Crf wtih fluid overload mx pathway summary

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  • 1. CHRONIC RENAL FAILURE WITH FLUID OVERLOAD – PATHWAY Treatment Orders: 1. Diuresis with IV frusemide:Investigations: 120-240 mg/8hrly (if serum Cr > 400 μmol/L)• FBC--anaemia 80-120 mg/8hrly (if serum Cr < 400μmol/L)• PT/PTT, GXM—for dialysis, transfusion If no response, step up to maximum OR infusion at 30 mg/hr• U/E/Cr/HCO3/Glucose—renal fxn, DM Urinary catheter if no urine output > 6hrs• HbA1c if diabetic--DM• Ca/Phosphate/Magnesium—renal osteodystrophy 2. Exclude cardiac event• Fasting iPTH—endocrine compx Check baseline ECG• LFT If pt has IHD, do CK/CKMB/Trop T Repeat ECG x3• Fasting lipids--hyperlipidaemia• ECG/CXR ) 3. Consider acute dialysis/filtration (if hypoxic, severe fluid overload, acidosis, or• ABG on room air—metab acidosis ) exclude AMI hyperkalaemia)• CK/CKMB ) PT/PTT, GXM• UFEME, Urine c/s If for dialysis, trace Hep/HIV status. If results > 6mths, order HBsAg, Anti-HCV, HIVDay 2: 4. (Day 3) If anaemia workup negative, consider erythropoietin therapy – refer• If Hb<11 g/dL: pharmacist and inform on cost Fe/TIBC Ferritin 5. (Day 5) Review CXR: if clear, consider switching to oral frusemide. If well on oral B12 / folate frusemide, consider discharge Stool OB x3• If Hb<6 g/dL 6. Discharge plan: Consider OGD, transfusion, thal workup etc Fluid restriction Nutritional restriction (decreased protein, potassium, phosphate, calories (if DM))Nutrition: When to seek medical help: skin turgor, pitting oedema, weakness, fatigue,• Low salt muscle cramps, N/V• Low protein 0.8g/kg/day Skin care• Low phosphate Identify primary physician, appointments, home care etc.• Low potassium• DM 1500/1800/2000 kcal Referral Plan (Day 2 onwards): • If Cr > 400 μmol/LFluids: Assess ADL (toilet needs, dressing, feeding)• 500ml/day (if serum Cr > 400 μmol/L) If can’t do any one ADL, refer MSW• 800ml/day (if serum Cr < 400μmol/L) If can do all, refer renal coordinator, vascular surgeon • If Cr < 400 μmol/L, refer renal coordinator, MSW, vascular surgeon as required • Others: pharmacist, physiotherapist, psychologist etc.Assessment:• Vital signs• Height/weight• Urine dipstick• Pruritus• Oedema – sites and severity• Compliance with fluid restriction• I/O charting• IV plug• O2 therapy• Urinary catheter if required