Understanding renal failure

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Understanding Renal Failure

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Understanding renal failure

  1. 1. Reynel Dan L. Galicinao HD Nurse Trainee Nephrology Center of St. Alexius
  2. 2. Renal Failure • Kideny Failure, Renal Insufficiency • Loss of kidney function • Retention of wastes • Retention of fluids • Inability of the kidneys to regulate electrolytes
  3. 3. 2 Types of Renal Failure Acute Renal Failure Chronic Renal Failure
  4. 4. Characteristic Onset % of nephron involvement Duration Prognosis ARF Sudden (hrs-days) ≈50% 2-4wks; >3mos Good for return of renal fcn CRF Gradual (mos-yrs) 90-95% Permanent Fatal without replacement therapy ARF & CRF Compared
  5. 5. CAUSES OF RENAL FAILURE
  6. 6. Prerenal • Conditions that dec renal blood flow Intrarenal • Injury to renal tissue • usually associated with intrarenal ischemia, toxins, immunologic processes, systemic & vascular disorders Postrenal • obstruction or disruption to urine flow anywhere along the urinary tract
  7. 7. Causes of Renal Failure
  8. 8. ARF/AKI • Sudden loss of kidney fcn • Caused by renal cell damage from ischemia or toxic substances • Occurs abruptly, can be reversible • Leads to hypoperfusion, cell death, decompensation in renal fcn • Near-N or N kidney fcn may resume gradually
  9. 9. Causes of ARF • Infection • Renal artery occlusion • Obstruction • Acute kidney disease • Dehydration • Diuretic therapy • Ischemia o From hypovolemia, heart failure, septic shock, blood loss • Toxic substances o Medications, antibiotics
  10. 10. PHASES OF ARF
  11. 11. Oliguric Phase • Duration: 8-15 days o Longer duration, less chance of recovery • Sudden drop in urine output o UO > 400mL/day • Dec. urine specific gravity
  12. 12. Oliguric Phase S/sx • Anorexia, N&V • HPN • Dec. skin turgor • Pruritus • Tingling of the etremities • Drowsiness → disorientation → coma • Edema • Dysrhythmias • Signs of CHF & pulmonary edema, pericarditis, acidosis
  13. 13. • UO rises slowly, then diuresis occurs o 4-5L/day • Excessive UO indicates recovery of damaged nephrons • Hypotension • Tachycardia • LOC improves Diuretic Phase
  14. 14. • Recovery is a slow process • N urine volume • Inc in strength • LOC improves • BUN: stable, N • Pt can develop CRF Recovery Phase (Convalescent)
  15. 15. Oliguric • Dec GFR • Hyperkalemia • N or dec Na+ level • Fluid overload • Elevated BUN, crea Diuretic • Inc GFR • Hypokalemia • Hyponatremia • Hypovolemia • Gradual decline in BUN, crea Recovery • Stable & N BUN
  16. 16. Diagnostic Evaluation • U/A— proteinuria, hematuria, casts • Rising serum creatinine & BUN levels • Urine chemistry examinations to distinguish various forms of ARF; decreased sodium • Renal ultrasonography—for estimate of renal size & to exclude a treatable obstructive uropathy
  17. 17. MANAGEMENT
  18. 18. Preventive Measures • Identify pts with preexisting renal disease. • Initiate adequate hydration before, during, & after any procedure requiring NPO status. • Avoid exposure to nephrotoxins. • Majority of drugs or their metabolites are excreted by the kidneys. • Monitor chronic analgesic use—some drugs may cause interstitial nephritis & papillary necrosis.
  19. 19. • Prevent & treat shock with blood & fluid replacement • Prevent prolonged periods of hypotension • Monitor UO & CVP hourly in critically ill pts to detect onset of renal failure at the earliest moment • Schedule diagnostic studies requiring dehydration so there are “rest days,” especially in elderly pts who may not have adequate renal reserve
  20. 20. • Pay special attention to draining wounds, burns, which can lead to dehydration, sepsis & progressive renal damage. • Avoid infection; give meticulous care to pts with indwelling catheters & I.V. lines. • Take every precaution to make sure that the right person receives the right blood to avoid severe transfusion reactions, which can precipitate renal complications.
