acute and chronic renal failure student 2013

Acute and Chronic Acute and Chronic Renal FailureRenal Failure

Tina Bayer-Hummel RN ANPAssistant Professor Of Nursing

Queensborough Community College

Spring 2013 NU 202 1

Objectives Based on the QCC Objectives Based on the QCC FrameworkFramework

Assessment: Identify physical assessment changes in the client in renal failure.

Communication: Utilize SBAR format and information technology to support and communicate plan of care for in acute renal failure.

Caring Interventions:. Identify social, cultural, economic factors that impact care.

Clinical decision Making: Identify and discuss nursing interventions appropriate for the client in acute/chronic renal failure.

Teaching/Learning: Explain dialysis to families, significant others.


Objectives Based on the QCC Objectives Based on the QCC FrameworkFramework

Collaboration: Describe collaborative management of the client in acute/chronic renal failure.

Managing Care: Identify the nursing management of the client in acute/chronic renal failure.


Kidney System FunctionsKidney System Functions

1. Eliminate water-soluble nitrgoenous end- products of protein metabolism; Excretion of waste products.

2. Maintain electrolyte balance in body fluids3. Get rid of the excess electrolytes.4. Discharge excess water in the urine. 5. Maintain acid-base balance in body fluids

and tissue. 6. Control of blood pressure.7. Regulation of red blood cell production.8. Synthesis of vitamin D to active form.9. Regulates calcium and phosphorus

balance.


Important Lab ValuesImportant Lab Values

BUN - Blood urea nitrogen.measure of the kidneys' ability to excrete

urea, the chief waste product of protein breakdown

Elevated in renal failure and dehydration7 - 20 mg/dl

Creatinine: A waste product from protein in the diet and from the muscles of the body.

removed from the body by the kidneysIncreased in kidney disease 0.5 to 1.0 mg/dL


Important TestImportant Test

Creatinine Clearance Test◦compares the level of creatinine in urine with

the creatinine level in the blood◦24-hour urine sample ◦Male: 97 to 137 ml/min. ◦Female: 88 to 128 ml/min. ◦estimate the glomerular filtration rate (GFR) --

the standard by which kidney function is assessed range 90 - 120 mL/min


GFRGFR

GFR-Levels below 60 mL/min for 3 or more months are a sign of chronic kidney disease. Those with GFR results below 15 mL/min are a sign of kidney failure.


DefinitionsDefinitions

Parenchyma - The key elements of an organ essential to its functioning

Uremia –retention in the bloodstream of waste products normally excreted in the urine, urea, creatinine and other nitrogen containing waste products of proteins .

Also called Azotemia. resulting from kidney diseaseAnuria - total urine output less than 50 mL in 24

h

Oliguria - total urine output less than 400 mL in 24 h


Risk Factor for ARFRisk Factor for ARF

Increased age

Preexisting renal disease

Administration of several nephrotoxic agents simultaneously

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Renal FailureRenal Failure

Severe impairment or total lack of kidney function

Inability to excrete metabolic waste products and water

Classified as acute or chronicMay manifest as oliguria, anuria, or

normal urine volume

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Acute Renal FailureAcute Renal Failure

Rapid decline in renal function Potentially reversible but does have high

mortality rateNephrotoxins, Ischemia, Obstructions,

Most Common Causes

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Progressive Azotemia- accumulation off nitrogenous wastes (BUN)

Increased serum CreatinineOliguria↑K

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Mechanisms:Pre-renal -- volume depletion, poor

cardiac efficiency, vasodilationIntra-renal -- prolonged ischemia,

myoglobinuria, infections, nephrotoxins, glomerulonephritis

Post-renal -- obstruction from stone, tumor

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Mechanisms: Pre-renal -- volume

depletion, poor cardiac efficiency, vasodilation

Intra-renal -- prolonged ischemia, myoglobinuria, infections, nephrotoxins, glomerulonephritis, trauma

Post-renal -- obstruction from stone, tumor MECHANICAL OBSTRUCTION from the tubules to urethra. BPH-most common

