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Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
Acute Renal Failure1
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Acute Renal Failure1

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  • 1. ACUTE RENAL FAILURE Trish Keresztes, PhD, RN, CCRN
  • 2. ARF: REVIEW RENAL FUNCTION <ul><li>Regulate fluid volume. </li></ul><ul><li>Regulate electrolyte balance. </li></ul><ul><li>Regulate acid-base balance. </li></ul><ul><li>Regulate blood pressure. </li></ul><ul><li>Excrete nitrogenous waste products. </li></ul><ul><li>Produce erythropoietin. </li></ul><ul><li>Metabolism of vitamin D. </li></ul>
  • 3.  
  • 4. ACUTE RENAL FAILURE <ul><li>Precipitous and significant (>50%) decrease in glomerular filtration rate (GFR) over a period of hours to days with an accompanying accumulation of nitrogenous wastes in the body. </li></ul>
  • 5. ACUTE RENAL FAILURE <ul><li>Glomerulus: tuft of capillaries. The wall of the glomerular capillary serves as a filtration membrane with three layers </li></ul><ul><ul><li>Inner capillary endothelium </li></ul></ul><ul><ul><li>Middle basement membrane </li></ul></ul><ul><ul><li>Outer layer of capillary epithelium </li></ul></ul>
  • 6. ACUTE RENAL FAILURE <ul><li>The glomerular filtrate passes through the three layers of the glomerular membrane and forms the primary urine. </li></ul><ul><li>GFR: the filtration of the plasma per unit of time. Directly related to the perfusion pressure in the glomerular capillaries. </li></ul>
  • 7. ACUTE RENAL FAILURE <ul><li>Process of urine formation: </li></ul><ul><ul><li>Glomerular filtration-> tubular reabsorption->tubular secetion->excretion. </li></ul></ul><ul><ul><li>Proximal tubules reabsorbs 60-70% sodium and water and 90% other electrolytes. </li></ul></ul><ul><ul><li>Distal tubules reabsorb sodium, secrete potassium and hydrogen ions (regulate acid base balance. </li></ul></ul>
  • 8. ACUTE RENAL FAILURE
  • 9. ACUTE RENAL FAILURE
  • 10. ACUTE RENAL FAILURE
  • 11. ARF: RISKS FOR DEVELOPMENT <ul><li>Hx DM, HTN, CV disease, calculi. </li></ul><ul><li>Family history calculi, HTN. </li></ul><ul><li>Hypotensive episodes. </li></ul><ul><li>Drugs with potential for nephrotoxicity. </li></ul><ul><li>Major trauma, crushing injuries, severe allergic reactions. </li></ul>
  • 12. Acute Renal Failure <ul><li>Occurs in 4% of all hospital admissions. </li></ul><ul><li>Occurs in 20% of those admitted into critical care units. </li></ul><ul><li>Mortality rate 50% overall. </li></ul><ul><li>Mortality rate for hospital acquired ARF is 70%. </li></ul>
  • 13. Pathophysiology <ul><li>Glomerular pressure is primarily dependant upon renal blood flow. </li></ul><ul><li>Depressed renal blood flow eventually leads to ischemia and tubular cell death. </li></ul><ul><li>As tubular cells die, they slough off into the tubules and form obstructing casts which further decrease GFR and lead to oliguria. </li></ul>
  • 14. ACUTE RENAL FAILURE <ul><li>Azotemia: refers to an abnormally high level of nitrogenous wastes (urea nitrogen, uric acid, creatinine) in the blood related to a decrease in the GFR. </li></ul><ul><li>Uremia: a clinical syndrome that comprises the signs and symptoms associated with end stage renal disease. </li></ul>
  • 15. ARF CAUSES <ul><li>Prerenal: decreased blood flow to the kidney. </li></ul><ul><li>Intrarenal: Direct damage to the kidney parenchyma. </li></ul><ul><li>Postrenal: Obstruction to the flow of urine which may cause hyronephrosis. </li></ul><ul><li>Before-within-after the kidney. </li></ul>
