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  • 290,000 individuals with ESRD are treated with dialysis or kidney transplants.
  • Diminished renal reserve - This stage is usually asympmtomatic - This stage is characterized by normal BUN and saerum creatinine levels. Nephrons may be ceasing function, but since kidneys have huge renal reserve, symptoms don’t appear until things are pretty much shot. Some individual live normal active lives with compensated renal failure - others progress rapidly to ESRD. Renal insufficiency occurs with the GFR is 25% of normal. BUN and Creatinine levels increase. Fatigue and weakness are common symptoms. Nocturia and polyuria may occur as the kidney looses ability to concentrate urine. ESRD is the last stage - GFR is 5-10% of normal. Become very ill, unable to carry out basic ADL.
  • Cause of CNS depression associated with electrolyte imbalacnes, increased nitrogenious wast products, demyelination of nerve fibers caused by uremic toxins. The change in mental status is often the signal that dialysis must be initiated. It should improve CNS symptoms, but may not halt the neuropathy.
  • Hyperkalemia - most serious electrolyte problem associated with renal failure. Fatal arrhythmias can occur with K > 7 mEq/L. Hyperkalemia results from failure of the kidney to excrete potassium as well as metabolic acidosis (which causes a shift of K+ out of the cells) Sodium - sodium becomes a problem because with retention of sodium comes retention of water. This causes a diluational hyponatremia - and the extra fluid can then make edema worse; also to make hypertension and congestive heart failure worse. Metabolic acidosis - Results from the imparied ability of the kidneys to excrete the acid load (primarily ammonia) and from defective reabsorption and regeneration of bicarbonate. Average adult produces 80-90 mEq of acid/day - kidneys job is to get rid of this; Compensation is Kussmall and extra bicarbonate
  • Hypertension, edema, CHF from sodium and fluid retention Cardiac arrhythmias may result from hyperkalemia, hypocalcemia and decreased coronary artery perfusion.
  • Uremic Lung is an interstitial edema - usually seen on a chest x-ray. This edema can cause increased likeihood of pneumonia, pleurisy and pleural effusions.
  • Anemia is caused by decreased production of the hormone erythropoietin by the kidneys. This results in decreased erythropoiesis by the bone marrow - this is necessary for the bone marrow to produce RBC’s. - So, this is usually given as supplement. If patient on dialysis, this will also cause loss of RBC’s. - also GI bleeding Bleeding tendencies in ESRD is caused by impaired platelet aggregation and impariment in platlet factor 3 - may cause GI bleeding. Immune response is down due to changes in leukocyte function and altered immune response.
  • Kidney plays a role in Activation of vitamin D. In renal failure, there is a decreased Vitamin D activiation, thus Calcium does not get absorbed from the gut causing hypocalemia. This causes various types of body problems. Ostemalacia results from lack of mineralization of newly formed bone. Osteitis fibrosa results from calcium resorption
  • Yellowish discoloration of the skin due to absorption and retention of urinary chromogens that normally give characteristic color to urein. Also, takes on a pale look due to anemia. Skin gets very dry due to decreased activity of sweat gland activity. Pruritis results from dry skin, calcium-phosphate depostion in skin and sensory neuropathy. Uremic Frost - urea crystallizes on the skin and is usally seen only when BUN levels are extremely high. Not usually seen unless pt off dialysis. Ecchymoses may be present - due to changes in clotting abnormalities.
  • Personality and behavior changes commonly observed. Changes in body image due to edema, integumentary changes, access devices, etc can contribute to anxiety and depression. Dull affect - sometimes this is perceived by others as disinterested Grief - change in lifestyle, occupation, financial, loss of kidney
  • Fluid Restriction needed - depends on the daily urine output, in any. Generally 500 - 600 ml. If on dialysis - goal is to not gain more than 1.0 to 1.5 kg between dialysis sessions.
