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Butler Community College Department of Nursing
NR 203: Leadership and Management in Nursing
Management of Chronic or Progressive & Irreversible Alterations in Health
Renal Failure – Acute and Chronic/ Renal Dialysis
Pharmacology
Please be advised that portions of the following content have been taken directly from references listed.
Drug
Accupril
Captopril
Enalapril,
etc
Classification
Ace Inhibitors
AngiotensionConverting
Enzyme
Inhibitors
Indication / Action
 Treatment of
hypertension
 Treatment of
proteinuria
 Blocks conversion
of angiotension I
to vasoconstricting
angiotension II
 Increases plasma
renin levels
 Decreases
aldosterone levels
 Reduces
proteinuria and
slows
progression of
renal failure.
Dose
Nursing Implications/ Side Effects/ Patient Teaching
Enalapril:
 Normal Dose 2.5 to
5 mg once daily, up
to 40mg/day 1-2
divided doses.
 NOTE: Give 75%
of normal dose
with renal
impairment.
Captopril:
 Normal Dose: 12.5
to 25 mg 2 – 3
times daily
 NOTE: Administer
50% - 75% of
normal dose with
renal impairment,
based on
creatinine
clearance results.
Accupril:
 Normal Dose 10 to
20 mg once daily.
 NOTE: decrease
dose in renal
impairment based
on creatinine
clearance results

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
Adjust dose for patients in renal failure.
May need to adjust dose if BUN, creatinine and K+
increase.
Monitor BP and pulse frequently during initial dose
adjustment and periodically during therapy.
Assess patient for signs of angioedema (dyspnea,
facial swelling).
Assess renal protein prior to and periodically during
therapy.
Hold & call Dr. is BP is less than 100 or if patient
has bradycardia.
Hold BP meds prior to dialysis.
Adverse Effects: dizziness, drowsiness, fatigue,
headache, cough, hypotension, taste disturbances,
abdominal pain, N,V,D.
Drug
Aluminum
Hydroxide
(amphojel,
basage,
Classification
Phosphate
Binders
alternaGEL)
Vitamin D
Compounds
Vitamins (fat
soluable)
Indication / Action
 Decrease
phosphate level in
patients with renal
failure.
 Adjunctive therapy
in ulcer disease.
 Binds phosphate
in the GI tract.
Dose
 1.9 to 4.8 G 3 to 4
times daily
 Given in either
regular or
concentrated
suspension OR
chewable tablets.

Calcitriol:
Dialysis Patients
(PO):
 O.25mcg/day or
every other day
 May increase by
0.25 mcg/day at 4
to 8 week intervals.
 Typical dose = 0.5
– 1 mcg/day.
Hypoparathyroid
(PO):
 Same initial dose.
 Increase in 2 to 4
week intervals.
 Typical dose = 0.5
– 2 mcg/day.
Dialysis Patients (IV):
 0.5 mcg 3 times
weekly.
 May increase at 2-4
week intervals.
 Typical dose = 0.01
- 0.05mcg/kg
3 times/week.
(Calcitriol,
Calcijex,
Rocaltrol)


Management of
hypocalcemia in
chronic renal
dialysis (IV and
PO)
Treatment of
hypocalcemia in
patients with
hypoparathyroidi
sm or
pseudohypopara
thyroidism (PO
only)
Improves
calcium &
phosphorous
homeostasis in
chronic kidney
disease.(Decrea
se phosphate
levels, normalize
calcium).
Nursing Implications/ Side Effects/ Patient Teaching
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
Monitor serum phosphate and calcium levels periodically
during chronic use.
May cause increased serum gastrin and decreased serum
phosphate concentrations.
Can result in constipation. If laxatives are needed, avoid
laxatives with Mg+.
Separate administration of aluminum hydroxide and oral
medication by at least 1 – 2 hours.
Chew tablets well.
Shake liquid preparations well.
Follow dose with a full glass of water or fruit juice.
Give with meals or times of phosphate ingestion.
Assess for symptoms of vitamin deficiency prior to
and periodically during therapy.
Assess patient for bone pain and weakness prior to
and during therapy.
Observe for signs of hypocalcemia (paresthesia,
muscle twitching, laryngospasm, colic, cardiac
arrhythmias and Chvostek’s or Troussea’s sign.
Toxicity is manifested as hypercalcemia.
Early toxicity symptoms include: nausea, vomiting,
anorexia, weakness, constipation, headache, bone
pain and metalic taste.
Later symptoms include polyuria, polydipsia,
photophobia, rhinorrhea, pruritus and cardiac
arrhythmias.
Drug
Calcium
Salts
Calcium
acetate;
Calcium
carbonate
(Tums, OsCal,
Rolaids),
Calcium
chloride,
Calcium
citrate
(citrical),
Calcium
gluconate,
Calcium
lactate,
Tricalcium
phosphate
Classification
Indication / Action
Mineral &

