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Nursing Diagnosis of Chronic Renal Failure 5/25/2017 Mary Roche, RN 1 Nursing Diagnoses Renal Failure • Fluid Volume Deficit/Fluid Volume Excess • Altered Nutrition: Less Than Body Requirements • Risk Of Impaired Skin Integrity Related to Poor Nutrition/Edema And Pruritus • Anxiety Related to Unknown Outcome of Disease 5/25/2017 Mary Roche, RN 2 Chronic Renal Failure • Progressive Reduction of Functioning Renal Tissue – Remaining Kidney Can No Longer Maintain Internal Environment • Insidiously or Acutely Post Renal Failure • Hypertension and Diabetes the Most Common Causes 5/25/2017 Mary Roche, RN 3 Nursing Management of Electrolyte Imbalances in ARF • Check potassium after dialysis • Check magnesium levels • Add water soluble vitamins 5/25/2017 Mary Roche, RN 4 Dietary Restrictions • Fluid • Protein • Potassium – 60-70 Meq Per Day • Sodium • Phosphorus 5/25/2017 Mary Roche, RN 5 Medications for Chronic Renal Failure • • • • • • Diuretics Vitamins and Minerals Sodium Bicarbonate Erythropoietin Calcium Preparations and Phosphorus Binders Antihypertensives 5/25/2017 Mary Roche, RN 6 Goals for Dialysis • Removal of Blood Urea and Creatinine • Maintenance of Safe Concentration of Serum Electrolytes • Correction of Acidosis, Replenishment of Bicarbonate Buffer System • Removal of Excess Fluid from Blood 5/25/2017 Mary Roche, RN 7 Key Concepts of Dialysis • • • • Diffusion Filtration and Ultrafiltration Concentration Gradient Osmosis – See Page 283 Of Handout 5/25/2017 Mary Roche, RN 8 5/25/2017 Mary Roche, RN 9 Medical Goals of Chronic Renal Failure • • • • Preservation of Renal Function Delay of Need for Dialysis or Transplant Improvement of Body Chemistry Alleviation of Extrarenal Effects 5/25/2017 Mary Roche, RN 10 Electrolyte Imbalances • • • • Potassium Increases Phosphate Increases Sodium - Normal or Decreased Magnesium Increases 5/25/2017 Mary Roche, RN 11 Vascular Access For Hemodialysis • • • • Subclavian/Internal Jugular Double Lumen Udall (Subclavian or Femoral) Mahurkar and Permacath (Subclavian) Av Fistula/Av Graft – Refer To Iggy Page 1923, Figure 75.9 5/25/2017 Mary Roche, RN 12 5/25/2017 Mary Roche, RN 13 Nursing Care of Arteriovenus Fistula • Initally Assess Hemorrhage, Infection, Edema. Elevate Arm • No B/P, Venipunctures, IV in Access Arm • Assess Function Of Fistula – Bruit And Thrill • Assess Distal Pulse Circulation • Allen’s Test • No Carrying Heavy Objects 5/25/2017 Mary Roche, RN 14 5/25/2017 Mary Roche, RN 15 Dialysis - Nursing Care • Prior to Dialysis • During Dialysis – See Pages 283 To 292 in Handout • Post Dialysis 5/25/2017 Mary Roche, RN 16 Nursing Management of Peritoneal Dialysis • Installations and Dwell Periods • Dialysate • Outflow Times 5/25/2017 Mary Roche, RN 17 Nursing Management of Peritoneal Dialysis • Installations – 1 to 2 liters over 30 minutes • Dwell Periods • Dialysate • Outflow Times 5/25/2017 Mary Roche, RN 18 Nursing Care Highlights • Patients with Peritoneal Dialysis Catheter – sterile procedure • A mask should be worn by the patient also – aseptic techniques • follow procedure as defined – catheter site • must be free of signs and symptoms of infection (redness, pus, odor) 5/25/2017 Mary Roche, RN 19 Chronic Renal Failure Continuous Renal Replacement Therapies 5/25/2017 Mary Roche, RN 20 Four Primary Types of CRRT (CAVH) Continuous Arteriovenous Hemofiltration. Blood flows through a semipermeable filter and an extracorporeal circuit. CAVH is not a controlled procedure for fluid removal. It is used primarily when a machine with more advanced CRRT systems isn’t available. Its ability to remove and replace fluid is effective and a relatively simple technology. 5/25/2017 Mary Roche, RN 21 Four Primary Types of CRRT (CAVHD) Continuous Arteriovenous Hemodiafiltration. Blood flows through a semipermeable filter and an extracorporeal circuit compartment. CAVHD is used when CAVH does not provide adequate waste removal. 5/25/2017 Mary Roche, RN 22 Four Primary Types of CRRT (CVVH) Continuous Venovenous Hemofiltration. Blood flows through a semipermeable fiber filter and an extracorporeal circuit. It requires use of a pump to propel blood through the circuit. CVVH uses a process called convective transport to effect solute removal. Replacement solution can be added and fluid removal can occur if desired. 5/25/2017 Mary Roche, RN 23 Four Primary Types of CRRT (CVVHDF) Continuous Venovenous Hemodiafiltration. Blood flows through a semipermeable filter and dialysate is delivered through the extracorporeal compartment of the filter. It increases solute removal (via diffusion) more effectively than convective transport of CVVH does. Fluid removal can occur as well, if desired. 