  21. 21. DRUG ALERT! Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce GFR in people at risk for renal insufficiency, causing renal failure.
  22. 22. Corrective & Supportive Measures • Correct reversible cause of ARF (eg, improve renal perfusion, maximize cardiac output, surgical relief of obstruction). • Correct underlying fluid excesses or deficits. • Correct & control biochemical imbalances—tx of hyperkalemia. • Restore & maintain BP. • Maintain nutrition. • Initiate HD, PD, or CRRT for pts with progressive renal failure & other life-threatening complications.
  23. 23. Other Therapy • Sodium polystyrene sulfonate (Kayexelate) can be administered PO or PR to reduce potassium. • Sodium bicarbonate may be ordered to correct metabolic acidosis. • HD pts need water-soluble vitamins supplements because they are removed during dialysis • Antihypertensives to control BP • Antibiotics to manage secondary infections • Diphenhydramine (Benadryl) to manage itching • Recombinant human erythropoietin to inc RBC production.
  24. 24. Complications • Infection • Arrhythmias due to hyperkalemia • Electrolyte abnormalities o sodium, potassium, calcium, phosphorus • GI bleeding due to stress ulcers • Multiple organ systems failure
  25. 25. NURSING MANAGEMENT
  26. 26. Nursing Assessment • Assess hx of cardiac disease, malignancy, sepsis, intercurrent illness • Determine if pt has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents) • Physical examination for tissue turgor, pallor, alteration in mucous membranes, BP, HR changes, pulmonary edema, peripheral edema. • Monitor I&O.
  27. 27. Nursing Diagnoses • Excess Fluid Volume r/t decreased GFR & sodium retention • Risk for Infection r/t alterations in the immune system & host defenses • Imbalanced Nutrition: Less Than Body Requirements r/t catabolic state, anorexia, & malnutrition associated with ARF • Risk for Injury r/t GI bleeding
  28. 28. NURSING INTERVENTIONS
  29. 29. Nursing Interventions • Achieving Fluid and Electrolyte Balance • Preventing Infection • Maintaining Adequate Nutrition • Preventing GI Bleeding • Preserving Neurologic Function
  30. 30. Achieving Fluid & Electrolyte Balance • Monitor for s/sx of hypo/hypervolemia • Monitor UO & urine sp. gr. • Measure & record I&O including urine, gastric suction, stools, wound drainage, perspiration (estimate). • Monitor serum & urine electrolyte concentrations. • Weigh pt daily to provide an index of fluid balance; expected wt loss is ½ to 1 lb (0.25 to 0.5 kg) daily.
  31. 31. • Adjust fluid intake to avoid volume overload & dehydration. • Fluid restriction is not usually initiated until renal fcnis quite low. • During oliguric-anuric phase, give only enough fluids to replace losses (usually 400 to 500 mL/24 hours plus measured fluid losses). • Fluid allowance should be distributed throughout the day. • Avoid restricting fluids for prolonged periods for laboratory & radiologic examinations because dehydrating procedures are hazardous to pts who cannot produce concentrated urine. • Restrict salt & water intake if there is evidence of
  32. 32. • Regular BP with pt in supine, sitting, standing • Auscultate lung fields for rales • Inspect neck veins for engorgement & extremities, abdomen, sacrum, & eyelids for edema. • Evaluate for s/sx of hyperkalemia, monitor serum potassium levels • Notify health care provider of value above 5.5 mg/L. • Watch for ECG changes—tall, tented T waves; depressed ST segment; wide QRS complex. • .
