Download End-stage renal disease

Nursing Care and Interventions in
Managing Chronic Renal Failure
Keith Rischer RN, MA, CEN
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Todays Objectives…
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Review the pathophysiology and causes of chronic renal failure
(CRF).
Contrast lab findings and physiologic changes associated with
acute vs. chronic renal failure.
Identify relevant nursing diagnosis statements and prioritize
nursing care for clients with CRF including dietary modifications.
Compare and contrast the following treatment modalities:
peritoneal dialysis, hemodialysis, and continuous renal
replacement therapies.
Identify nursing care priorities with hemodialysis and peritoneal
dialysis.
Prioritize teaching needs of clients with CRF.
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Patho
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Patho:Chronic Renal Failure
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Progressive, irreversible kidney injury
Kidney function does not recover
 Azotemia
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Uremia
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Increase nitrogenous wastes such as BUN
Creatinine
azotemia with symptoms (chart 75-5 p.1739)
Anorexia, N&V, fatigue, SOB
Uremic syndrome (urine in the blood)
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Altered fluid, lyte and acid-base balance
clinical and lab manifestations of renal failure
More severe weakness, lethargy, confusion…coma..death
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Patho:Stages of Chronic Renal Failure
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Diminished renal reserve
 GFR
½ normal
 Compensation w/healthy nephrons
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Renal insufficiency
 Nephrons
destroyed…remaining adapt
 BUN, creatinine, uric acid elevate
 Priorities: fluid volume, diet, control of HTN,
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End-stage renal disease
 Severe
fluid, acid-base imbalances
 Dialysis needed or will die
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Patho:Physiologic Changes
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Kidney
• Decreased GFR
• Poor H2O excretion
Metabolic
– BUN and creatinine increased
Electrolytes
– Sodium- later stages sodium retention
– Potassium increased
– EKG changes
– Kayexelate
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Acid-base balance: metabolic acidosis
Calcium decreased and phosphorus increased
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Patho:Physiologic Changes
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Cardiac
– Hypertension
– Hyperlipidemia
– Congestive heart failure
– Uremic pericarditis
Hematologic
• anemia
Gastrointestinal
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Halitosis
Stomatitis
PUD
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Patho:Physiologic Changes
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Neurologic
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Respiratory
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pulmonary effusion
SOB
Urinary
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lethargy
Uremic encephalopathy
proteinuria, oliguria, dilute
Skin
 dry,
pallor, pruritus, ecchymosis
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Drug Therapy
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chart 75-3 p.1737
Cardioglycides
 Digoxin/Lanoxin
Calcium channel blockers
Diuretics
Vitamins and minerals
 Folic Acid
 Ferrous Sulfate
Biologic response modifiers
 Erthropoetin (Epogen)
Phosphate binders
 Aluminum hydroxide
Stool softeners and laxatives
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Patho of One Dialysis/ESRD Client
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DM II
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ESRD…hemodialysis 3x/week
Anemia
CAD
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PTCA 1994 w/redo 2005
AMI 2005-stent to LAD, Cx
CHF
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Retinopathy
25% EF w/global hypokinesis and
severe inferior hypokinesis
AFib
AAA
Neuropathy
Obesity
Rt Femoral Bypass
Rt BKA
Medications
 ASA
 Phoslo
 Coumadin
 Digoxin
 Epoetin
 Lantus insulin
 Novolog per sliding scale
 Lipitor
 Neurontin
 NTG subl prn
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ED Renal Case Study
69yr female
 HPI: Hemodialysis earlier in day. Found to
have HR in the 40’s afterwards. Did not
increase. Has no c/o lightheadedness.
Has no other physical c/o
 VS: T-97.8 P-42 (AFib) R-20 BP-122/76
sats 96% 3l per n/c
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Labs
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Excess Fluid Volume
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Interventions:
 Monitor
I&O
 Promote fluid balance
 Daily
weights
 1 kg=1liter fluid
 Assess
for manifestations of volume excess:
 Crackles
in the bases of the lungs
 Edema
 Distended
neck veins
 Diuretics
 Contraindicated
w/ESRD
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Decreased Cardiac Output
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Interventions:
 Control
hypertension
 calcium
channel blockers
 ACE inhibitors
 alpha- and beta-adrenergic blockers
 vasodilators.