5/25/2017 Mary Roche, RN 24 Advantages • • • • • • Less risk of overload. TPN is enhanced. Optimizes hemodynamic status. Decreases extravascular lung water. Corrects lactic acid levels. Corrects clear chemical mediators such as leukotrienes. • Associated with lower rates of morbidity and mortality. 5/25/2017 Mary Roche, RN 25 Advantages • Associated with higher rates of complete renal recovery. • Gentle continuous hemofiltration avoids complicates associated with hemodialysis (cardiac stress, rapid fluid shifts, etc.). • High ultrafiltration rate permits large-volume fluid administration as in TPN and drug dosing. • CVVH and CVVHDF do not require arterial access making management safer. 5/25/2017 Mary Roche, RN 26 Disadvantages Need for arterial access in CAVH and CAVHD. – These two methods use the patient’s own BP and clotting may occur. • Clearance of nephrotoxic substances is limited in patients who are catabolic. • Bleed is a risk. – If line is disconnected, exsanguination would be rapid. • No air detectors, – Possibility of air embolism exists. • Limited patient mobility. • Slower solute and fluid removal. • Anticoagulation often needed to maintain patency. 5/25/2017 Mary Roche, RN 27 Indications for Use Indications include: – – Hemodynamic instability, and. Multiple organ dysfunction syndrome. When accompanied by: 1. Renal failure, 2. Fluid volume overload, and. 3. Metabolic and acid-base disturbances. 5/25/2017 Mary Roche, RN 28 Conditions or Situations Necessitate Strict Fluid Regulation • • • • • • • • • The period after MI The period after open heart surgery Resistance to diuretic therapy Total parenteral nutrition End-stage renal disease in patients too unstable to tolerate hemodialysis or peritoneal dialysis Adult respiratory distress syndrome Crush injuries Lactic acidosis Heart failure 5/25/2017 Mary Roche, RN 29 Contraindications • include the following: – Coagulopathy – Liver disease – Active bleeding 5/25/2017 Mary Roche, RN 30 Contraindications • Anticoagulant therapy – an integral part of CRRT, – administration may be contraindicated in some patients with bleeding or clotting disorders or liver disease. • Heparin – need not always be used, – nurses should be aware of the increased risk of filter clotting. – Alternatives to heparin, such as sodium citrate, may be used. Because of possible metabolic derangements with sodium citrate, it should be used only with CAVHD or CVVHDF. 5/25/2017 Mary Roche, RN 31 Contraindications • Hyperkalemia – Because of slow solute removal, CAVH and CVVH are not recommended in patients with life-threatening hyperkalemia. • Diffusion – the movement of solutes from an area of higher concentration, passing across a semipermeable membrane, to an area of lower concentration, until equilibrium is reached. 5/25/2017 Mary Roche, RN 32 How CRRT Works • Convection – involves the transfer of solutes and solvents simultaneously across a semipermeable membrane. • When water moves across a semipermeable membrane, the pressure gradient causes friction. Some molecules are then dragged across with the water, creating a sort of vacuum. • This solute movement is convective transport. • Both the CAVH and CVVH processes use convection to remove some solutes. 5/25/2017 Mary Roche, RN 33 How CRRT Works In CAVHD and CVVHDF, both diffusion and convective transport take place, resulting in a greater clearance of solute than in CAVH and CAVVH, which involve only convective transport. 5/25/2017 Mary Roche, RN 34 Extracorporeal Systems • All four methods of CRRT have relatively simple extracorporeal systems. • Each uses a semipermeable membrane of hollow fibers, a collection bag, and two blood lines. • The access line (arterial or venous) is where blood travels from the patient to the filter. • The return line (venous) is where the blood returns from the filter to the patient. 5/25/2017 Mary Roche, RN 35 Extracorporeal Systems • The hollow fiber filter comprises a cylindrical support case that surrounds the semipermeable membrane (the hollow fibers). • The space between the support case and the outside of the membrane is the extracapillary side. • The inside of the membrane is the blood or capillary side. • There are two ports on the filter casing, one leading to a collection bag for filtrate and another that delivers the dialysate to the filter. • The dialysate ultimately drains into the same collection bag as the filtrate. 5/25/2017 Mary Roche, RN 36 Nursing Management • CRRT is performed in the ICU to minimize complications. – It is essential to continually assess the hemodynamic status as well as BP, heart rate and rhythm while blood is pumped onto extracorporeal circulation. 