  • Hyperkalemia - acute hyperkalemia - IV glucose and insulin or 10% calcium gluconate. Dietary restrictions of K+. Kayexalate - may be used to reduce levels as well. Hypocalcemia - inability of GI tract to absorb calcium in absence of Vitamin D. Vitamin D supplementation will help this; Phosphate excess - restriction of phosphate (1000/day) phosphate binders (calcium carbonate)
  • calcium channel blockers (have renoprotective properties; also decrease proteinuria and delay progression of CRF. ACE inhibitors - used cautiously in ESRD because they can further decrease DFR and increase K+ levels.
  • Takes 3 weeks for change in hematorcrit once erythropoietin is started. Patients have improved cardiac performace, inmproved exercise tolerance and enhanced quality of life. Side Effects of Erythropoietin - aggravation of hypertension - due to increased whole blood viscosity. Also, erythropoietin therapy causes functional iron deficiency to support the erythropoiesis.; - so these patients need iron replacement - this tends to cause GI upset. Transfusions are avoided in this patients unless acute blood loss because transfusion suppresses erythropoiesis.
  • Low protein diet is indicated because the restriction will reduce the decline of renal function. Remember, protein causes accumulation of nitrogenous waste products, so this is rationale behind this. Amount of protein restriction is based on whether pt is on conservative management; hemodialysis or peritonal dialysis. Diet is supplemented with amino acid as a dietary supplementaiton - this keeps nitrogen to a minimum. Biggest concern with low protein intake is malnutrition.
  • Diffusion is the movement of solute from area of greater concentration to area of lesser concentration. In RF, urea, creatinine uric acid and eletrolytes move from the blood to the dialysate with a net effect of lower their concentratioan in the blood. Osmosis is the movement of fluid from area of lesser concentration of solute to a greater concentration of solute. Glucose is added to the dialysate to enhance water removal.
  • Systems - Automated Peritoneal Dialysis - machine does entire cycles at preset times and preset number of cycles - cycles in 1-2 hours. Number of cycles is dependent on individualized need - some individuals do this during the night while at sleep. Continuous Ambulatory Peritoneal Dialysis - done manually without a machine - do exchanges up to 4 times a day with dwell times of 4-10 hours. Inflow - dialysate solution (2-3 Liters) is infused through the access into the peritoneum - takes about 10 minutes. Dwell - diffusion and osmosis occur between the patient’s blood and the periotenal cavity - lasts anytime from 30 minutes to 10 hours. Drain - takes about 30 minutes to an hour - this is done by dependent drainage facilitated by massaging the abdomen.
  • Infection from: Exit Site - from where catheter exits abdomen. Peritonitis - from contamination of the dialysate or tubing or a progression from an exit site infection. Abdominal Pain - low pH of diaysate solution and irritation from the catheter. Mechanical Problems - what goes in does not come out…...
  • this is one of the major problems with long-term HD. Shunt 0 an excternal access cannjla placed in the radial artery and basilic vein. This is rarely used. AV Fistulas and Grafts - an anastomosis between an artery and vein to provide raid blood flow required by an HD. These can be either from person’s own vessles, or with a synthetic graft. Less complications with fistula’s, however, people with long-standing hypertension and diabeteis may not be sutible - may need graft. Catheter - may be temporary (Acute Renal Failure) or may be permenent - similar to a long term Central Line - same problems too.
