Adult 2

1. Nursing care of patients with
Renal Disorders:
Acute and Chronic Renal Failure
Dr. Mohammad Alsadi, RN,
Ph.D.
Dr. Mohammad Alzaatrah, RN Ph.D.
Dr. Hedaya Hina, RN, Ph.D.

2. 2
LEARNING OBJECTIVES:
On completion of this chapter, the learner will be able to:
1. Define renal failure.
2. Identify the types of renal failure.
2. Describe the pathophysiology of renal failure.
3. Explain the clinical manifestations of renal failure.
4. Describe the management of patients with renal failure.
5. Discuss the nursing interventions appropriate for patients with
renal failure.
6. Use the nursing process as a framework for care of the patient
with renal failure.

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▪Acute Renal Failure (ARF)
❑Known also as acute kidney injury (AKI).
❑ A widely accepted criterion for AKI is a 50% or greater increase
in serum creatinine above baseline (normal creatinine is less
than 1 mg/dL) (The Acute Dialysis Quality Initiative, 2004).
❑Urine volume may be normal, or changes may occur including
nonoliguria (greater than 800 mL/day), oliguria (less than 400
mL/day or 0.5 mL/kg/h over 6 hours), or anuria (less than 50
mL/day) (Odom, 2017).

4. 4
▪Acute Renal Failure (ARF)
❑Renal failure is a rapid loss of renal function due to damage to the
kidneys. Results when the kidneys are unable to remove
metabolic waste and perform their regulatory functions.
❑Acute renal failure (ARF) is a rapid loss of renal function due to
damage to the kidneys.
❑Three major types of ARF are:
A. Prerenal (hypoperfusion, as from volume depletion disorders,
extreme vasodilation, or impaired cardiac performance).
B. Intrarenal (parenchymal damage to the glomeruli or kidney
tubules, as from burns, crush injuries, infections, transfusion
reaction, or nephrotoxicity, which may lead to acute tubular
necrosis [ATN]).
C. Postrenal (urinary tract obstruction, as from calculi, tumor,
strictures, prostatic hyperplasia, or blood clots).

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7. ▪Clinical Manifestations
• Lethargy with persistent nausea, vomiting, and diarrhea.
• Skin and mucous membranes are dry.
•CNS manifestations: drowsiness, headache,
muscle twitching, seizures.
• Urine output scanty to normal; urine may be bloody with low
specific gravity.
• Steady rise in blood urea nitrogen (BUN) may occur depending
on degree of catabolism; serum creatinine values increase with
disease progression.
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8. ▪Clinical Manifestations
➢Symptoms of uremia:
• Cognitive dysfunction (problems with thinking and
remembering).
• Fatigue.
• Shortness of breath from fluid accumulation.
• Loss of appetite.
• Muscle cramps.
• Nausea and vomiting.
• Itching.
• Unexplained weight loss
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9. 9
•Clinical Manifestations
• Hyperkalemia may lead to dysrhythmias and cardiac
arrest.
• Progressive acidosis, increase in serum phosphate
concentrations, and low serum calcium levels may be
noted.
• Anemia from blood loss due to uremic GI lesions,
reduced red blood cell life-span, and reduced
erythropoietin production.

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▪Assessment and Diagnostic Methods
• Urine output measurements
• Renal ultrasonography, CT and magnetic resonance imaging
(MRI) scans
• BUN, creatinine, electrolyte analyses.

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▪Medical Management
➢Treatment objectives are to restore normal chemical balance
and prevent complications until renal tissues are repaired and
renal function is restored.
➢Possible causes of damage are identified and treated.
• Fluid balance is managed on the basis of daily weight, serial
measurements of CVP, serum and urine concentrations, fluid
losses, blood pressure, and clinical status.
• Fluid excesses are treated with mannitol, furosemide, or
ethacrynic acid (loop diuretic) to initiate diuresis and prevent or
minimize subsequent renal failure.

12. Cont…..Medical Management
• Blood flow is restored to the kidneys with the use of
intravenous (IV) fluids, albumin, or blood product
transfusions.
• Dialysis (hemodialysis, hemofiltration, or peritoneal dialysis)
is started to prevent complications, including hyperkalemia,
metabolic acidosis, pericarditis, and pulmonary edema.
• ECG changes: IV dextrose 50%, insulin, and calcium may be
given to shift potassium back into the cells.
• Shock and infection are treated if present.
•Arterial blood gases are monitored when severe acidosis is
present.
• Sodium bicarbonate to elevate plasma pH.
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13. Dialysis
When the kidneys fail, kidney
transplantation or dialysis may be the
patient’s only chance for survival.
Dialysis options include:
1. Hemodialysis, which filters blood
through a dialysis machine
2. Peritoneal dialysis, in which a
catheter is placed in the peritoneal
cavity for instillation of dialysate.
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Reference: Hinkle, Janice. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing. Available from: Wolters Kluwer, (15th Edition). Wolters
Kluwer Health, 2021.