  33. 33. • Administer sodium bicarbonate or glucose & insulin to shift potassium into the cells. • Administer cation exchange resin (sodium polystyrene sulfonate [Kayexalate]) PO/PR to provide more prolonged correction of elevated potassium. • Watch for cardiac arrhythmia & heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. • Resuscitation equipment on hand in case of cardiac arrest. • Instruct on importance of following prescribed diet; avoid foods high in potassium.
  34. 34. • Prepare for dialysis when rapid lowering of potassium is needed. • Administer BT during dialysis to prevent hyperkalemia from stored blood. • Monitor acid-base balance. • Monitor ABG • Ventilator therapy for severe acidosis • Administer sodium bicarbonate for symptomatic acidosis (bicarbonate deficit). • Be prepared to implement dialysis for uncontrolled acidosis
  35. 35. Preventing Infection • Monitor for all signs of infection. Renal failure pts do not always demonstrate fever & leukocytosis. • Remove bladder catheter as soon as possible; monitor for UTI. • Use intensive pulmonary hygiene—high incidence of lung edema & infection. • Carry out meticulous wound care. • If antibiotics are administered, care must be taken to adjust the dosage for renal impairment.
  36. 36. Maintaining Adequate Nutrition • Work collaboratively with dietitian to regulate protein intake according to impaired renal fcn • High biologic value protein—rich in essential amino acids (dairy products, eggs, meat) • Low-protein diet may be supplemented with essential amino acids & vitamins. • As renal fcn declines, protein intake may be restricted proportionately. • Pt on dialysis: inc. protein to allow for the loss of amino acids occurring during dialysis
  37. 37. • Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power & provide additional calories. • Weigh pt daily. • Monitor BUN, creatinine, electrolytes, serum albumin, prealbumin, total protein, transferrin. • Be aware that food & fluids containing large amounts of Na, K, and Ph may need to be restricted.
  38. 38. Preventing GI Bleeding • Examine all stools & emesis for gross & occult blood. • Administer H2-receptor antagonist (or PPI) or nonaluminum or magnesium antacids as prophylaxis for gastric stress ulcers. If H2-receptor antagonist is used, care must be taken to adjust the dose for the degree of renal impairment. • Prepare for endoscopy when GI bleeding occurs.
  39. 39. Preserving Neurologic Function • Speak to the pt in simple orienting statements, use repetition when necessary • Maintain predictable routine, keep change to a minimum. • Watch for & report mental status changes • Somnolence, lassitude, lethargy, fatigue progressing to irritability, disorientation, twitching, seizures. • Correct cognitive distortions.
  40. 40. • Use seizure precautions—padded side rails, airway, suction equipment at bedside. • Encourage & assist pt to turn & move because drowsiness & lethargy may prevent activity. • Use music tapes to promote relaxation. • Prepare for dialysis, which may help prevent neurologic complications.
  41. 41. Patient Education & Health Maintenance • Explain that the pt may experience residual defects in kidney fcnfor long period after acute illness. • Routine U/A; follow-up examinations. • Avoid any medications unless specifically prescribed. • Resume activity gradually because muscle weakness will be present from excessive catabolism.