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Types of Renal FailureTypes of Renal Failure

Prerenal -- Systemic CauseHypo perfusion-↓ in blood pressureHypovolemia R/T-hemorrhageCardiogenic ShockSepsis

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Intrarenal Causes: Direct Damage to the Kidneys

Ischemia from MIMyoglobinuria cause of RhabdomylysisHemoglobinuriaNephrotoxic AgentsAcute plyleonephrirtis

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Post Renal Causes : Obstruction of Urine Flow

TumorsSTONESClotsStrictures

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Clinical ManifestationsClinical Manifestations

Four clinical phases:Initiation: Initial insult to oliguria -

≤400ML/24hrsOliguria: ↑Bun/Creatinine, Rise in serum

concentration of substances excreted by kidney K+, Magnesium, ↓U/O

Diuresis: Gradually increasing U/O lab values stabilize

Recovery: Improvement of renal function3-12 monthsPermanent 1-3% reduction in GFR

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Clinical ManifestationsClinical Manifestations

Every system of the body is affectedCNS-Lethargy, Confusion,

Headache ,SeizuresCV-Congestive Heart Failure ,HTNLungs- SOBSkin/Hair/Nails-Dry thin scalyGI- Diarhea ,Nausea, Vomiting, Uremic GI

lesionsGu-Oliguria Anuria Blood in urine

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Abnormal lab valuesAbnormal lab values

↑BUN, Creatinine-Azotemia As a result of catabolism( breakdown of

protein) and impaired renal perfusion ↑Creatinine ↑Glomerular damage

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Abnormal lab valuesAbnormal lab values

Hyperkalemia as result of the ↓ in GFRPatients can not excrete K+ normally↑Protein catabolism ↑K+ = in body fluidCan cause dysrhythmias and cardiac

arrestSource of K+ is GI blood loss, dietary,

extracellular shift related to metabolic acidosis

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AnemiaAnemia

↓ RBC ,Hemoglobin/HCTR/T abnormally low production of red

blood cells by the bone marrow R/T inability of the failing kidneys to

secrete the hormone erythropoietinUremic GI lesionsBlood lossReduced RBC life span

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Metabolic AcidosisMetabolic Acidosis

Related to oliguria unable to eliminate acidsNormal renal buffering system failsFall in CO2 combining powerProgressiveCan cause cardiac arrhythmias

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Changes in Calcium and Changes in Calcium and Phosphorus Phosphorus

Increase in serum phosphateDecrease in calcium levelsDecreased CA++ absorption from GI tractAt risk for stress fractures

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Summary of ARF CategoriesSummary of ARF CategoriesCharacteristics PreRenal Intrarenal Postrenal

Etiology Hypo-perfusion Parenchymal damage

Obstruction

BUN Increased

(out of normal 20:1 proportion to creatinine)

Increased Increased

Creatinine Increased Increased Increased

Urine output Decreased Varies, often decreased

Varies, may be decreased, or sudden anuria

Urine sodium Decreased to <20 mEq/L

Increased to >40 mEq/L

Varies, often decreased to 20 mEq/L or less

Urinary sediment

Normal, few hyaline casts

Abnormal casts & debris

Usually normal

Urine osmolality

Increased to 500 mOsm

About 350 mOsm similar to serum

Varies, increased or equal to serum

Urine specific gravity

Increased Low normal Varies Spring 2013 NU 202 26

Medical ManagementMedical Management

Restore normal electrolyte balancePrevent complications Prevent anuria if possibleAllow kidneys time to regenerate until

normal kidney function resumes

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TreatmentTreatment

Pre-Renal Intra-Renal Post-Renal

Increase renal perfusion

Supportive Remove obstruction

Blood loss – Blood transfusion

Restrict meds that are excreted by kidneys

Avoid Complications

Hypovolemia -Infuse Albumin ,Normal Saline

Remove causative agent

Aggressive Management of prerenal and post renal causes

Supportive Management

Fluid balance based on daily body weight, CVP, serum and urine concentrations, losses, B/PMeasure all output Spring 2013 NU 202 28