  • 16. ARF PRERENAL CAUSES <ul><li>Inadequate intravascular volume:hypovolemia </li></ul><ul><ul><li>Fluid loss from N/V </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Excessive diuresis </li></ul></ul><ul><li>Redistribution of blood volume </li></ul><ul><ul><li>Peripheral vasodilation with sepsis </li></ul></ul><ul><ul><li>Third spacing </li></ul></ul>
  • 17. ARF PRERENAL CAUSES <ul><li>Reduced cardiac output </li></ul><ul><ul><li>Acute MI -> cardiogenic shock </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Cardiac tamponade </li></ul></ul><ul><li>Renal artery thrombosis </li></ul><ul><li>Interruption of blood flow during surgery </li></ul>
  • 18. ARF INTRARENAL CAUSES <ul><li>Acute Tubular Necrosis most common form </li></ul><ul><li>ATN: Prolonged ischemic damage: MAP <60 for 40 minutes </li></ul><ul><li>Nephrotoxic damage </li></ul><ul><ul><li>Radiographic contrast dye </li></ul></ul><ul><ul><li>Drugs: antibiotics (aminoglycosides), NSAIDS </li></ul></ul><ul><ul><li>Heavy metals (lead, mercury) </li></ul></ul><ul><li>Glomerulonephritis </li></ul>
  • 19. ARF INTRARENAL CAUSES <ul><li>Rhabdomyolysis: breakdown of skeletal muscle </li></ul><ul><li>Blood transfusion reactions </li></ul><ul><li>Pesticides </li></ul><ul><li>Lupus </li></ul>
  • 20. ARF POSTRENAL CAUSES <ul><li>Obstruction due to </li></ul><ul><ul><li>Calculi </li></ul></ul><ul><ul><li>Blood clots </li></ul></ul><ul><ul><li>BPH </li></ul></ul><ul><ul><li>Obstruction of indwelling catheter </li></ul></ul><ul><ul><li>Tumors </li></ul></ul>
  • 21. ARF FOUR PHASES <ul><li>Onset </li></ul><ul><li>Oliguria (U/O <400ml/day) </li></ul><ul><li>Diuresis </li></ul><ul><li>Period of recovery </li></ul>
  • 22. ARF ONSET <ul><li>Begins with insult and ends with oliguria </li></ul><ul><li>Associated with decreased renal blood flow and GFR and decreased cardiac output. </li></ul><ul><li>The key is prevention </li></ul><ul><li>Monitor blood pressure </li></ul><ul><li>Monitor volume status </li></ul><ul><li>Monitor cardiac function </li></ul><ul><li>Monitor labs </li></ul><ul><li>Identify potential nephotoxins </li></ul>
  • 23. ARF OLIGURIC PHASE <ul><li>Obstruction of tubules by cellular debris, tubular casts or tissue swelling. </li></ul><ul><li>Total reabsorption of urine filtrate back into circulation. </li></ul><ul><li>Renal vasoconstriction ensues. </li></ul>
  • 24. ARF OLIGURIC PHASE <ul><li>Can last up to 8 weeks. The longer this phase the poorer the prognosis. </li></ul><ul><li>See a volume overloaded patient. </li></ul><ul><li>Lab values altered. </li></ul><ul><li>Acidosis. </li></ul><ul><li>Diet changes. </li></ul><ul><li>May treat with low dose dopamine. </li></ul>
  • 25. ARF DIURESIS PHASE <ul><li>See an increase in urine output. </li></ul><ul><li>Urine output as much as 1L/hr. </li></ul><ul><li>Creatinine clearance 15ml/min. </li></ul><ul><li>Signifies tubular function is returning. </li></ul><ul><li>Need to monitor volume status-FVD. </li></ul><ul><li>What happens to lab values during this phase? </li></ul><ul><li>What are your concerns? </li></ul>
  • 26. ARF RECOVERY PHASE <ul><li>Lasts about six months. </li></ul><ul><li>ATN irreversible in about 55% of patients. </li></ul><ul><li>GFR returns to 70% to 80% of normal within 1-2 years. </li></ul>
