Problem statement for research purpose: Hypertension can be a cause as well as a consequence of chronic kidney disease (CRD). A number of clinical studies have identified the harmful effects of uncontrolled hypertension on the kidney function (Kokubo, 2012; Berlowitz, 2016)). According to NIH statistics, 23.3% individuals without CKD had hypertension in a representative sample. On the other hand, 35.8% of individuals in stage 1, 48.1% in stage 2, 59.9% of stage 3 and 84.1% in stage 4-5 CKD had hypertension (National Institutes of Health, 2010). In stage 4 CKD, the glomerular filtration is the lowest at <15 ml/min/m2. Progressive kidney dysfunction can cause hypertension, which in turn can lead to poor clinical outcome. For many, the primary cause of death with CKD is cardiovascular diseases (Ting et al., 2015). Hypertension is a serious risk factor for cardiovascular diseases and life-threatening conditions like stroke and heart failure.
In later stages of kidney failure, there is a decline in excretory volume and accumulation of fluid will result in hypertension associated with hypervolemia (Bomback & Bakris, 2011). Apart from volume related hypertension, increased efferent artery constriction or increased afferent artery dilation, can also lead to hypertension (Bomback & Bakris, 2011). These two conditions are more common in early stages of CRD. Hypertension increases glomerular capillary pressure. Though in normal cases, it may be harmless, in a damaged kidney with already failing glomeruli, this high pressure can worsen the further damage. The goal of treating hypertension in patients with CKD and proteinuria is to bring it down to <125/75 (Bomback & Bakris, 2011). As the kidney damage progresses, the functional cells in the kidney are permanently replaced by fibrosis. Thus, the purpose of the research is to identify the ideal nursing care plan and to evaluate its effectiveness in reducing and the progression of chronic kidney failure in patients.
PICOT: In a (P) population of individuals with CKD, does the (I) treatment of hypertension with use of best nursing plan, (O) slow the progress of chronic kidney failure, by ameliorating hypertension, (C)when compared to a control population which lacks the best nursing plan, in (T) a period of 6 months?
P (Population) -population of individuals with CKD
I (Intervention)- best nursing plan to reduce hypertension
C (Control) -compared to the individuals with CKD and poorly controlled hypertension
O (Outcome)- Slow the progress of chronic kidney failure by ameliorating hypertension,
T (Time) - In a time period of 6 months.
Part 2:
Background: Kidney has an important function in maintaining the body’s homeostasis. It receives 20-25% of the cardiac output (Schrier, 2010). Blood entering the kidney is filtered through the glomerular nephrons and tubules. A healthy kidney has approximately 1 million nephrons (Schrier, 2010). In chronic kidney failure, there is a progressive loss of nephrons and the kidney loses its function gradually. In end stage kidney failure, more than 90% of the nephrons in the kidney are damaged. The (Bomback & Bakris, 2011) kidney function in the CKD is monitored by measuring the glomerular filtration rate (GFR).
Hypertension occurs in a large majority of patient with kidney failure. Hypertension causes endothelial dysfunction and death from cardiovascular diseases. Aggressive blood pressure control and reduction in proteinuria can help to reduce the progression of kidney damage. Hypertension increases damage to the glomerular capillaries in a kidney that is already fragile from illness. Angiotensin II constricts efferent blood vessels in the kidney and causes the buildup of pressure in glomerular capillaries. Angiotensin 2 blockers were effective in reducing blood pressure to <125/75 and in reducing proteinuria to a significant extent (Velkoska, Patel, & Burrell, 2016). According to a meta-analysis of 11 clinical trials, angiotensin inhibitors and blockers were effective in reducing the risk of end-stage kidney failure by 31% (Jafar et al., 2003). Use of angiotensin inhibitors is contraindicated in acute injury to the kidney. The use of these drugs should be monitored, as they have the risk of increasing potassium and creatinine level in some patients.
The purpose of this study is to develop and evaluate the best nursing plan that can prevent the progress of chronic kidney disease, by controlling hypertension in the patient. The research question for the study would be: Does the nursing plan help reduce progression of chronic kidney disease by controlling hypertension? The research hypothesis for the study would be: The best nursing plan is effective in reducing progression of kidney disease by controlling hypertension.
The defining variables in this study are the nursing plan, hypertension control, and progression of chronic kidney disease.