5/25/2017 Mary Roche, RN 37 Nursing Management • Assessment of fluid status, including central venous pressure, pulmonary artery pressure, and pulmonary artery occlusive pressure, provides clinical data. – Nurses should watch for changes in mental status, breath sounds, and skin turgor and for the presence of arrhythmias, edema and signs and symptoms of bleeding or infection. • Calculation of fluid balance is based on hourly and cumulative measurement of fluid intake and output. 5/25/2017 Mary Roche, RN 38 Nursing Management • Aggressive management of hypotension related to hypovolemia is required to avoid alterations in tissue perfusion. – Monitoring for signs of hemorrhage as there is high risk caused by accidental disconnection of the lines from the body. • Monitoring heat loss as a significant amount of heat is lost as the blood makes its way through the extracorporeal part of the circuit. – Assessing for infection at catheter sites and monitoring white blood count as well as monitoring for fever. 5/25/2017 Mary Roche, RN 39 Managing The CRRT System • The nursing role – Nurses have a pivotal role in assessing patient’s tolerance to therapy and in managing equipment and the patency of the circuit • Electrolyte and acid-base imbalances – Patients receiving CRRT are at risk for electrolyte and acid-base imbalance either as a result of the underlying condition or through loss in the ultrafiltrate – The nurse must manage and monitor the acid-base balance and administer supplements as necessary 5/25/2017 Mary Roche, RN 40 Managing The CRRT System • Filter clotting and anticoagulation – Heparin is often administered to maintain the patency of the circuit and prevent filter clotting – Monitoring both patients and filters is essential to preventing complications of heparin therapy 5/25/2017 Mary Roche, RN 41 Managing The CRRT System • Air and blood leakage detectors – During CAVH, ultrafiltrate should be tested for the presence of occult blood every four to six hours – An air detector to prevent the development of an air embolus is part of the CVVH circuit – Another part of the CVVH system is a blood leakage detector which helps identify ruptured hollow fibers within the filter. If blood is detected an alarm will sound 5/25/2017 Mary Roche, RN 42 Peritoneal Dialysis • • • • Osmosis Diffusion Dialysate concentrations Dwell times 5/25/2017 Mary Roche, RN 43 Post Dialysis Nursing Management • Observe for: – Disequilibrium syndrome – Orthostatic Hypotension • Monitor for: – Bleeding – Hematoma – Patency 5/25/2017 Mary Roche, RN 45 Post Dialysis Nursing Management • Obtain vital signs and weight • Perform frequent Neuro assessment • See pages 287 to 291 in handout 5/25/2017 Mary Roche, RN 46 Complications of Peritoneal Dialysis • Peritonitis – Use meticulous aseptic technique – Check for • Fever, rebound tenderness, nausea, malaise – Monitor WBC count • Hyperglycemic and Hyperosmolar states • (Especially with high glucose dialysate) 5/25/2017 Mary Roche, RN 47 Nursing Diagnoses For Chronic Renal Failure Patient • Fluid volume deficit or excess • Altered nutrition – Less than body requirements – Related to anorexia, nausea • Fatigue – Related to anemia and altered metabolic state • Impaired skin integrity 5/25/2017 Mary Roche, RN 48 Nursing Diagnoses For Chronic Renal Failure Patient Continued: • Knowledge deficit – Related to disease process and treatment • Ineffective management of therapeutic regime • Ineffective family coping 5/25/2017 Mary Roche, RN 49 Kidney Transplants • Intervention for irreversible kidney failure • Implantation of a human kidney to one patient from another 5/25/2017 Mary Roche, RN 50 5/25/2017 Mary Roche, RN 51 Living Related Donor • Requirements – Two properly functioning kidneys – Excellent health – Compatible • ABO – Blood type • Tissue type • HLA – Human leukocyte antigen 5/25/2017 Mary Roche, RN 52 Cadaver Donor • Requirements – – – – – – 5/25/2017 Must meet criteria for brain death Under 60 years of age Normal renal function Normal BP Negative hepatitis antigen Negative HIV antibody Mary Roche, RN 53 Post Operative Management • Rejection – Hyperacute • Within 48 hr after surgery – Acute • 1 wk to 2 yr post operatively – Chronic • Occurs gradually during a period of months to year 5/25/2017 Mary Roche, RN 54 Immunosuppressant Drugs • • • • • • • Cyclosporine (Sandimmune) Muromonab-cd3 Tacrolimus (Prograf, FK-506) Mycophenolate (Cellcept) Prednisone Azathioprine (Imuran) Sirolimus (Rapamune) 5/25/2017 Mary Roche, RN 55 The End Mary Roche, MSN, RN, CS 5/25/2017 Mary Roche, RN 56 Public Version • This presentation was developed for Mary Roche by peter martin dba Stacy house designs • A public version is available under the web developments section of www.stacyhouse.com 5/25/2017 Mary Roche, RN 57 Using The Umbilicus For Catheterization 5/25/2017 Mary Roche, RN 61 The Mitrofanoff Procedure • Creates a catheterizable channel between a stoma on the skin of the abdomen (usually the umbilicus) and the bladder. • Allows patients to intermittently empty their bladder by inserting a disposable catheter into the channel. – Also called an appendicovesicostomy because the appendix is used to create the channel. • First described in 1980, has become the most widely used alternative to urethral selfcatheterization in the world. 