  • Hypotension - occurs from the rapid removal of vascular volume, decreased CO and decreased SVR. This often occurs during or after diaylsis. BP meds may need to be held. Hepatitis - Hepatitis B and Hepatitis C - this is due to comtaminated eqipment Sepsis - Usually caused from infections of vascular access sites - although contaminated equipment used for dialysis could also contribute to this. Blood loss - residule blood in the unit or from
  • CRF.ppt

    2. 2. <ul><li>Chronic renal failure involves progressive, irreversible destruction of the nephrons. The end result is a systemic disease that affects every body organ…... </li></ul>
    3. 3. ESRD Fact <ul><li>African Americans and Native Americans have highest incidence of ESRD. </li></ul><ul><li>African Americans more likely to develop ESRD from hypertension </li></ul><ul><li>Native Americans more likely to develop ESRD from Diabetes. </li></ul>
    4. 4. Stages of Chronic Renal Failure <ul><li>Diminished Renal Reserve </li></ul><ul><li>Renal Insufficiency </li></ul><ul><li>End-stage Renal Disease (ESRD) </li></ul>
    5. 5. Body System Effects <ul><li>Neurologic System </li></ul><ul><li>Depression of CNS </li></ul><ul><ul><li>lethargy </li></ul></ul><ul><ul><li>apathy </li></ul></ul><ul><ul><li>decreased ability to concentrate </li></ul></ul><ul><ul><li>altered mental ability </li></ul></ul><ul><li>Peripheral neuropathy </li></ul>
    6. 6. Body System Effects <ul><li>Fluids, Electrolytes, Acid-base </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>Calcium </li></ul><ul><li>Magnesium </li></ul><ul><li>Sodium </li></ul><ul><li>Metabolic acidosis </li></ul>
    7. 7. Body System Effects <ul><li>Cardiovascular System </li></ul><ul><li>hypertension </li></ul><ul><li>edema </li></ul><ul><li>acceleration of atherosclerotic vascular disease </li></ul><ul><li>CHF </li></ul>
    8. 8. Body System Effects <ul><li>Respiratory System </li></ul><ul><li>dyspnea </li></ul><ul><li>pulmonary edema (from CHF) </li></ul><ul><li>uremic lung </li></ul>
    9. 9. Body System Effects <ul><li>Hematologic System </li></ul><ul><li>Anemia </li></ul><ul><li>Bleeding Tendencies </li></ul><ul><li>Infection </li></ul>
    10. 10. Body System Effects <ul><li>Urinary System </li></ul><ul><li>Early sign is polyuria and specific gravity decreases due to inability to concentrate urine. </li></ul><ul><li>Later signs - oliguria and/or anuria </li></ul>
    11. 11. Body System Effects <ul><li>Gastrointestinal System </li></ul><ul><li>Inflammation of the GI tract </li></ul><ul><li>Ulcers </li></ul><ul><li>Anorexia, nausea </li></ul>
    12. 12. Body System Effects <ul><li>Musculoskeletal System </li></ul><ul><li>Renal Osteodystrophy </li></ul><ul><ul><li>osteomalacia </li></ul></ul><ul><ul><li>Osteitis fibrosa </li></ul></ul><ul><ul><li>metastatic calcification </li></ul></ul>
    13. 13. Body System Effects <ul><li>Integument System </li></ul><ul><li>yellowish discoloration to skin </li></ul><ul><li>pruritis </li></ul><ul><li>uremic frost </li></ul><ul><li>ecchymosis </li></ul><ul><li>dry & brittle hair </li></ul>
    14. 14. Body System Effects <ul><li>Reproductive System </li></ul><ul><li>decreased libido </li></ul><ul><li>decreased sexual function </li></ul><ul><li>females: anovulation/menstrual changes </li></ul><ul><li>males: decreased testosterone </li></ul><ul><li>improved with dialysis </li></ul>
    15. 15. Psychologic Effects <ul><li>Personality & Behavior changes </li></ul><ul><li>Withdrawal </li></ul><ul><li>Depression </li></ul><ul><li>Body Image </li></ul><ul><li>Dull affect </li></ul><ul><li>Grief </li></ul>