  • 27. ARF SIGNS AND SYMPTOMS <ul><li>CNS: lethargy, confusion, tremors, seizures, coma </li></ul><ul><li>CV: EKG changes, tachycardia, edema </li></ul><ul><li>PULM: SOB, rales, frothy sputum with CHF, rapid respirations (Kussmaul’s) </li></ul><ul><li>GI: N/V/D </li></ul><ul><li>GU: urine scant, cloudy, sediment </li></ul><ul><li>Integ: dry skin, edema, pallor, uremic frost, pruritis </li></ul>
  • 28. ARF LABORATORY DATA <ul><li>BUN Normal BUN:Cr ration is 10:1. If excess in ration of 20:1 suspect dehydration, catabolic state. </li></ul><ul><li>Creatinine </li></ul><ul><ul><li>Creatinine 1.0 mg/dl: normal GFR </li></ul></ul><ul><ul><li>Creatinine 2.0mg/dl: 50% reduction GFR </li></ul></ul><ul><ul><li>Creatinine 4.0mg/dl: 70-85% reduction GFR </li></ul></ul><ul><ul><li>Creatinine 8.0mg/dl: 90-95% reduction GFR </li></ul></ul>
  • 29. ARF LABORATORY DATA <ul><li>Creatinine Clearance </li></ul><ul><ul><li>Determines presence and progression of renal disease. </li></ul></ul><ul><ul><li>Estimation of % of functioning nephrons. </li></ul></ul><ul><ul><li>Determine medication dosages. </li></ul></ul><ul><ul><li>Calculation= U cr x V/P cr </li></ul></ul>
  • 30. ARF LABORATORY DATA <ul><li>ABGs </li></ul><ul><li>Potassium </li></ul><ul><li>Phosphorus </li></ul><ul><li>Calcium </li></ul><ul><li>RBC, HGB </li></ul>
  • 31. ARF TREATMENT <ul><li>Correct cause </li></ul><ul><li>Manage volume status. </li></ul><ul><li>Correct electrolyte imbalances. </li></ul><ul><li>Correct acidosis. </li></ul><ul><li>Treat azotemia: dialysis. </li></ul><ul><li>Nutritional requirements. </li></ul><ul><li>Stimulate kidneys: drugs. </li></ul>
  • 32. ARF HYPERKALEMIA <ul><li>Kayexalate enema, po </li></ul><ul><li>Sorbitol retention enema </li></ul><ul><li>D50W with Humulin R insulin </li></ul><ul><li>Sodium Bicarbonate IV </li></ul><ul><li>IV calcium gluconate </li></ul><ul><li>Dialysis </li></ul>
  • 33. ARF DIETARY CHANGES <ul><li>Restrict protein </li></ul><ul><li>High CHO, fat </li></ul><ul><li>Restrict fluids </li></ul><ul><li>Restrict sodium </li></ul><ul><li>Restrict potassium </li></ul>
  • 34. ARF MEDICATIONS <ul><li>Diuretics: lasix, bumex, mannitol </li></ul><ul><li>Aluminum hydroxide preparations: </li></ul><ul><li>Calcium replacement </li></ul><ul><li>Epogen/ iron supplements </li></ul>
  • 35. ARF: Complications <ul><li>GI Bleed: occurs in 1/3 of patients with ARF. Accounts for 3% to 8% deaths in patients with ARF. </li></ul><ul><li>Pulmonary complications </li></ul><ul><li>Pericarditis </li></ul><ul><li>Infections: 33% of patients. Usually pulmonary or urinary </li></ul><ul><li>Jaundice </li></ul>
  • 36. ARF CASE STUDY <ul><li>61 y/o male admitted to the ER with N/V, abd. pain, general malaise, s/w lethargic, resp’s deep and rapid T99.6, P106 R 32, BP 156/92 +1 edema to mid calves, states he’s not been eating or drinking too much and that he’s had the flu x1 wk. At home meds maxide ?mg. for “blood pressure” and has been taking “a lot” of motrin for aches with the flu </li></ul>
  • 37. ARF CASE STUDY <ul><li>LABS: Na 135, K 5.0, Bun 70, Cr 4.3 Ca 8.3, Phos 4.9, H&H 10 &35 </li></ul><ul><li>ABG pO2 98, pCO2 29,pH 7.30, HCO3 20 </li></ul><ul><li>What is your impression and why? </li></ul><ul><li>Identify ALL factors that made you think of ARF. </li></ul><ul><li>What phase and what cause? </li></ul>
  • 38. HEMODIALYSIS <ul><li>Indications for use: </li></ul><ul><ul><li>Acute renal failure </li></ul></ul><ul><ul><li>Chronic renal failure </li></ul></ul><ul><ul><li>Remove potassium </li></ul></ul><ul><ul><li>Remove drugs from overdose </li></ul></ul><ul><ul><li>Remove fluids </li></ul></ul>