  42. 42. Evaluation: Expected Outcomes • BP stable, no edema or SOB • No signs of infection • Food intake adequate, maintaining wt • Stools heme negative • Appears more alert, sleeps less during the day
  43. 43. CRF/CKD • Progressive loss & ongoing deterioration in kidney function • Occurs slowly over a period of time • Irreversible • Results in uremia or ESRD • Affects all major body systems
  44. 44. PATHOPHYSIOLOGY & ETIOLOGY
  45. 45. Causes of CRF DM HPN Glomerulonephritis Others
  46. 46. Dec Renal Fcn Retention of Na & H20 Edema HF HPN Ascites Dec GFR RAAS stimulation Inc BP Inc serum Ph Dec serum Ca Bone resorption of Ca Inability to Metabolic Acidosis Excrete hydrogen ions Produce ammonia Coserve bicarbonate Dec EPO production Profound anemia Uremia CNS Altered mental fcn Personality change Seizure Coma
  47. 47. UREMIA • Metallic taste in the mouth • Anorexia • N&V • Muscle cramps • Itching • Fatigue & lethargy • Hiccups • Edema • Dyspnea • Paresthesia
  48. 48. Dec. Renal Reserve Renal Insufficiency Renal Failure ESRD Stages
  49. 49. Stage 1 2 3 4 5 Description Kidney damage with N /supraN GFR Mild dec in GFR Moderate dec in GFR Severe dec in GFR Kidney failure GFR (ml/min) >90 60-89 30-59 15-29 <15 KDOQI Suggested Stages of CKD
  50. 50. • Diagnosis & tx; treat comorbid dses • Slow progression of dse (diet, meds) • Evalauate and tx • Monitor progression of dse • Evaluate & treat complications • Monitor progress of dse • Prepare for RRT • RRT: HD, PD, KT
  51. 51. CLINICAL MANIFESTATIONS
  52. 52. • GI • anorexia, N&V, hiccups, ulceration of GI tract, hemorrhage • CV • hyperkalemic ECG changes, HPN, pericarditis, pericardial effusion, pericardial tamponade • Respi • pulmonary edema, pleural effusions, pleural rub
  53. 53. • Neuromuscular • fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma • Metabolic & endocrine • glucose intolerance, hyperlipidemia, sex hormone disturbances (dec libido, impotence, amenorrhea) • F&E, acid-base disturbances • usually salt & H20 retention but may be Na loss with DHN, acidosis, hyperkalemia, hypermagnesemia, hypoc alcemia
  54. 54. • Dermatologic • pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost • Skeletal abnormalities • renal osteodystrophy resulting in osteomalacia • Hematologic • anemia, defect in quality of platelets, inc bleeding tendencies • Psychosocial fcns • personality & behavior changes, alteration in cognitive
  55. 55. DIAGNOSTIC EVALUATION
  56. 56. • Complete blood count (CBC)—anemia (a characteristic sign) • Elevated serum creatinine, BUN, phosphorus • Dec serum calcium, bicarbonate, proteins, especially albumin • ABG levels—low blood pH, low CO2, low bicarbonate • 24-hour urine for creatinine, protein, creatinine clearance
  57. 57. MANAGEMENT
  58. 58. • Detection & tx of reversible causes of renal failure (eg, bring diabetes under control; treat HPN) • Dietary regulation—low-protein diet supplemented with essential amino acids • Minimize uremic toxicity; prevent wasting & malnutrition Goal: Conservation of renal function as long as possible
  59. 59. • Treatment of associated conditions to improve renal dynamics • Anemia—ESAs: epoetin alfa, darbepoetin • Acidosis—infusion or oral administration of sodium bicarbonate • Hyperkalemia—restriction of dietary potassium; administration of cation exchange resin • Phosphate retention—dec in dietary phosphorus (chicken, milk, legumes, carbonated beverages); phosphate-binding agents because they bind phosphorus in the intestinal tract • Maintenance dialysis or KT when symptoms can no longer be controlled with conservative management
  60. 60. Other Drugs • Hypocalcemia & hyperphosphatemia may be treated with aluminumantacids that bind dietary phosphorus. If long- term effects of aluminum hydroxide are a concern, an oral calcium (with vitamin D) preparation may be given. • Recombinant erythropoietin (Epogen) may be given for the tx of anemia. • If the pt undergoes renal transplantations, immunosuppressives • azathioprine (Imuran) or cyclosporine (Sandimmune) • Corticosteroids to dec antibody formation
  61. 61. Complication • Death
  62. 62. NURSING MANAGEMENT
  63. 63. Nursing Assessment • Obtain hx of chronic disorders & underlying health status • Assess degree of renal impairment & involvement of other body systems; obtain a ROS, review lab results • Perform thorough PE, including VS, cardiovascular, pulmonary, GI, neurologic, dermatolog ic, musculoskeletal systems. • Assess psychosocial response to disease process, availability of resources, support network.