Prerenal treatmentPrerenal treatment

Increase renal perfusionBlood loss – Blood transfusionHypovolemia -Infuse Albumin ,Normal

Saline

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Intra Renal TreatmentIntra Renal Treatment

SupportiveRestrict meds that are excreted by

kidneysRemove causative agentAggressive Management of prerenal and

post renal causes

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Post Renal TreatmentPost Renal Treatment

Remove obstructionAvoid Complications

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ManagementManagement

Fluid balance based on daily body weight, CVP, serum and urine concentrations, losses, B/P

Measure all output

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Dietary ModificationsDietary Modifications

Limit protein to 1g/kg during oliguric phase to minimize protein breakdown and avoid accumulation of toxic end products

High carbohydrate protein sparing diet provides energy and lets protein be used for tissue healing

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Diet ModificationsDiet Modifications

Foods with K+ are restricted including bananas, citrus juices, coffee

K+ intake restricted to 40-60 mEq/day Na restricted to 2 g/day

Oliguric phase may go for 20 daysProtein may be increased after the

diuretic phase is over

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Medical ManagementMedical Management

Hyperkalemia - Give Kayexalate (Sodium

Polystyrene Sulfonate) exchange Na for K+ in the intestinal tract orally/ Retention Enema

High Phosphate - Use aluminum base antacid

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Nursing ManagementNursing Management

Monitor fluid and electrolyte balance strict I/O

Monitor V/SReduce metabolic rate- catabolism

releases K+ and accumulates urea and creatinine

Bed rest, treat fever promptlyPromote pulmonary function- cough and

deep breathePrevent skin infection, skin care

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Dialysis supportFull Assessment –listen to lungs check for

rales check for edema at periorbital, sacral, pedal areas

Monitor for infection prevent where possible

Monitor CVP Swan Ganz readings if available

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Statistics ESRDStatistics ESRD

Prevalence (2010): More than 10 percent of people, or more than 20 million, ages 20 years and older in the United States have CKD

End-stage Renal Disease (ESRD)Prevalence (2008): 547,982 U.S. residents were under treatment as of the end of the calendar year.

http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/

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Causes of Chronic Renal FailureCauses of Chronic Renal Failure

Diabetes mellitusHypertensionChronic glomerulonephritisPyelonephritis or other infectionsObstruction of urinary tractHereditary lesionsVascular disordersMedications or toxic agents

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Chronic Renal FailureChronic Renal Failure

Rate of decline, progression of CRF related to underlying disorder, hypertension, rate of protein excretion

Manifestations: CV problems manifested in ESRD-Hypertension, CHF, pulmonary edema, pericarditis, pericardial friction rub, hyperkalemia,hyperlipidemia

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Chronic Renal FailureChronic Renal Failure

Progressive irreversible deterioration in renal function

Results in impaired fluid and electrolyte imbalance

Azotemia retention of nitrogenous wastes in the blood

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ManifestationsManifestations

Periorbital edemaGU - progressively less to no urine outputCV- CHF HTN edemaPulmonary – rales, SOB, depressed cough

reflex, ↑ respirations, GI- Nausea, Vomiting, metallic taste, mouth

ulcerations, and bleeding, constipation, diarrhea

Skin- Puritits, grey bronze color, ecchymosis, thinning hair

Hematologic – Anemia,ThrombocytopeniaMusculoskeletal- muscle cramps Bone

fractures

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ManifestationsManifestations

Calcium and Phosphorus imbalance happens R/T decreased filtration rate there is a increase in serum phosphate level and decrease in serum calcium level

Increased parathyrohormone abnormal response with Calcium leaving bone causes bone disease uremic bone disease renal osteodystophy