    16. 16. Collaborative Treatment - CRF <ul><li>PC: Fluid Management </li></ul><ul><li>PC: Electrolyte Imbalances </li></ul><ul><li>PC: Hypertension </li></ul><ul><li>PC: Anemia </li></ul>
    17. 17. PC: Fluid Imbalances <ul><li>Fluid restriction </li></ul><ul><li>Dialysis </li></ul>
    18. 18. PC: Electrolyte Imbalances <ul><li>Hyperkalemia </li></ul><ul><li>Hypocalcemia </li></ul><ul><li>Phosphate excess </li></ul>
    19. 19. PC: Hypertension <ul><li>Antihypertensive agent most commonly used are: </li></ul><ul><ul><li>calcium channel blockers </li></ul></ul><ul><ul><li>ACE inhibitors </li></ul></ul><ul><li>Be cautious about causing hypotension </li></ul>
    20. 20. PC: Anemia <ul><li>Anemia due to decreased production of erythropoietin. </li></ul><ul><li>Administration of Erythropoietin - IV or SQ </li></ul><ul><li>Monitor hemoglobin & hematocrit </li></ul>
    21. 21. Nursing Diagnoses <ul><li>Impaired skin integrity </li></ul><ul><li>Risk for injury </li></ul><ul><li>Activity intolerance </li></ul><ul><li>Risk for infection </li></ul><ul><li>Anticipatory Grieving </li></ul><ul><li>Self-esteem disturbances </li></ul><ul><li>Risk for sexual dysfunction </li></ul>
    22. 22. Altered Nutrition <ul><li>Special Dietary Needs </li></ul><ul><ul><li>fluid restriction </li></ul></ul><ul><ul><li>protein restriction </li></ul></ul><ul><ul><li>sodium restriction </li></ul></ul><ul><ul><li>potassium restriction </li></ul></ul>
    23. 23. Dialysis <ul><li>Treatment to correct fluid and electrolyte imbalances and remove waste products in renal failure. </li></ul><ul><ul><li>Peritoneal Dialysis (PD) </li></ul></ul><ul><ul><li>Hemodialysis Dialysis (HD) </li></ul></ul>
    24. 24. General Principles of Dialysis <ul><li>Solutes and water move across the membrane from the blood to the dialysate </li></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><li>Osmosis </li></ul></ul>
    25. 25. Peritoneal Dialysis <ul><li>Peritoneum acts as semi-permeable membrane for exchange </li></ul><ul><li>Different PD systems APD & CAPD </li></ul><ul><li>Dialysis Exchange </li></ul><ul><ul><li>infusion </li></ul></ul><ul><ul><li>dwell </li></ul></ul><ul><ul><li>drain </li></ul></ul>
    26. 27. Problems with Peritoneal Dialysis <ul><li>Infection, Infection, Infection </li></ul><ul><ul><ul><li>(Did someone say infection?) </li></ul></ul></ul><ul><li>mechanical problems </li></ul><ul><li>abdominal discomfort </li></ul>
    27. 28. Hemodialysis <ul><li>Vascular Access </li></ul><ul><ul><li>Shunts </li></ul></ul><ul><ul><li>AV Fistula’s and Grafts </li></ul></ul><ul><ul><li>Vascular access catheters </li></ul></ul>
    28. 29. Dialysis Procedure <ul><li>Take blood out of arterial side - send to dialysis unit. </li></ul><ul><li>Blood enters unit, filtered with dialysate, and returned to vein. </li></ul><ul><li>Process takes 3-4 hours. </li></ul><ul><li>Unit removes various amount of fluid - usually no more than 1.0-1.5 kg wt. </li></ul>
    29. 31. Complications HD <ul><li>Hypotension </li></ul><ul><li>Hepatitis </li></ul><ul><li>Sepsis </li></ul><ul><li>Blood loss </li></ul>
    30. 32. Renal Failure Summary <ul><li>ARF can lead to : </li></ul><ul><ul><li>Death </li></ul></ul><ul><ul><li>Normal recovery ( may take 12 months) </li></ul></ul><ul><ul><li>Chronic Renal Failure </li></ul></ul><ul><li>CRF treated by </li></ul><ul><ul><li>PD, CAPD </li></ul></ul><ul><ul><li>HD </li></ul></ul><ul><ul><li>Transplantation </li></ul></ul><ul><li>EVERY BODY SYSTEM AFFECTED </li></ul>