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Renal Failure
Acute and Chronic
CM O. O. Adekoya
Snr. Matron R. U. Umenwa
INTRODUCTION
Renal Failure is a worldwide public health
problem commonly associated with underlying
medical condition such as hypertension, DM,
ingestion of herbal concoction etc. In our
environment; there is a rising incidence and
prevalence of kidney failure, the outcome of
which is complicated by poor socio-economic
condition.
RENAL IMPAIRMENT
This results when the kidneys cannot remove the
body’s metabolic wastes or perform their
regulatory functions. The substances normally
eliminated in the urine accumulates in the body
as a result of impaired renal excretion leading to
disruption in endocrine and metabolic functions
as well as fluid, electrolyte and acid base balance
disturbances.
RENAL IMPAIRMENT
It is mainly determined by a decrease in
glomerular filtration rate, it is detected
by a decrease in or absence of urine
production or presence of waste product
(creatinine or urea) in the blood,
depending on the cause heamaturia and
protein may be noted in the Urine.
INCIDENCE
The global burden of chronic kidney Disease is
enormous. The World Health Report 2002 and
Global Burden of Disease project reports show
that diseases of the kidney and urinary tract
caused one million deaths in 2002,ranking
twelfth in the list of world’s major causes of
deaths. The global incidence and prevalence of
CKD have increased exponentially in the last
decade. In Nigeria like many other developing
countries, accurate data is lacking principally due
to unavailability of national registry.
INCIDENCE
Racially – The incidence of renal failure is
significantly higher in blacks than white.
The united state renal disease system 2004
annual data, showed the incident rate of
renal failure as higher in males than in
females.
Demographically – Age related showed
that it cuts across all age group. The highest
incidence is between the ages of 30 – 60yrs.
BRIEF ANATOMY OF THE KIDNEY AND ASSOCIATED ORGANS.
Definition: Bean shaped organs of excretion.
Side: wt 150g, length 11cm, 6cm wide 3 cm thick
Position: lie on the posterior abdominal wall, one on
each side of the vertebral column, behind the peritoneum
and below the diaphragm extending from the 12th
thoracic vertebral to the 3rd lumbar.
The right kidney is slightly lower than the left probably
because of the liver space.
ANATOMY - Organs in Association:-
ANATOMY - Organs in Association:-
Right Kidney
Superiorly – the right adrenal gland
Anteriorly – the right lobe of the liver, the duodenum
and the hepatic flexure of the colon.
Posteriorly – the diaphragm and muscles of the
posterior abdominal wall.
ANATOMY - Organs in Association:-
Left Kidney
Superiorly – the left adrenal gland
Anteriorly – the spleen, stomach, pancreas,
jejunum and spleenic flexure of the colon.
Posteriorly – The diaphragm and muscles of the
posterior abdominal wall.
ANATOMY Continues
Gross Structure
•Longitudinal section of the kidney
reveals a fibrous capsule surrounding
the kidney the cortex – a reddish brown
layer immediately below the capsule.
•The medulla, the innermost layer
consisting of renal pyramids.
ANATOMY Continues
Microscopic Structure
The kidney composed of about
1million functional units called
nephrons and a smaller number
of collecting tubules.
ANATOMY – contd.
ANATOMY Continues
The Nephron composed of the glomerular capsule
(Bowman’s capsule) encloses a network of
capillaries called the glomerulus.
The proximal convoluted tubules
The medullary loop (loop of Henle)
The distal convoluted tubules leading into a
collecting duct.
The collecting ducts unite forming larger ducts that
empty into the minor calyxes.
Blood Supply
◦Arterial
– Renal Artery
ANATOMY Continues
The kidneys receive approximately 20 – 25% (about
1200ms) of cardiac output under normal physiological
conditions. This is called the renal fraction. The body’s
total blood supply circulates through the kidney,
approximately 12 times per hour. Approximately 90%
of the renal blood supply circulates through the cortex at
a rate of about 4-5ml/min and 10% circulates through
the medulla at about 1ml/min. Each kidney has one renal
artery that branches from the abdominal aorta to enter
the kidney at the hilum.
