renal_failure

8/13/2019 Renal_Failure

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Renal Failure

Gail l Lupica PhD, RN,CNE

Nurs 211


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The renal system works together withthe bodys urinary system to collect thebodys waste products and expel them as

urine. One kidney is located on each side of

the abdomen, near the lower back.

The kidneys filter about 45 gallons offluid each day.

The functional unit of the kidney is thenephron. Each kidney contains about 1

million nephrons.


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Functions of the Renal System

1. ADH: controls the collecting tubules permeability to wateraccording to the osmoreceptors ability to sense highconcentration of solute in the plasma. (In other words when theplasma is concentrated, ADH is secreted to hold on to

more water. When the plasma is dilute, ADH is not secreted sothe permeability to water changes in the collecting tubules, andwater is released.)

2. Aldosterone: regulates water reabsorption in the distaltubules by increasing sodium reabsorption andtherefore water reabsorption when released from the adrenal

cortex. (It is released as the final response in the renin angiotensinaldosterone system.) The presence of Aldosterone also helpsincrease the excretion of potassium.


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Functions of the Renal System>

Failure

When the kidneys fail:

Patients retain fluidand you see:

Peripheral edemaPulmonary edema

Decreased urine output

Hypertension


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The regulation of acid-base balance:

The kidneys regulate acid base balance by:

Excretingjust enough hydrogen ions to keepthe ph of the blood in the normal range.

Manufacturing bicarbonate (a base) asneeded to maintain ph between 7.35-7.45.


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Failure


Metabolic acidosis results.

Patients may develop Kussmaulrespirations.whats that?


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The secretion of erythropoietin:

The kidneys secrete erythropoietin when

the oxygen supply in the tissue blood drops.This hormone prompts the bone marrow toproduce more RBCs.


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Failure

When the kidneys fail :

The patient becomes anemic.

(Remember also they are anemic due to the increased

destruction of RBCs & PLTS by the uremic toxins,and even due to their bleeding tendency secondary to their

low PLTS.)


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Maintenance of electrolyte balance:

The kidneys function to regulate electrolyteconcentrations.

When the kidneys fail, electrolyte levels are

not maintained:K+, Na, Phosphate, Ca+


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Failure

Potassium: ypokalemia may occur

with vomiting or excessive diarrheain early renal failure

when uremic toxins begin to circulate.in the diuretic phase of acute renal failure as the kidney is

unable to conserve water and electrolytes. .ARRYTHMIAS, NAUSEA, and LETHARGY occur.

yperkalemiaoccurs with.. decreased renalexcretion of potassium both in the oliguric phase ofacute renal failure and in end stage renal disease.Hyperkalemia could lead to life threatening ARRYTHMIAS!!


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Failure

Sodium: Hyponatremia also occurs in the diuretic phase of acute

renal failure when the kidneys cannot conserve sodium or water.MUSCLE WEAKNESS, CONFUSION, and ABDOMINALCRAMPING occur.

Hypernatremiaoccurs with decreased renalexcretion of sodium. This will occur in the end stages ofrenal diseaseand the person will be on a sodium-

restricted diet. DRY MUCOUS MEMBRANES, andOLIGURIA occurs.


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Failure

Calcium:

Hypocalcemia occurs for two reasons:

1. A hyperphosphatemia occurs because of a decreasedexcretion of phosphate.

There is an inverse relationship between phosphate and Calcium, so a

hypocalcemia occurs. ( These electrolytes are regulated by the parathyroid

gland, so when the phosphate level rises out of control due to the kidneys

inability to excrete it, the parathyroid hormone (from the gland) is over

secreted and starts to get Calcium from the bones, due to a depletion in theserum) OSTEOPOROSIS, OSTEODYSTROPHY (bone disease), AND

TETANY occurs.


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Failure

Hypocalcemia

2. The kidneys normally secrete an

active form of vitamin D (2-3 DPG),

which help the intestines absorb calcium.

When theres decreased absorption,

theres hypocalcemia.


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You tube . com

chvostek's sign and trousseau's sign


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RENIN

1. I ncreasing per ipheral vasoconstr iction

2. Stimulating Aldosterone secretionAldosterone promotes the reabsorption of sodium and

water to correct the fluid deficit and/or inadequate

blood flow (renal ischemia)


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Failure


Patients are often HYPERTENSIVE.


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The collection and elimination ofmetabolic waste such as urea and

creatinine:The kidneys job is to excrete the waste products of metabolism.

Urea is a byproduct of protein metabolism. It is not as adequate an indicator

of renal disease as elevated creatinine levels are because urea (BUN)levels elevate with an increased protein intake, trauma, dehydration etc..