  64. 64. Nursing Diagnoses • Excess Fluid Volume r/t disease process • Imbalanced Nutrition: Less Than Body Requirements r/t anorexia, nausea, vomiting, restricted diet • Impaired Skin Integrity r/t uremic frost & changes in oil & sweat glands • Constipation r/t fluid restriction & ingestion of phosphate- binding agents • Risk for Injury while ambulating r/t potential fractures & muscle cramps due to calcium deficiency • Ineffective Therapeutic Regimen Management r/t restrictions imposed by CRF & its treatment
  65. 65. NURSING INTERVENTIONS
  66. 66. Nursing Interventions • Maintain Fluid & Electrolyte Balance • Maintain Adequate Nutritional Status • Maintain Skin Integrity • Prevent Constipation • Ensure a Safe Level of Activity • Increase Understanding & Compliance with Treatment Regimen
  67. 67. Maintaining Skin Integrity • Keep skin clean while relieving itching & dryness. • Soap for sensitive skin, such as basis soap • Sodium bicarbonate added to bath water • Oatmeal baths • Bath oil added to bath water • Ointments or creams to relieve itching. • Keep nails short & trimmed to prevent excoriation. • Keep hair clean & moisturized. • Antihistamines for relief of itching; discourage pt from taking OTC drugs without discussing with health care provider
  68. 68. Preventing Constipation • Phosphate binders cause constipation that cannot be managed with usual interventions. • High-fiber diet; bear in mind the potassium content of some fruits & vegetables. • Commercial fiber supplements (Fiberall, Fiber-Med) • Stool softeners as prescribed. • Avoid laxatives & cathartics that cause electrolyte toxicities (compounds containing magnesium or phosphorus).
  69. 69. Ensuring a Safe Level of Activity • Monitor serum Ca & phosphate levels; watch for signs of hypo/hypercalcemia • Inspect pt's gait, ROM, muscle strength. • Administer analgesics, as ordered • Provide massage for severe muscle cramps. • Monitor X-rays & bone scan results for fractures, bone demineralization, joint deposits.
  70. 70. • Inc activity as tolerated—avoid immobilization because it increases bone demineralization. • Administer medications as ordered: • Phosphate-binding medications, such as sevelamer (Renagel) or calcium carbonate (Os-Cal), with meals & snacks to lower serum phosphorus • Calcium supplements between meals to inc serum calcium • Vitamin D to inc absorption & utilization of calcium
  71. 71. Increasing Understanding of & Compliance with Treatment Regimen • Prepare pt for dialysis or KT • Offer hope tempered by reality. • Assess understanding of tx regimen, concerns, fears • Explore alternatives that may reduce or eliminate adverse effects of tx. • Adjust schedule so rest can be achieved after dialysis. • Offer smaller, more frequent meals to reduce nausea & facilitate taking medication.
  72. 72. • Encourage strengthening of social support system & coping mechanisms to lessen the impact of the stress of CKD • Social work referral • Contract with pt for behavioral changes if noncompliant with therapy or control of underlying condition • Supportive psychotherapy for depression • Promote decision making by pt • Refer pts & family members to renal support agencies
  73. 73. Patient Education & Health Maintenance • Weigh self every morning to avoid fluid overload • Drink limited amounts of fluids only when thirsty • Measure allotted fluids, save some for ice cubes; sucking on ice is thirst quenching • Eat food before drinking fluids to alleviate dry mouth • Use hard candy or chewing gum to moisten mouth
  74. 74. • Encourage all people with the following risk factors to obtain screening for CKD: • elderly people • native Americans • Blacks • Latinos • Diabetics • people with HPN, autoimmune disease, with family hx of kidney disease
  75. 75. Evaluation: Expected Outcomes • BP stable, no excessive wt gain • Tolerates small feedings of low-protein, high-carbohydrate diet • No skin excoriation; reports some relief of itching • Passes small, firm stool daily • Ambulates without falls • Asks questions & reads education materials about dialysis

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