The nursing care plan is the independent variable in this study. A nurse led clinic will be established to manage hypertension in CKD patients. The nursing team will be provided training on various aspects of the disease that will help them execute their task efficiently. The different components of the nursing care plan are given below:
a. Detection and diagnosis of hypertension: Nurses will assess blood pressure as a routine, in order to identify hypertension at the earliest. Correct techniques will be used to estimate hypertension.
The patient will be informed about the current BP and the need to achieve and maintain the target blood pressure.
b. Development of a treatment plan based on individual patient: The treatment plan will take into consideration: lifestyle intervention, diet, maintaining healthy BMI, exercise, alcohol, smoking, stress management, medications to be administered, adherence to treatment, ways to promote adherence, monitoring, follow-up, and documentation. Details about each component can be found in nursing best practice guidelines. (Registered Nurses association of Ontario, 2010)
Hypertension and progress of chronic kidney diseases are dependent variables. They are the outcome of the intervention. Diagnostic and laboratory techniques will be used to monitor BP. Glomerular filtration rate and proteinuria will be monitored to determine the progress of CKD. Blood pressure will be monitored through auscultation techniques.
The patients with CRD will be randomly assigned to usual care or to usual care with adjunct nurses led clinic to manage hypertension. Nurses and the patients will participate in the study, for a period of 6 months. The blood pressure will be monitored at every 4 weeks’ interval and the progress in kidney function will be monitored. The data collected from the study will be analyzed to identify overall improvement in patient condition in both the groups. The effect of the nursing care plan in achieving target blood pressure and reducing the progress of chronic kidney diseases will be assessed.
Conclusion: Keeping blood pressure under control is key to preventing complication in CRD. Uncontrolled blood pressure can worsen kidney disease. The evidence provided by this study will be used to support the nursing care plan as an effective addition to usual treatment of patients with CRD. It could act as a proven method of delivering quality care to people with CRD.
References
Berlowitz, D. (2016). Understanding Uncontrolled Hypertension. J Clin Hypertens. http://dx.doi.org/10.1111/jch.12875
Bomback, A. & Bakris, G. (2011). Chronic kidney disease (CKD) and hypertension essentials. Sudbury, Mass.: Physicians' Press/Jones & Bartlett Learning.
Jafar, T., Starck, P., Schmid, C., Landa, M., Maschio, G., & de Jong, P. (2003). Progression of Chronic Kidney Disease: The Role of Blood Pressure Control, Proteinuria, and Angiotensin-Converting Enzyme Inhibition: A Patient-Level Meta-Analysis. Annals Of Internal Medicine, 139(4), 244. http://dx.doi.org/10.7326/0003-4819-139-4-200308190-00006
Kokubo, Y. (2012). The mutual exacerbation of decreased kidney function and hypertension. Journal Of Hypertension, 30(3), 468-469. http://dx.doi.org/10.1097/hjh.0b013e328350ade8
National Institutes of Health,. (2010). U S Renal Data System,. Bethesda, Md, USA: National Institute of Diabetes and Digestive and Kidney Diseases.
Registered Nurses association of Ontario,. (2005). Nursing Management of Hypertension (pp. 1-139). Ontario: Heart and Stroke Foundation of Ontario. Retrieved from http://www.spitjudms.ro/_files/protocoale_terapeutice/nursing/607_bpg_hypertension.pdf
Schrier, R. (2010). Renal and electrolyte disorders. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Ting, S., Hamborg, T., McGregor, G., Oxborough, D., Lim, K., & Koganti, S. et al. (2015). Reduced Cardiovascular Reserve in Chronic Kidney Failure: A Matched Cohort Study. American Journal Of Kidney Diseases, 66(2), 274-284. http://dx.doi.org/10.1053/j.ajkd.2015.02.335
Trinkley, K., Nikels, S., Page II, R., & Joy, M. (2014). Automating and estimating glomerular filtration rate for dosing medications and staging chronic kidney disease. International Journal Of General Medicine, 211. http://dx.doi.org/10.2147/ijgm.s61795
Velkoska, E., Patel, S., & Burrell, L. (2016). Angiotensin converting enzyme 2 and diminazene. Current Opinion In Nephrology And Hypertension, 25(5), 384-395. http://dx.doi.org/10.1097/mnh.0000000000000254
