perth: Western Australia Department of Health. Rhaghunathan, K. (2013). Legal and ethical aspects of nursing care. In G. Koutoukidis (Ed.), Tabbner's Nursing care: Theory and practice (6th ed., pp. 23-40). Chatswood, NSW: Elsevier. Sabatino, C.P. (2010). The evolution of health care planning law and policy. The Milbank Quarterly , 88 (2), 211-239. Thomas, N. (2009). Chronic kidney disease. British Journal of Primary Care Nursing, 6 (2), 34-35. Zadrazil, J. & Horak, P. (2015). Pathophysiology of anemia in chronic kidney disease: A review. Biomedical Papers, 159 (2), 197-202. Read More