Veinous Drainage – Renal vein exists through the
hilum to join inferior venal cava.
FUNCTIONS OF THE KIDNEY
Urine formation
Excretion of waste products
Regulation of electrolytes
Regulation of acid-base balance
Control of water balance
Control of blood pressure
Regulation of red blood cell production
Synthesis of vitamin D to active form
Secretion of Erythropoetin
Regulates calcium and phosphorus balance
Activates growth hormone.
AETIOLOGY (CAUSES)
Pre-renal factors
• Volume depletion resulting from:Haemorrhage, burns, shock, peritonitis,
nephrotic syndrome, G I losses, renal losses
(e.g. diuretics, diabetes insipidus)
Impaired cardiac efficiency resulting from:• Myocardial infaction, congestive heart failure,
cardiac arrhythmias, cardiogenic shock.
Vasodilation resulting from:• Sepsis, anaphylaxis, antihypertensive
medications and other causes of vasodilation.
AETIOLOGY (CAUSES) Continues
Intra renal factors
Prolonged renal ischemic resulting from pigment nephropathy
(associated with the breakdown of blood cells containing pigment that
in turn occlude kidney structures).
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Myoglobinuria (trauma, crush injuries, burns)
Haemoglobinuria (transfusion reaction, haemolytic anaemia).
Nephrotoxic agents such as Aminoglycoside antibiotics
(gentamicin)
Radiopague contrast agents
Heavy metals (lead, mercury)
Solvents and chemicals (carbon tetrachloride, arsenic)
Nonsteriodal anti-inflammatory drugs (NSAIDs)
Angiotensin – converting enzymes inhibitors (ACE
inhibitors).
AETIOLOGY (CAUSES) Continues
Infections processes such as acute pyelonephritis,
Acute glomerulonephritis.
Post-Renal Factors
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Urinary tract obstruction including calculi
(stones)
Tumors
Benign prostatic hypertrophy
Strictures
Blood clots
STAGES OF RENAL FAILURE
Stages are based on the Glomerular Filtration
Rate (GFR). The normal GFR is
125ml/min/1.73m2
Stage I
•GFR > 90ml/min/1.732
•Kidney damages with normal or increased GFR
Stage II
•GFR 60 – 89ml/min/1.732
•Mild decrease in GFR
STAGES OF RENAL FAILURE
Stage III
GFR 30 – 59ml/min/1.73m2
Moderate decrease in GFR
Stage IV
GFR 15 – 29ml/min/1.73m2
Severe decrease in GFR
Stage V
GFR < 15ml/min/1.73m2
Kidney failure (ESRD)
CLINICAL
FEATURES
CM O. O. Adekoya
CLINICAL FEATURES
Symptoms can vary from person to person. Someone in early stage of kidney
failure may not feel sick or notice symptoms as they occur when the disease
progresses symptoms become noticeable. This include the following:-
Early Signs
High level of urea in the blood known as ureamia which result in
vomiting/diarrhoea, which may lead to dehydration.
Nausea, Weight loss, Nocturia
More frequent urination or in greater amounts than usual, urinary frequency.
Less frequent urination or in small amounts than usual, with dark coloured
urine (oligouria) Anuria
Heamaturia
Pressure or difficulty in urinating
As the failure progresses the build up of potassium, phosphates in the blood
results in the following signs and symptom.
 Abnormal: heart rhythm, muscle cramps itching, muscles paralysis at a time,
CLINICAL FEATURES
Continues
Failure of kidney to remove excess fluid will
bring about the following:Swelling of the legs ankles feet, face or hands.
Shortness of breath due to extra fluid in the lungs.
Reduction in the production of erythropoetin, the
hormone responsible for production of red blood cells
results.
Anaemia, Tiredness or weakness
Memory problem
Dizziness
Low blood pressure
CLINICAL FEATURES
Continues
Other symptoms include
◦ Loss of Appetite
◦ Difficulty in sleeping insomnia
◦ Darkening of the skin
◦ They may experience seizure, Diarrhoea,
(ureamic stool – with offensive odour).