 Education:
monitor blood pressure
 client’s weight
 Diet
 Drug regimen
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Potential for Pulmonary Edema
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Interventions:
 Assess
for early signs of pulmonary edema
 Restlessness/anxiety
 Tachycardia
 Tachypnea
 oxygen
saturation levels
 Crackles in bases
 Hypertension
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Imbalanced Nutrition
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Interventions:
 Dietary evaluation for:
 Protein
 Fluid
 Potassium
 Sodium
 Phosphorus
 Vitamin supplementation
 Iron
 Water soluable vitamins
 Calcium
 Vitamin D
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Risk for Infection
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Interventions:
 Meticulous
skin care
 Preventive skin care
 Inspection of vascular access site for dialysis
 Monitoring of vital signs for manifestations of
infection
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Risk for Injury
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Interventions:
 Drug
therapy
 Education
prevent fall
 Injury
 pathologic fractures
 bleeding
 toxic effects of prescribed drugs
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– Digoxin
– Narcotics
– Heparin or Coumadin
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Fatigue
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Interventions:
 Assess
for vitamin deficiency
 Administer
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vitamin and mineral supplements
anemia
 Give
iron supplements as needed
 Erythropoietin therapy
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Buildup of urea
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Anxiety
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Interventions:
 Health
care team involvement
 Client and family education
 Continuity of care
 Encouragement of client to ask questions and
discuss fears about the diagnosis of renal
failure
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Indications for Dialysis
Uremia
 Persistent hyperkalemia
 Uncompensated metabolic acidosis
 Fluid volume excess unresponsive to
diuretics
 Uremic pericarditis
 Uremic encephalopathy
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Hemodialysis
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Client selection
 Irreversible
renal failure
 Expectation for rehab
 Acceptance of regimen
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Dialysis settings
 Acute-hospital
 Out
patient centers
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Hemodialysis:Patho
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Diffusion
Dialysate
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Lytes and H2O
Dialyzer
Anticoagulation
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Heparin to prevent
blood clots in dialyzer
or tubing
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Complications of Hemodialysis
Dialysis disequilibrium syndrome
 Infectious diseases
 Hepatitis B and C infections
 HIV exposure—poses some risk for
clients undergoing dialysis
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Vascular Access
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Arteriovenous fistula, or
arteriovenous graft for longterm permanent access
Hemodialysis catheter, dual
or triple lumen, or
arteriovenous shunt for
temporary access
Precautions
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Bruit & thrill
BP restrictions
Complications
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Thrombosis
CMS
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Hemodialysis: Nursing
Interventions
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Predialysis care:
 Medications to hold…why?
Postdialysis care:
 Monitor for complications such as hypotension,
headache, nausea, malaise, vomiting, dizziness,
muscle cramps.
 Monitor vital signs and weight.
 sepsis
 Avoid invasive procedures 4 to 6 hours after dialysis.
 Continually monitor for hemorrhage.
 Assess for thrill
 No BP or blood draws on arm
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Peritoneal Dialysis
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Peritoneal Dialysis
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Phases
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Inflow
Dwell
Drain
Contraindications
 history
of abd surgeries
 recurrent hernias
 excessive obesity
 preexisting vertebral disease
 severe obstructive pulmonary disease
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Complications of Peritoneal Dialysis
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Peritonitis (cloudy outflow)
Pain
Exit site and tunnel infections
Poor dialysate flow
Dialysate leakage
Monitor color of outflow
 cloudy (peritonitis)
 brown (bowel)
 bloody (first week OK)
 urine (bladder)
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Nursing Care During Peritoneal
Dialysis
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Pre PD:
 Vital signs pre and q 15-30” during
 Weight
 laboratory tests
Continually monitor the client for:
 respiratory distress
 pain
 discomfort
Monitor prescribed dwell time and initiate outflow
Observe outflow amount & pattern of fluid
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Education Priorities
Pathophysiology and manifestations
 Complications
 When to call the doctor
 Keep record of all labs
 Take medications and follow plan of care
set out by case manager
 Monitor weight, fatigue levels closely
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