16. Arteriovenous Fistula
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Reference: Hinkle, Janice. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing. Available from: Wolters Kluwer, (15th Edition). Wolters
Kluwer Health, 2021.

17. Arteriovenous Graft
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18. Peritoneal Dialysis
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Reference: Hinkle, Janice. Brunner & Suddarth's Textbook of Medical-
Surgical Nursing. Available from: Wolters Kluwer, (15th Edition). Wolters
Kluwer Health, 2021.

19. Cont…..Medical Management
• If respiratory problems develop, ventilatory measures are
started.
• Phosphate-binding agents to control elevated serum
phosphate concentrations.
• Replacement of dietary proteins is individualized to provide
the maximum benefit and minimize uremic symptoms.
• Caloric requirements are met with high-carbohydrate
feedings; parenteral nutrition (PN).
• Foods and fluids containing potassium and phosphorus are
restricted.
• Blood chemistries are evaluated to determine amount of
sodium, potassium, and water replacement during oliguric
phase.
•After the diuretic phase, high-protein, high-calorie diet is given
with gradual resumption of activities.
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Nursing Management
1) Monitoring Fluid and Electrolyte Balance
• Screen parenteral fluids, all oral intake, and all medications for
hidden sources of potassium.
• Monitor cardiac function and musculoskeletal status for signs of
hyperkalemia.
• Pay careful attention to fluid intake (IV medications should be
administered in the smallest volume possible), urine output,
apparent edema, distention of the jugular veins, alterations in heart
sounds and breath sounds, and increasing difficulty in breathing.
• Maintain daily weight and intake and output records.
• Report indicators of deteriorating fluid and electrolyte status
immediately. Prepare for emergency treatment of hyperkalemia.
• Prepare patient for dialysis as indicated to correct fluid and
electrolyte imbalances.

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2) Reducing Metabolic Rate
• Reduce exertion and metabolic rate during most acute stage
with bed rest.
• Prevent or treat fever and infection promptly.
3) Promoting Pulmonary Function
•Assist patient to turn, cough, and take deep breaths frequently.
• Encourage and assist patient to move and turn.
4) Preventing Infection
• Practice asepsis when working with invasive lines and
catheters.
•Avoid using an indwelling catheter if possible.

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5) Providing Skin Care
• Perform meticulous skin care.
• Bath the patient with cool water, turn patient frequently, keep
the skin clean and well moisturized and fingernails trimmed for
patient comfort and to prevent skin breakdown.
6) Providing Psychosocial Support
• Assist, explain, and support patient and family during
hemodialysis treatment; do not overlook psychological needs
and concerns.
• Explain rationale of treatment to patient and family. Repeat
explanations and clarify answers as needed.
• Encourage family to touch and talk to patient during dialysis.
• Continually assess patient for complications and their
precipitating causes.

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❑Chronic Renal Failure (End-Stage Renal Disease
(ESRD))
➢When a patient has sustained enough kidney damage to require
renal replacement therapy (RRT) on a permanent basis, the
patient has moved into the final stage of chronic kidney
disease.
➢The rate of decline in renal function and progression of ESRD is
related to the underlying disorder, the urinary excretion of
protein, and the presence of hypertension. The disease tends
to progress more rapidly in patients who excrete significant
amounts of protein or have elevated blood pressure than in
those without these conditions.

24. Stages of Chronic Kidney Failure
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25. Stages of Chronic Kidney Failure
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▪ Pathophysiology
Nephron damage is progressive. Damaged nephrons can no longer function.
Healthy nephrons compensate for destroyed nephrons by enlarging and
increasing their clearance capacity. The kidneys can maintain relatively
normal function until about 75% of the nephrons are nonfunctional.
Eventually, the healthy glomeruli are so overburdened they become sclerotic
and stiff, leading to their destruction as well. Additionally, the kidneys lose
the ability to concentrate the urine, maintain blood pressure control, and
secrete erythropoietin.
If this condition continues unchecked, toxins accumulate and produce
potentially fatal changes in all major organ systems.