Serum creatinine levels are an accurate indicator of renalfunction/dysfunction. The urinary excretion should equal the amountproduced by the body (by skeletal muscle catabolism).


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Failure


The patient suffers from an overload of these

circulating uremic toxins.All body systems may be affected.

the CNS is affected by the uremic toxins. Drowsiness,

poor memory, inability to concentrate, seizures, and even come

may result.

GI distress may result such as nausea, vomiting,

abdominal distension, diarrhea, and constipation.


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Failure

Pericarditis may result as pericardium isinflamed due to the buildup of these uremicwastes. A pericardial friction rub and pain may

result. Pruritis may result as the excretory

function of the skin attempts to excrete thewaste products. A uremic frost may be notable

on skin and collect on eyebrows. Skin maybecome a pale yellowish color, as urochromepigments are present.

Anemia and thrombocytopenia occur

because the uremic toxins destroy RBCs and


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Acute Renal Failure:

Etiology:

Acute renal failure is defined as loss of functional

ability of the kidney. It has a sudden onset and isreversible.

I t may be classif ied as:

1. Prerenal

2. Renal (intrarenal) Causes 3. Postrenal


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Pre-renal- renal artery notgetting the job done


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Diseases affect basement membrane which leadsto nephrotic syndrome= proteinuria


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Pyelonenritis-

Intra-renal fx


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Bladder/uretal stones- post renal fx.


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Acute Renal Failure- Phases

Phases:

The course of acute renal failure is characterized bythree phases.

The oliguric phaseoccurs at the onset of symptoms andcould last as long as eight weeks. It is characterized by adecreased urine output (less than 400ml in 24 hours).The kidney is trying to conserve sodium and water, andtherefore hypervolemia, edema, weight gain, pulmonaryedema, and elevated blood pressure occur. The BUN andcreatinine rise thereby causing uremic signs andsymptoms. (nausea, changes in mental acuity, fatigue,

pericarditis)


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The diuretic phaseis marked by urine output

that can range from 1-5 L/day. The kidney

has lost its ability to conserve water.Hypovolemia, (fluid) weight loss,

hypokalemia, hyponatremia all can result.

The BUN and creatinine begin to level out.

May last 7-14 days.


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The recovery phaseis reached when the

BUN and creatinine have returned to normal.

This phase can last from 3-12 months.


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Acute Renal Failure- Diagnostic

Findings:

Laboratory data and other assessments reveal thefollowing:

.....(In the oliguric phase)

1. Decreased or absent urinary output

2. Increased BUN, creatinine, sodium, potassium, chloride

3. Decreased calcium (high phos), bicarbonate (acidosis),H/H (anemic)

4. Metabolic acidosis


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Acute Renal Failure -

Management

What do you th ink is done to manage f lu id

over load?

What do you th ink is used to manage the

hyper tension?

What do you think is used to manage the

anemia?

(Fluid restriction may be based on the previous daysoutput plus 400-500ml for insensible losses.)


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Chronic Renal Failure-irreversible

Chronic renal failure is a progressive and irreversibledeterioration of kidney function. Eventually, in endstage renal disease there is less than 20% of nephron

function left.Any diseases involving the kidney could progress to chronic

renal fai lure. (Acute renal failure could terminate in

chronic renal failure if left untreated.)

Examples of causes .include renal calculi, polycystic kidney disease, andDiabetes Mell i tus.


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Chronic Renal Failure- Clinical

Manifestations:

Uremic Signs and Symptoms

Electrolyte Disturbances, acidbase imbalances, and

anemias

Fluid Volume Excess:


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Chronic Renal Failure-

Management

Diet

Protein?

Sodium?

Potassium?

Fluid?


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Chronic Renal Failure-

Management

Drug therapy

Which drugs are used to treat the patient in ESRD inthe following areas? Please provide specific

examples. Fluid overload & edema?

Blood pressure?

Nausea and vomiting?

Gastric acid secretions?

Constipation? Anemia?

Itching /Pruritis?

Hyperphosphatemia?


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Chronic Renal Failure- Emergency

Management of Hyperkalemia

Emergency measures:

Hyperkalemia

1.2.

3.

4.

Any more??????


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Chronic Renal Failure- Emergency

Management

Cardiac tamponade

Pleural effusions

Pulmonary edema


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Dialysis

Dialysis is a treatment used to:

Restore fluid and electrolyte balance

Correct Acid-base im balanceRemove wastes like BUN &creatinine

Remove toxic materials from thebody.


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Dialysis three principles

It is based on three principles: 1. Diffusion: which is the movement of particles

across a semipermeable membrane from areas of

higher concentration to lower concentration. Thisclears solutesfrom the body.