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ComplicationsComplications

Hyperkalemia due to catabolism, excessive intake of medications

Pericarditis- pericardial effusion, tamponade

Hypertension- malfunction of renin-angiotensin aldosterone system

Anemia- decreased RBC production and life span at risk for GI bleeding

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Reverse obstructions EpogenIronPhosphate binding agentsCalcium supplementsDialysisAntacids aluminum based bind to

phosphorus calcium carbonate with food avoid magnesium-based antacids

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Internal AV Fistula and Graft Internal AV Fistula and Graft Spring 2013 NU 202 47

DialysisDialysis

Used to remove fluid and uremic waste products when the kidneys can not do so

Used to treat edema (severe) hyperkalemia, hypercalcemia,

Hypertension, hepatic coma and uremia -Types-Hemodialysis, Peritoneal, (CRRT)

Contiuous Renal Replacement Therapy

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DialysisDialysis

Hemodialysis most common 3-4 times a week for 3-4 hrs Wastes removed by diffusion excess fluid

by osmosisAccess achieved via double lumen

catheter Into Femoral, Subclavian, Internal Jugular,

Veins

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Internal Arteriovenous Fistula and Internal Arteriovenous Fistula and Graft Graft

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HemodialysisHemodialysis

Permanent access via surgically created synthetic graft between artery and vein

Or a Fistula by joining an artery to a vein -Needles inserted into vessel -Arterial segment used for arterial flow -Venous for reinfusion of dialyzed blood - 4-6 weeks for Fistula to mature

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Care of Fistulas/GraftsCare of Fistulas/Grafts

No Blood pressure on affected armMonitor for infectionFeel for thrill as part of daily assessmentListen for Bruit with stethoscope as part of

daily assessment “Whooshing Sound”

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Complications of HemodialysisComplications of Hemodialysis

CV-CHF,CAD, DysrthymiasPulmonary- SOB, RalesGU- InfectionsGI-Gastric Ulcers, Nausea/VomitingHematological- Anemia,↑Tryglycerides,

Thrombocytopenia

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Complications of Hemodialysis Complications of Hemodialysis

Disconnect from tubing pt can bleed outMalnourishmentPainful muscle crampingPruritisFluid overloadHypotension

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Protect vascular access◦ assess for patency and signs of infection◦ do not use it for BP or blood draws

Bruit, or “thrill,” at least every 8 hours Monitor fluid balance indicators & IV therapy carefully;

keep accurate I&O and IV administration pump records

Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data

Monitor cardiac and respiratory status carefullyMonitor BP; antihypertensive agents must be held on

dialysis days to avoid hypotension

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Reverse obstructions EpogenIronPhosphate binding agentsCalcium supplementsDialysisAntacids aluminum based bind to

phosphorus calcium carbonate with food avoid magnesium-based antacids

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QuestionQuestion

Tell whether the following statement is true or false.

Hypercalcemia is the most life-threatening of the fluid and electrolyte changes that occur in patients with renal disturbances

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Peritoneal Dialysis Peritoneal Dialysis

Peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane

More gradual change Sterile dialysate fluid

◦ Medications added◦ Warmed◦ infused by gravity into the peritoneal cavity◦ 5 to 10 minutes is usually required to infuse 2 to 3 L of

fluid◦ Prepare tubing to prevent air entering catheter

Abdominal catheter ◦ Catheters for long-term use (Tenckhoff, Swan, Cruz) ◦ have three sections and two cuffs

stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms.

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Peritoneal DialysisPeritoneal Dialysis

The patient must be alert and have good fine motor skills Pt must be independently able to perform dialysis at home

Risk of peritonitis from introduction of bacteria into the peritoneal cavity

The higher the dialysate the greater the osmotic gradient the more water is removed

Solutions used 1.5% 2.5% 4.25%

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CAPDCAPD

C Continuous Dialysis carries on all the time. A Ambulatory Unlike Haemodialysis you can move around as normal and carry out your daily activities.

P Peritoneal An enclosed layer of tissue where Dialysis takes place. The Peritoneal surrounds your intestines.

D Dialysis Dialysis removes waste products from your blood.