MEDICAL MANAGEMENT
The medical management is mainly to maintain
kidney function for as long as possible, factors that
are reversible e.g. obstruction are identified and
treated.
 Hypertension is managed with anti-hypertensives
Cardiac medication:Diuretics e.g. lasix,
 Erythropoetin is administered to correct anaemia
and
 Iron supplements can also be given e.g. Iron
Sucrose
 Nutrition and diet adjustment
 Renal replacement therapy is initiated.
MEDICAL MANAGEMENT Continues
INVESTIGATIONS
Urine Analysis:• To reveal presence of glucose, protein, red or white
blood cell, malignant cells.
• Urine Culture, FBC, ESR, E/U creatinine
• Plain abdominal X-ray may show calculi
• Renal USS, IVU
• Renal Biopsy.
Serum tests which include
• Creatinine level, Normal value – 0.7 – 1.4mg.
• Urea nitrogen – BUN (Normal value 10 – 20mg/dl)
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
The nursing management is based on
the following principles.
Monitoring fluid and electrolytes balance
Reducing metabolic rate
Prevention of infection
Providing support
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
On admission:
Patient full history is taken:Past medical history
ii. Present medical history
iii. Family history
iv. Lifestyle from relation or the patient if possible
 Physical assessment of the patient is done so as to
have baseline, data, which includes the vital signs,
Temperature Pulse Respiration.
 R.B.S check and all these will be documented.
i.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
Assessment of patients with renal failure reveals
the following nursing diagnosis and how they are
being managed.
Nursing Diagnosis
ii) Fluid volume excess. i.e. (oedema) related to
decreased urine output and retention of sodium
+ water.
Goals:- To reduce the excess fluid within 2
weeks of intervention.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
Intervention:(1) Assess for level of oedema
(2) Limit fluid intake to prescribed volume.
(3) Explain to patient and family rational: for restriction,
strict intake/output chart.
(4) Assist patient to cope by giving continuous
encouragement, advise, on daily fluid intake.
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Placed patient on low salt diet, give prescribed diuretic e.g.
lasix
◦ Expected outcome is to have reduction in the excess fluid.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
2) Imbalance Nutrition: less than body
requirement related to vomiting, nausea,
anorexia.
Goals: maintenance of adequate
nutritional intake throughout admission.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
Intervention:
(i) Patient diet history is taken
(ii) Ask patient for food preference.
(iii) Provide patient food preference within dietary restrictions.
•Placed patient on high calorie, low salt, low protein, low
potassium diet.
•Explain rationale for dietary restriction and relationship to his or
her condition.
•Provide pleasant surroundings at meal times.
•Schedule drug administration so they are not given immediately
after meal.
•Give prescribed drugs like: anti-emetics
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(3) Deficient knowledge regarding condition and
treatment
Goal:- Patient will be enlightened on disease condition
and treatment.
Intervention:•Provide explanation of renal function and consequences
of failure
•Allow patient to ask questions and explain in a simple
language the patient will understand.
•The expected outcome. The patient will cooperate with
the nursing staff during admission and nutritional balance
will be maintained.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(4) Activity intolerance related to fatigue, anaemia, retention of
waste products and dialysis procedure.
Goal:- patient will be able to participate in daily living activity
within two weeks of nursing intervention.
Intervention:
•Nursing staff should promote activities and exercises within limit
of tolerance.
•Assist patient in self care e.g. bed bath, oral toilet
•Encourage patient to rest especially after dialysis
Outcome:- the patient should be able to participate in self-care
activity.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(5) Low Self Esteem related to dependency role
and loss of renal function.
Goal:- To achieve improved self esteem
Intervention:
Encourage open discussion especially changes
in lifestyle, occupation, finance and domestic
issues.
Encourage family and friends to show love and
affection.
Inform social worker for assistance in extreme
cases.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(6) Impaired skin integrity
Goal:- patient’s skin will be intact throughout
hospitalization and not get infected.
Intervention: Assess skin for change in colour. Bath
patient with tepid water.