electrolyte
replacements/s
upplements


Calcium is
essential for
nervous,
muscular and
skeletal systems.
It maintains cell
membrane and
capillary
permeability. Act
as an activator in
the transmission
of nerve
impulses and
contraction of
cardiac, skeletal
and smooth
muscle.
Used
therapeutically to
replace calcium
in deficiency
states.
Helps control
hyperphosphate
mia in end-stage
renal disease
without
promoting
aluminum
absorption
(calcium
acetate).
Dose
Nursing Implications/ Side Effects/ Patient Teaching
ADULT Doses
Prevention of
hypocalcemia,
osteoporosis:
 0.5 to 1.5 Gm as
needed PO


Hyperphosphatemia in
end-stage renal
disease:
 Amount necessary
to control serum
phosphate and
calcium PO.
Emergency treatment
(cardiac standstill)
 1-7mEq (IV)
Tetany:
 0.5 -0.7 mEq/kg 3
to 4 times daily (IV)
 Repeat until
symptoms are
controlled.
Hyperkalemia with
cardiac toicity:
 2.25 – 14 mEq;
may repeat in 1-2
minutes.
Hypermagnesemia:
 7 mEq
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Use cautiously in patient receiving digitalis.
Adverse Reactions/Side Effects:
o Syncope (IV Only), Tingling, Cardiac
arrhythmias, bradycardia, constipation,
nausea, vomiting, phlebitis (IV Only)
Monitor blood pressure, pulse, and EKG with
parenteral therapy.
Watch IV site for patency. Extravasation may
cause cellulitis, necrosis and sloughing.
Watch for signs of dig toxicity.
Monitor serum calcium, chloride, sodium,
potassium, magnesium, albumin and PTH before
and periodically during therapy.
Pay close attention to drug that is ordered.
Errors have occurred due to confusion over
which salt is ordered.
Administer PO calcium carbonate or phosphate 1 to
1.5 hours after meals and at bedtime.
Chew tablets well before swallowing.
Follow oral doses with a full glass of water, except
when using calcium carbonate as a phosphate
binder in renal dialysis.
Do not administer IM; can cause tissue sloughing.
Warm IV solution to body temperature and give
through a small-bore needle in a large vein to
minimize phlebitis.
Drug
Kayexalate
Classification
Indication / Action
Dose
Nursing Implications/ Side Effects/ Patient Teaching
Electrolyte
Modifers

Use to treat mild
to moderate
hyperkalemia.
Exchanges
sodium ions for
potassium ions
in the GI tract. (1
G Na is
exchanged for
1mEq
potassium).
Reduces serum
potassium levels
ADULT Dosages
PO:
 15 G 1 to 4
times daily in
water or
sorbitol
Rectal:
 30 to 50 G
as retension
enema

Indication / Action
 Stimulates
erythropoiesis,
(production of red
blood cells).
 Used to treat
anemia associated
with chronic renal
failure.
 Treats anemia
secondary to AZT
therapy in HIV.
 Treats anemia in
chemotherapy
patients.
Dose
ADULT dosages
Renal Failure:
 IV: 50 to 100
units/kg 3 times
weekly initially.
Adjust to attain
target hemoglobin
of 10-12 g/dl.
AZT Anemia:
 IV, SQ: 100
units/kg 3 times
weekly for 8
weeks. May
increase every 48 weeks to max
of 300 units/kg 3
times weekly.
Chemotherapy
Anemia:
 SQ: 150 units/kg
3 times weekly or
 40,000 units
weekly.