2. Osmosis: which is the movement of f luid acrossa semipermeable membrane from an area of lessersolute concentration to an area of greater solute

concentration.

3. Ultrafiltration: which is the movement of f luidacross a semipermeable membrane as a result of anartificially created pressure gradient.


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Dialysis

Goals of Dialysis To remove metabolic waste

productsLike what? To maintain safe concentrations of

electrolytes(Especially potassium!!)Why?

To correct acid-base imbalancesWhich one?

To remove excess fluids


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There are two types of dialysis available

1. Peritoneal Dialysis

2. Hemodialysis


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Peritoneal Dialysis

In intermittent peritoneal dialysis:

2 liters of dialysate is instilled into the

peritoneal cavity every night at bedtime. It isallowed to drain after 5-7 hours. During

the day the abdomen remains empty.


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Peritoneal Dialysis

Other methods leave the dialysate in the peritoneal cavity(dwell time)for as little as 30 minutes.

Sometimes an automatic cycler is used and other times

the dialysate is timed manually. Smaller amounts than 2 liters of dialysate may be used at

first until the client adjusts.)

Dialysate concentrations can be 1.5% or 4.25%


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Peritoneal Dialysis

A thick catheter is used to gain access to the

peritoneal cavity.

The catheter can be used for long term or

temporary use. Tenckhoff

Gore-Tex

Column-disc


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Peritoneal Dialysis

Peritonitis:

Meticulous aseptic technique must be maintainedduring handling of the catheter, tubing, and dialysate

solution.What do you think the clinical evidence of

peritonitis would be?


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Peritoneal Dialysis

Catheter related complications:

Displacement or obstruction may occur.

Obstruction may be due to the adherence of the

catheter tip to the omentum,or to exudates

present due to infection, or to malposition of the

catheter. Peristalsis facilitates outflow, so

constipation can reduce catheter flow.


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Peritoneal Dialysis

Fibrin clot formation may be a problem inside thecatheter so heparin is often added to thedialysate.

Bowel perforation may occur especially in thosewho are malnourished. What do you thinkyour first clue would to tell if this complicationhas occurred?


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Peritoneal Dialysis

Dialysis related complications:

Pain: This may be due to rapid instillation of

dialysate, incorrect dialysate temp or ph,dialysate accumulation under the diaphragm,or excessive suction during outflow.

Fluid and electrolyte imbalancemay occur.

Hyperglycemia Why do you think thiscould occur?


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You tube peritoneal dialysis in renal failure

#8 Sam Scarce


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Hemodialysis

In hemodialysis toxin-filled blood is removed from the

patient via some type of vascular access site,

pumped through a dialyzer,and then returned to the

client.

The dialyzer has a blood compartment and a

dialysate compartment. The two compartments are

separated by a semipermeable membrane. Toxinsand wastes diffuse across the membrane from the

blood to the dialysate.


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Hemodialysis Vascular access


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Hemodialysis -Vascular access

Sites

Various vascular access sites may be used:

Internal Arteriovenous Fistulas: This involves asurgical creation of an arteriovenous anastomosis to

provide easy access to blood. This is used for clientsrequiring chronic dialysis.

An artery is anastomosed to a vein so that there is anopening (fistula) between the artery and vein. The

flow of arterial blood causes the vein to becomeengorged, and therefore usable in the dialysisprocedure. These fistulas require 6 weeks to bemature enough for use. Other dialysis approaches

are used until then.


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Sites

Internal Arteriovenous Grafts: An artificial graft is made to create an artificial vein for

blood flow. One end of the graft if anastomosed to an

artery, tunneled under the skin and then anastomosed to a

vein. It can be used two weeks after insertion.



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Sites

External Arteriovenous Shunts:

An external arterial cannula is connected to the dialyzer.

Blood returns through the venous cannula. When not

connected to the hemodialyzer, the cannulas are connectedto each other.


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Hemodialysis-Vascular access


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Hemodialysis-Vascular access

Sites

Femoral or Subclavian Vein:

These catheters are temporary sources of vascular

access, and must be replaced frequently.


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Hemodialysis

Schedule:

Hemodialysis must be continued intermittently for

a clients lifetime if they have ESRD. A typicaltreatment is 3-4 hours of treatment, 3-4 days a

week.


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Hemodialysis

Complications of Hemodialysis:

Hypovolemic shock

Blood loss

Electrolyte imbalance

Air embolus


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Hemodialysis on you tube

hemodialysis procedure video

Hemo Dialysis (Labs, H/H, Cautions)Nursing Students

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