 Change patient position when necessary
 Keep patient nails short and clean
 Apply appropriate cream as necessary.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(7) Risk of Injury related to confusion
Goal: patient will not develop injury during
hospitalization.
Intervention:Provide safe environment
Restrict patient movement when necessary e.g.
using a restrainal, bed side railings.
Assess patient for elevated urea and encourage
dialysis as at when due.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(8) Frequent stooling related to G.I Inflammation.
Secondary to increase urea level
Goal:- reduction in bowel motion, prevention of
dehydration and to make patient comfortable.
Intervention:
 Replace fluid loss as necessary
 Make patient comfortable by changing bed linen when
soiled.
 Check vital signs as necessary e.g. 4hrly, 6hrly.
 Encourage patient to dialyse
 Give bedpan when necessary and provide privacy
 Keep perineal area clean.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(9) Breathlessness related to pulmonary oedema
Goal:- Patient breathing to improve within 2hrs of
nursing intervention.
Intervention:
 Placed patient in an upright position.
 Administer oxygen if necessary
 Relieve anxiety
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
(10) Risk of Infection
Goal: Patient will not acquire any infection during
hospitalization.
Intervention: Daily bathing, changed bed linen as
necessary
 Asepsis is essential with invasive lines.
 Indwelling catheter is avoided whenever possible to
avoid U.T.I
 Keep patient environment clean.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
HAEMODIALYSIS
The treatment for most patient with ESRD (End Staged
Renal Disease) is to dialyse at least 3 times in a week.
This is being done by a DIALYSER also referred to as an
artificial kidney, which serves as a synthetic semi
permeable membrane replacing the renal glomeruli and
tubules, which serves as the filter for the impaired
kidneys.
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
For patient with chronic renal failure, haemodialysis prolonged
their life though it does not cure renal disease, it is necessary for
survival and control of ureamic symptoms. It is better to initiate the
treatment before the sign and symptoms associated with uremia
become severe.
Goal:- The objective of dialysis is to extract toxic nitrogeneous
substances from the blood and to remove excess water.
Nursing Care:- pre dialysis
 Assist patient to cope by ensuring enough rest before dialysis,
reducing patient visitors as much as possible, relieve anxiety, and
monitor vital signs.
 Do not give drugs especially antihypertensives before
haemodialysis.
 Weigh patient before the procedure
NURSING MANAGEMENT OF PATIENT WITH RENAL FAILURE
Post Dialysis: check vitals signs 4hrly, observe
for bleeding from the cannulation site.
Complications:
 Although haemodialysis can prolong life
indefinitely, it does not alter the natural cause of
the underlying kidney disease nor does it
completely replace kidney function.
NURSING MANAGEMENT AND PATIENT EDUCATION
The patient is subjected to a number of
problems and complications, like
Coronary heart disease and anginal pain
Heart failure
Fatigue which contribute to physical and
emotional well being.
Gastric ulcer and other G.I problem, resulting
from the physiological stress of chronic
illness.
Insomnia, Hypotension
Malnutrition, infection .
NURSING MANAGEMENT AND PATIENT EDUCATION
PATIENT EDUCATION
Nursing Management is not complete without patient
education on management of disease condition.
Patient is educated on the following:
 To keep to diet and other treatment regime.
 Should quit self medication
 All habit of drinking and smoking should stop.
 Visit hospital as soon as possible in case of illness
 Keep hospital appointment
 Should also keep to renal replacement schedule.
PROGNOSIS & PREVENTION
PROGNOSIS
This is generally poor especially in this environment, rate
of progression to increased morbidity and death depend
on many factors among which are:
 Underlying diagnosis e.g. DM
 Successful implementation of secondary preventive
measure i.e. timely intervention of obstructive cases
 Age of the patient
 Timely initiation of renal replacement therapy.
.
PROGNOSIS & PREVENTION
PREVENTION:- The society should be
enlightened to purchase drugs at recognized
pharmacy store and stop patronizing drug
hawkers to avoid the use of fake drugs.
Health Promotion programmes should be
encouraged like general screening for
hypertension, diabetes, prevention is
paramount because the management is
expensive and complex.