Download AV shunt (less common)

RENAL FAILURE 2008
ACUTE RENAL FAILURE
CHRONIC RENAL FAILURE
OBJECTIVES
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Identify normal functioning of the kidney and laboratory
tests that assess kidney function
Define renal failure
Discuss the causes of acute renal failure and compare
those with chronic renal failure
Compare prerenal, intrarenal and postrenal conditions
Identify the alterations seen in patients, explaining why
they exist
Identify nursing measures appropriate to the
alterations
NORMAL KIDNEY
FUNCTION
What does the kidney do in terms of?
• wastes and water balance?
• Acid base balance?
• Controlling BP?
• Controlling anemia?
RENAL FAILURE DEFINED
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Kidneys no longer function properly
Kidneys unable to excrete waste
kidneys cannot concentrate urine
Kidneys cannot conserve electrolytes
HORMONES WHICH
INFLUENCE THE KIDNEY
• ALDOSTERONE
– Produced:
– Action:
• RENIN/ANGIOTENSIN
– Produced:
– Action:
HORMONES WHICH
INFLUENCE THE KIDNEY
• ANTIDIURETIC HORMONE
– Produced:
– Action:
• ERYTHROPOIETIN (EPO)
– Produced:
– Action:
IDENTIFYING THE THREE
PRIMARY RENAL FUNCTIONS
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GLOMERULAR FILTRATION:glucose, amino acids,
creatinine, urea, phosphates, uric acid
GLOMERULAR REABSORPTION:bicarbonate,
phosphates, sulfates, 65% of Na and water, glucose,
K, amino acids, H ions, urea
GLORMERULAR SECRETION: hydrogen and
potassium, remove acids (hydrogen) to maintain
appropriate acid base balance, potassium, urea
ASSESSMENTS OF RENAL
FUNCTION
• u/a: negative for glucose, protein, blood,
leukocytes, nitrites, ketones
• Specific gravity: measures concentration of
the urine; normal values: 1.010-1.025
• Urine osmolality: normal 300-900 mOsm/
kg/24
• Serum creatinine: 0.6-1.2mg/dl
• BUN: 7-18mg/dl
• BUN to creatinine ratio: about 10:1
DIAGNOSTIC ASSESSMENTS
CONTINUED
• STANDARD FOR RENAL FUNCTION:
assess glomerular filtration rate (GFR)
• Norm for this assessment is the
creatinine clearance test done over 24
hours: normal rate is 80-125ml/min
DEFINITIONS
• OLIGURIA: urine output is less than 30
ml/hr
• ANURIA: no urinary output
• NORMAL URINARY OUTPUT: 15001800ml/day
CAUSES OF ACUTE RENAL
FAILURE
• PRERENAL or factors external to the kidney
which interferes with renal perfusion (55%
cases of ARF)
• INTRARENAL: conditions that cause direct
damage to renal tissue (35-40% cases of
ARF)
• POSTRENAL: mechanical obstruction in the
urinary tract (5% cases of ARF)
CAUSES OF RENAL FAILURE
CONTINUED
• Multiple problems may exist at same
time
• AGING
RENAL FAILURE DEFINED
• To define renal failure ask yourself: How
is the kidney functioning with regard to?
• Excreting nitrogenous wastes
• Concentrating urine
• Conserving electrolytes
PROBLEMS FOR PATIENT
• Retention of metabolic wastes
• Imbalance of fluid and electrolytes
• Alterations of sensorium
3 phases of acute renal failure
• Oliguria
• Diuresis
• Recovery
OLIGURIC PHASE (lasts 10-14
days)
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Urinary changes
Fluid volume excess
Metabolic acidosis
Sodium balance
Potassium excretion
OLIGURIC PHASE (lasts 10-14
days)continued
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Hematologic disorders
Calcium deficit and phosphate excess
Waste product accumulation
Neurologic disorders
DIURETIC PHASE (lasts 1-3
wks)
Gradual increase of urine output as a
result of osmotic diuresis
• Why does this happen?
• What is the state of nephron?
• Can the kidney excrete wastes?
• Can the kidney concentrate urine?
• What would we see in the patient during
this stage?
RECOVERY PHASE
• When does this begin?
• Do all patients recover?
GOALS OF TREATMENT
• Restore renal function
• Identify cause
• Eliminate cause
MAINTAINING FLUID AND
ELECTROLYTE BALANCE
• How do we assess fluid excess?
• How can we control fluid intake?
• What physical assessments would be
done?
• What would you expect to see?
• What laboratory tests would be used to
assess client status?