5/25/2017 Mary Roche, RN 62 The Mitrofanoff Procedure • It is highly successful with continence achieved in more than 90% of patients. • Is used for patients who have: – A neurogenic bladder or other conditions that interfere with continence and. – Who are unable to easily self-catheterize through the urethra. 5/25/2017 Mary Roche, RN 63 The Mitrofanoff Procedure • Typically, this procedure is performed in pediatric specialty institutions or major medical centers. • Understanding this procedure is important if you work in med-surg, long-term care, school, or rehab setting. • For most patients, the primary reason to undergo the Mitrofanoff procedure is physiological – to maintain a healthy urinary tract and establish urinary continence through intermittent catheterization via an easily accessible stoma. 5/25/2017 Mary Roche, RN 64 The Mitrofanoff Procedure • For patients with spinal cord injuries, the procedure can help stem the continued potential for deterioration of renal function. • For others, there is improved quality of life. • It is essential to make sure that the patient has the physical ability, mental capacity, self-discipline, and psychological readiness to perform the selfcatheterizations. 5/25/2017 Mary Roche, RN 65 Screening Candidates • The majority of patients who undergo a Mitrofanoff procedure will require a rigid schedule of self-catheterization – typically once every four hours while awake – to achieve dryness and prevent the complications of continued incontinence. • There is extensive bowel prep, antibiotic therapy and laboratory work preop. – Cystourethrogram and renal ultrasound are needed to assess the patient for any structural abnormalities of the urinary tract. 5/25/2017 Mary Roche, RN 66 Using The Appendix to Create a Channel • During the procedure, a channel from the bladder to the abdomen is created to achieve entrance to the bladder. • Because the appendix has a constant, reliable blood supply, supple muscular wall, and adequate lumen, it has proven to be the ideal tissue with which to create the channel. 5/25/2017 Mary Roche, RN 67 Using The Appendix to Create a Channel • After the mucosa to mucosa anastomy a flap valve is created to prevent reflux and leakage of urine. • The stoma is then created and concealed in the umbilicus. • Postoperatively, patients generally have a 12F cath placed through their appendicovesicostomy. • While undergoing surgery some patients may undergo bladder augmentation with segment of stomach or intestine. 5/25/2017 Mary Roche, RN 68 Using The Appendix to Create a Channel • The catheter remains in place about three weeks and the patient goes home with them. • After then, the stoma is healed and functional. 5/25/2017 Mary Roche, RN 69 Post Op And Followup • Patients are sent home with the appendicovesicostomy and urethral catheters in place, though the appendicovesicostomy catheter is clamped. • Approximately three weeks postop, the patient returns to the hospital. – Both catheters are removed and the patient is taught how to perform self-cath through the appendicovesicostomy. 5/25/2017 Mary Roche, RN 70 Post Op And Followup • Patient must be explained that since the catheter is entering the bladder from above, emptying is like siphoning liquid from a gas tank. – The container must be lower than the bladder, and when urine begins to flow, the catheter should be pushed in another one to one-and-one-half inches to insure adequate bladder drainage. • Patients should be taught to use sterile technique and report any signs of infection. 5/25/2017 Mary Roche, RN 71 Post Op And Follow-up • Patients must use the conduit regularly to ensure patency. – To date, minimal complications have been reported. – Stomal stenosis must be watched for and 7% to 24% of patients experience this. – Stomal stenosis can occur if the appencovesicostomy is not dilated frequently enough. – Repeated self dilation by intermittent selfcatheterization can usually remedy this problem. 5/25/2017 Mary Roche, RN 72 Post Op And Follow-up • Stone formation in the bladder or kidney can be a long-term complication. • The longer a channel is in place, the greater the chance for stone formation. 5/25/2017 Mary Roche, RN 73