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Peritoneal Dialysis Peritoneal Dialysis

Usually takes 36 to 48 hrs to achieve what hemodialysis accomplishes in 6 to 8 hrs

Diffusion and osmosis Ultrafiltration (water removal) occurs in

peritoneal dialysis through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration.

Signed consent Baseline vital signs, weight, and serum

electrolyte levels The patient is encouraged to empty the bladder

and bowel Aseptic technique

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Complications of Peritoneal Complications of Peritoneal DialysisDialysis

# 1 Peritonitis: evidenced by cloudy drainage, ABD pain, fever, rebound tenderness

Leakage causing infections and skin ulceration

BleedingHernias

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Monitor all medications and medication dosages carefully; avoid medications containing K & Mg

Address pain and discomfort

Implement stringent infection control measures

Monitor dietary sodium, potassium, protein, and fluid; address individual nutritional needs

Provide skin care: prevent pruritus; keep skin clean and well moisturized; trim nails and avoid scratching

Provide CAPD catheter care

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QuestionQuestion

A patient receiving peritoneal dialysis is complaining of pain with rebound tenderness. The dialysate drainage is cloudy. This symptom is indicative of which acute complication?

a. Herniab. Bleedingc. Leakaged. Peritonitis

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Nursing managementNursing management

Teaching regarding disease processTeaching regarding dietTeaching regarding Meds Teaching regarding technique especially

for Peritoneal Dialysis Evaluation of teaching

via return demonstration

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Nursing DiagnosisNursing Diagnosis

Fluid volume overloadFluid volume deficitAlteration in eliminationAlteration in skin integrityAlteration in respiration

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Kidney SurgeryKidney Surgery

Preoperative considerationsPerioperative concernsPostoperative management

◦ Potential hemorrhage and shock◦ Potential abdominal distention and paralytic

ileus◦ Potential infection◦ Potential thromboembolism

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Patient Positioning and Incisional Patient Positioning and Incisional ApproachesApproaches

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Renal TransplantationRenal Transplantation

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Types of transplantsTypes of transplants

Living Donor- RelativeCadaverLiving Donor- Non Relative

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InterventionsInterventionsPain relief measures and analgesic medicationsPromote airway clearance and effective breathing

pattern by appropriate pain relief, deep-breathing coughing exercises, and incentive spirometry and positioning

Monitor UO and maintain patency of urinary drainage systems

Monitor for signs and symptoms of bleedingEncourage leg exercises, early ambulation, and

monitor for signs of DVTSpring 2013 NU 202 71

Immunosuppressive Drugs Post Immunosuppressive Drugs Post TransplantTransplant

MUST STAY ON FOR LIFE!Cyclosporine: Block T cell communicationCorticosteroids Also blocks T cell

communicationAzathioprine: Slows production of T cells Newer antirejection drugs include:Sirolimus ,tacrolimus

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Case StudyCase Study

A 52 year old male with PMH of HTN and DM presents for a diagnostic Cardiac Catherization S/P a positive stress test. The patient has a stent placed in his RCA. After the procedure his BUN and Creatnine begin to rise and his urine output begins to decline

What type of renal failure is this patient experiencing?What lab values are most important to evaluate and

why?What are the phases of renal failure?What physical assessment changes would be

expected?What interventions might you expect?What are your nursing priorities/ diagnosis?

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True/FalseTrue/False

Although there has been a recent decrease in the number of cases, peritonitis is the most common and serious complication of peritoneal dialysis.

Because of protein loss with continuous peritoneal dialysis, the patient is instructed to eat a high-protein well-balanced diet.

Hypotension, a result of oversecretion of rennin, is common in renal failure

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The critical care nurse is caring for a patient with acute renal failure in the oliguric phase. The nurse will closely monitor the patient for which commonly experienced electrolyte imbalance?

A) HyperkalemiaB) HypercalcemiaC) HyperlipidemiaD) Hyperbilirubinemia

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acute and chronic renal failure student 2013

Documents

mgdl spring

acutechronic renal failure

acute renal failure

sign of kidney failure

metabolic waste products

bloodstream of waste

waste products of proteins

renal failuresevere