NURSING CARE FOR:
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Elevated serum phosphate:
Hypocalcemia:
Hypermagnesemia:
Hypovolemia:
Fluid retention: diuretics:
Hypertension:
Metabolic acidosis:
TREATING HYPERKALEMIA
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Regular insulin IV
Sodium bicarbonate
Calcium gluconate IV
Dialysis
Kayexalate
Dietary restriction
DIET FOR ACUTE RENAL
FAILURE
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dietary protein
calories
K and phosphorus
Na
Fe
CHRONIC RENAL FAILURE
DEFINED
• Progressive deterioration in renal
function resulting in fatal uremia (excess
of urea and other nitrogenous wastes in
the blood)
• Irreversible destruction of nephrons
• Called ESRD (end stage renal disease)
• Dialysis or transplant
TERMS ASSOCIATED WITH
CHRONIC RENAL FAILURE
• Azotemia: collection of nitrogenous
wastes in blood
• Uremia: azotemia
• Uremic syndrome: systemic clinical and
laboratory manifestations of ESRD
Alterations: Chronic Renal
Failure
• Metabolic Disturbances:
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elevated BUN,
creatinine,
hyponatremia,
hyperkalemia,
metabolic acidosis,
hypocalcemia,
hyperphosphatemia
• Reproductive Disturbances:
– For woman: menstrual irregularities, amenorrhea, infertility,
decreased libido
– For men: impotence, reduced sperm motility
• Integumentary Disturbances: pruritus,dry,hair brittle,
nails thin, UREMIC FROST: white/yellow crystals of
urate on skin
ALTERATIONS OF CHRONIC
RENAL FAILURE CONTINUED
• Gastrointestinal Disturbances: Anorexia, N&V,
metallic taste in mouth, breath smells like
ammonia, stomatitis, ulcers/GI bleeding,
constipation
• Neurological Distrubances: uremic
encephalopathy progresses to seizures &
coma
• CHF: from increased workload on heart from
anemia, hypertension and fluid overload
• Uremic pericarditis: pericardium becomes
inflammed from toxins
ALTERATIONS OF CHRONIC
RENAL FAILURE CONTINUED
• Respiratory:
– breath smells like urine: uremic fetor or
uremic halitosis
– Metabolic acidosis: see tachypnea
(increased rate) and hyperpnea (increased
depth) indicates worsening metabolic
acidosis
• See Kussmaul respirations extreme
hyperventilation
NURSING CARE FOR PT WITH
CHRONIC RENAL FAILURE
FOR ANEMIA:
FOR HYPOCALCEMIA
FOR FLUID RETENTION AND HYPERTENSION
FOR SKIN ITCHING
DIETARY RESTRICTIONS FOR
CHRONIC RENAL FAILURE
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calorie
protein
Na
K
calcium
Phosphorus
Magnesium
DIALYSIS: peritoneal and
hemodialysis
PERITONEAL DIALYSIS
• Diffusion of solute molecules through a semipermeable membrane passing from the side of higher
concentration to that of lower concentration
• Fluids passing through the semi-permeable
membrane via osmosis
• Renal Failure pt has dialysis to remove waste
products and to maintain life until kidney function can
be restored
• Dialysis indicated for high levels of K and fluid
overload
PERITONEAL DIALYSIS
• Sterile dialyzing fluid is introduced into
the peritoneal cavity
• Peritoneum is an inert semipermeable
membrane
• The dialyzing solution promotes
osmosis leading to diuresis
• Urea and creatinine are removed
NURSING CARE OF PT ON
PERITONEAL DIALYSIS
• Baseline VS and wgt
• Assess for fluid overload
• Maintain highly accurate inflow and outflow
records
• When PD starts the outflow may be bloody
or blood tinged
• This clears within a week/two
• Effluent should be clear and light yellow
Nursing care during PD
• Drainage bag is lower than the client’s
abdomen to enhance gravity drainage
• Avoid kinking or twisting, ensure
clamps are open
• Reposition client to stimulate inflow or
outflow
• Sitting/standing/coughing: increases
intraabdominal pressure
COMPLICATIONS OF
PERITONEAL DIALYSIS
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Respiratory difficulties
Hypotension
Infection:
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peritonitis: see cloudy or opaque dialysate outflow
(effluent), fever, abdominal tenderness, pain, malaise, N&V
Hypo-albuminemia
Bowel perforation:
Bladder perforation:
Catheter may get clogged
COMPLICATION OF PD: Fibrin
Clot formation
• Fibrin Clot formation
• Milking the tubing
• Xray
COMPLICATION OF PD:
LEAKAGE
• Dialysate leakage
• See with obese, diabetic, older clients,
those on long term steroids
HEMODIALYSIS
• Process by which the uremic toxins and
accumulated waste products are
removed from the blood
HEMODIALYSIS
CONTINUED
• A synthetic semi-permeable membrane
replaces the renal glomeruli and tubules
and acts as a filter for the impaired
kidneys
• Must have 3 times/week for 4 hours per
treatment for rest of life
Access to pt’s circulation via:
• AV shunt (less common): external silastic
tubing placed in an adjacent artery and vein
• AV Fistula: internal access using pts own
vessels (artery and vein)
• AV Graft: internal access using a foreign
material
COMPLICATIONS Hemodialysis
vascular access
• BLEEDING
• INFECTION
• CLOTTING
Assessment during Hemodialysis
– Assess for disequilibrium reaction
– CAUSE:
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due to rapid decrease in fluid volume and BUN levels
Change in urea levels can cause cerebral edema and
increased intracranial pressure
Neurologic complications: HA, N&V, restlessness,
decreased LOC, seizures, coma, death
• PREVENTION: starting HD for short periods
with low blood flows
Nursing care pre dialysis
• Vasoactive drugs which cause
hypotension are held until after
treatment
• CHECK WITH MD ABOUT WHICH
DRUGS TO BE HELD
• Know pt’s BP predialysis
Post dialysis nursing care
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BP and wgt
Hypotension
Temperature may also be elevated:
If client has a fever
Bleeding risk:
KIDNEY TRANSPLANT
• Involves transplanting a kidney from a
living donor or human cadaver to a
recipient who has end-stage renal
disease and requires dialysis to live
POSTOPERATIVE CONCERNS
AFTER TRANSPLANT
major concern is rejection
• Drugs given to suppress immunologic
reactions: Imuran, prednisone,
cyclosporin (Cyclosporin A)
Next concern is infection
NRSG CARE POST KIDNEY
TRANSPLANT
TO DETECT REJECTION:
• Assess for increased temp, pain or
tenderness over grafted kidney
• Assess for decrease in urine output,
edema, sudden wgt gain
• Assess for rise in serum creatinine and
BUN values