  • 39. HEMODIALYSIS <ul><li>Diffusion: movement of solutes across a semipermeable membrane from an area of higher concentration to lower concentration. Urea, creatinine, potassium. </li></ul><ul><li>Osmosis: passage of a solvent or water from area of lesser solute concentration to area of greater solute concentration. </li></ul>
  • 40. HEMODIALYSIS <ul><li>Components of hemodialysis </li></ul><ul><ul><li>Dialyzer </li></ul></ul><ul><ul><li>Dialysate </li></ul></ul><ul><ul><li>Vascular access </li></ul></ul><ul><ul><li>Hemodialysis machine </li></ul></ul><ul><ul><li>Anticoagulation during dialysis </li></ul></ul>
  • 41. HEMODIALYSIS COMPLICATIONS <ul><li>Hypotension (need 350cc blood to prime tubing) </li></ul><ul><li>Bleeding </li></ul><ul><li>Infection </li></ul><ul><li>Heart failure </li></ul><ul><li>Arrhythmias from hypoxia, hypokalemia </li></ul>
  • 42. HEMODIALYSIS VASCULAR ACCESS <ul><li>Permanent vascular access </li></ul><ul><li>AV fistula </li></ul><ul><li>AV graft tubing </li></ul><ul><li>Dual lumen </li></ul><ul><li>Complications: thrombus, infection, aneurysm formation, ischemia </li></ul>
  • 43.  
  • 44. HEMODIALYSIS VASCULAR ACCESS <ul><li>Temporary access </li></ul><ul><li>Used for short term dialysis or bridge until permanent access is available </li></ul><ul><li>Placed in subclavian, jugular, femoral veins. </li></ul>
  • 45. NURSING CARE AV FISTULA/GRAFT <ul><li>DO NOT take blood pressure in the extremity with the fistula/graft. </li></ul><ul><li>DO NOT perform venipunctures in the extremity with the fistula/graft. No IVs. </li></ul><ul><li>DO palpate for thrills and auscultate bruits over access. </li></ul><ul><li>DO assess for pulses in extremity. </li></ul>
  • 46. NURSING CARE AV FISTULA/GRAFT <ul><li>DO elevate extremity. </li></ul><ul><li>DO check site for bleeding and infection. </li></ul><ul><li>DO NOT allow patient to wear tight clothing or jewelry on extremity. </li></ul><ul><li>DO NOT let patient sleep on extremity. </li></ul><ul><li>DO NOT let patient carry heavy objects. </li></ul>
  • 47. VASCULAR ACCESS <ul><li>Complications </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Clotting </li></ul></ul>
  • 48. PERITONEAL DIALYSIS <ul><li>Good for patient that cannot tolerate HD due to hemodynamic instability, inability to tolerate anticoagulants, and those without venous access </li></ul><ul><li>Utilizes principles of diffusion & osmosis </li></ul>
  • 49.  
  • 50. TYPES OF PD <ul><li>CAPD-continuous ambulatory peritoneal dialysis </li></ul><ul><li>MB-CAPD- multiple bag </li></ul><ul><li>Automated PD </li></ul><ul><li>IPD-intermittent PD </li></ul><ul><li>CCPD-continuous cycle PD </li></ul>
  • 51. Steps of CAPD treatment <ul><li>Inflow-full bag in (10 minutes) </li></ul><ul><li>Cloudy outflow </li></ul><ul><li>Dwell-remains in the abdomen 4-8 hrs </li></ul><ul><li>Outflow-let gravity drain fluid out (15 minutes) </li></ul><ul><li>Inflow- start it over again </li></ul>
  • 52. PERITONITIS <ul><li>Cloudy outflow </li></ul><ul><li>Fever </li></ul><ul><li>Rebound abdominal tenderness </li></ul><ul><li>General malaise </li></ul><ul><li>Nausea </li></ul><ul><li>Vomiting </li></ul>
  • 53. NURSING CARE <ul><li>Stress cleanliness in the home </li></ul><ul><li>Sterile technique with the catheters </li></ul><ul><li>Dialysate must be room temperature (cold=cramps) </li></ul><ul><li>Diet and fluid restrictions are less with PD </li></ul><ul><li>Monitor BP (>with FVE, < with FVD) </li></ul>

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