Drug
Epoetin
(Epogen,
EPO,
Eprex
Procrit)
Classification
Antianemics Hormones
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
Monitor response of symptom of hyperkalemia
(fatigue, muscle weakness, paresthesia, confusion,
dyspnea, EKG changes.
Monitor I & O and daily weight.
Assess for symptoms of dig toxicity.
Access abdomen and note character and frequency
of stools.
Can cause constipation. Giving with sorbitol or
laxatives can help prevent constipation or
impaction.
Should have 1 to 2 watery stools each day during
therapy.
Monitor serum potassium daily during therapy.
Nursing Implications/ Side Effects/ Patient Teaching
 Monitor blood pressure before and during therapy.
 Monitor dialysis shunts (thrill & bruit). May need to
increase Heparin dose to prevent clotting.
 May cause increase in WBC and platelets.
 May decrease bleeding times.
 Monitor serum ferritin, transferrin and iron levels.
 Goal to maintain hematocrit of 30 to 36%
 Be aware that increased sense of well-being may lead to
decreased compliance with other therapies for renal
failure.
 Be aware of increase risk in seizures in the first 90 days
of therapy due to increasing hematocrit.
 Do not shake vial.
 SQ rate is preferred for AZT and Chemotherapy anemia.
IV route is used for renal failure patients.
 Teach patient to notify healthcare provider immediately if
signs of blood clots.
 Stress importance of compliance with dietary restriction,
medication and dialysis for renal failure patients.
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
Drug
Mannitol
(osmitrol);
Albumin
(normal
serum
albumin)
Classification
Osmotic
Diuretics
Indication / Action
 Adjunct in the
treatment of :
o Acute
oliguric
renal
failure
o Edema
o Increased
intracranial
or
intraocular
pressure
o Toxic
overdose
 Increases the
osmotic pressure
of the glomerular
filtrate which
inhibits
reabsorption of
water and
electrolytes.
 Causes excretion
of: Water, sodium,
potassium,
chloride, calcium,
phosphorus,
magnesium, urea
& uric acid.
 Helps mobilize
Discontinue when
chemotherapy
course is
completed.
Do not give if hgb
is > or equal to
10g/dl.
Dose
ADULT IV Doses:
Edema, oliguric renal
faiure:
 50 to 100 Gm as
a 5-25% solution.
May start with
test dose of
200mg/kg over 35 minutes. Titrate
to produce urine
output of 30 to
50ml/hr.
Intracranial/intraocular
pressure:

0.25 to 2 G/kg as
15 to 25%
solution over 30
to 60 minutes.
Diuresis in drug
intoxications:
 50 to 200G as a 5
-25% solution
titrated to
maintain urine
flow of 100 to 500
ml/hr
Nursing Implications/ Side Effects/ Patient Teaching
 Monitor vital signs, urine output, CVP and pulmonary
artery pressure if possible.
 Assess patient for signs of dehydration or signs of fluid
overload.
 If given for renal failure, monitor renal function and
serum electrolytes.
 Observe insertion site frequently for infiltration.
 Do not administer electrolyte-free mannitol solution with
blood.
 Discuss inserting foley catheter with physician for
accurate output measurements.
 Administer IV undiluted.
Drug
Albumin
Classification
Volume
Expander
excess fluid in
oliguric renal
failure or edema.
 Decreases
intraocular and
intracranial
pressure.
 Helps increase
urinary excretion
of toxic materials.
Indication / Action
 Expansion of
plasma volume
and maintenance
of cardiac output
in situations
associated with
fluid volume
deficit, including
shock,
hemorrhage, and
burns.
 Replacement of
albumin when
plasma protein
levels are low.
 Used to decrease
edema caused
from low plasma
protein levels.
 Provides colloidal
oncotic pressure,
which serves to
mobilize fluid from
extravascular
tissues back into
the intravascular
space.
 Increases
Dose
ADULT Doses
Dosages are highly
individualized
depending on
condition you are
treating.
 Hemodialysis:
o 25 Gm of
25%
solution
 Hypovolemic
Shock:
o 5%
Albumin.
25Gm
(500ml) IV
o May
repeat
within 30
minutes
o May give
rapidly as
tolerated.
As volume
nears
normal,
slow to 1
to 4
mL/min.
Nursing Implications/ Side Effects/ Patient Teaching
 Monitor VS, including CVP and I & O before and
frequently throughout therapy.
 Stop infusion immediately and notify Dr. if fever,
tachycardia or hypotension occurs.
 Assess for signs of vascular overload (elevated CVP,
rales/crackles, dyspnea, hypertension, JVD) before and
after administration
 Monitor serum albumin levels.
 Monitor serum sodium levels, which may increase.
 Monitor Hgb & Hct or for bleeding. These may decrease
because of hemodilution.
 Rate of administration is variable, depending on
indication. Any rate greater than 10mL/min may cause
circulatory overload and pulmonary edema.
 Alkaline phosphatase may be elevated due to albumin
administration.
intravascular fluid
volume.

Hypoproteininemia
o
o
o

25%
Albumin
50 to 75
Gm IV.
Give 2 to
3 mL/min.
Nephrotic
Syndrome:
o 25%
Albumin.
o
12.5 to 50
Gm/day in
3 to 4
divided
doses.
References
Adams, M., Josephson, D., & Holland, L. (2005). Pharmacology for nurses: a pathophysiologic approach.
Upper Saddle River: Pearson Prentice Hall.
Deglin, J.H., & Vallerand, A. H. (2009). Davis’s drug guide for nurses (12th ed.).
Philadelphia: F.A. Davis.
Gahart, B., & Nazareno, A. (2011). 2011 intravenous medications (27th ed.).
St. Louis: Mosby Elsevier