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▪ Clinical Manifestations
• Cardiovascular: hypertension, pitting edema (feet, hands,
sacrum), periorbital edema, pericardial friction rub, engorged
neck veins, pericarditis, pericardial effusion, pericardial
tamponade, hyperkalemia, hyperlipidemia
• Integumentary: gray-bronze skin color, dry flaky skin, severe
pruritus, ecchymosis, purpura, thin brittle nails, coarse thinning
hair, severe itching; and white urea deposits (uremic frost) in
critically ill patients.
• Pulmonary: crackles; thick, tenacious sputum; depressed
cough reflex; pleuritic pain; shortness of breath; tachypnea;
Kussmaul-type respirations; uremic pneumonitis.

28. Skin

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▪ GI: ammonia odor to breath, metallic taste, mouth ulcerations
and bleeding, anorexia, nausea and vomiting, hiccups,
constipation or diarrhea, bleeding from GI tract.
• Neurologic: weakness and fatigue, confusion, inability to
concentrate, disorientation, tremors, seizures, asterixis,
restlessness of legs, burning of soles of feet, behavior
changes.
• Musculoskeletal: muscle cramps, loss of muscle strength,
renal osteodystrophy, bone pain, fractures, foot drop.
• Reproductive: amenorrhea, testicular atrophy, infertility,
decreased libido.
• Hematologic: anemia, thrombocytopenia.

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▪Medical Management
➢Goals of management are to retain kidney function and
maintain homeostasis for as long as possible. All factors that
contribute to ESRD and those that are reversible (e.g.,
obstruction) are identified and treated.
Pharmacologic Management
➢Complications can be prevented or delayed by administering
prescribed phosphate-binding agents, calcium supplements,
antihypertensive and cardiac medications, antiseizure
medications, and erythropoietin (Epogen).

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▪Medical Management
• Hyperphosphatemia and hypocalcemia are treated with
medications that bind dietary phosphorus in the GI tract (eg,
calcium carbonate, calcium acetate, sevelamer
hydrochloride); all binding agents must be administered
with food.
• Hypertension is managed by intravascular volume control
and antihypertensive medication.
• Heart failure and pulmonary edema are treated with fluid
restriction, low-sodium diet, diuretics, inotropic agents
(eg, digoxin or dobutamine), and dialysis.
•Metabolic acidosis is treated, if necessary, with sodium
bicarbonate supplements or dialysis.

33. • Patient is observed for early evidence of neurologic
abnormalities (eg, slight twitching, headache, delirium, or
seizure activity); IV diazepam (Valium) or phenytoin
(Dilantin) is administered to control seizures.
• Hemoglobin and hematocrit are monitored frequently for
anemia.
•Heparin is adjusted as necessary to prevent clotting of
dialysis lines during treatments.
• Supplementary iron may be prescribed.
• Blood pressure and serum potassium levels are
monitored.
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34. Nutritional Therapy
• Dietary intervention is needed, with careful regulation of protein
intake, fluid intake to balance fluid losses, and sodium intake, and
with some restriction of potassium.
• Adequate intake of calories and vitamins is ensured. Calories are
supplied with carbohydrates and fats to prevent wasting.
• According to current guidelines, adults with mild CKD (stages 1 and 2)
are advised to avoid high protein intake (>1.30 g/kg/d), and those with
moderate or severe CKD (stages 3-5 not receiving dialysis) are advised
to restrict protein intake to 0.60 to 0.80 g/kg/d.
• Patients on dialysis need a higher intake of protein than healthy adults
and current protein recommendations for stable patients on HD is 1.2
g/kg/day and PD is 1.2 to 1.3 g/kg/day.
The allowed protein must be of high-biologic value (eggs, meats, fish).
High–biologic-value proteins are those that are complete proteins and
supply the essential amino acids necessary for growth and cell repair.
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35. Nutritional Therapy
• Fluid intake per day:
For patients who receive in-center HD who are anuric is about 1000
mL daily.
For those who produce urine, recommendations are individualized
based on the patient’s 24-hour urinary volume.
Dialysis
• The patient with increasing symptoms of renal failure is
referred to a dialysis and transplantation center early in the
course of progressive renal disease. Dialysis is usually
initiated when the patient cannot maintain a reasonable
lifestyle with conservative treatment.
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36. ▪Nursing Management
• Assess fluid status and identify potential sources of
imbalance.
• Implement a dietary program to ensure proper
nutritional intake within the limits of the treatment
regimen.
• Promote positive feelings by encouraging increased
self-care and greater independence.
• Provide explanations and information to the patient and
family concerning ESRD, treatment options, and
potential complications.
• Provide emotional support.
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37. Promoting Home- and Community-Based Care
• Teaching Patients Self-Care
• Provide ongoing explanations and information to patient and family
concerning ESRD, treatment options, and potential complications;
monitor the patient’s progress and compliance with the treatment
regimen.
• Refer patient for dietary counseling and assist with nutritional
planning.
• Teach patient how to check the vascular access device for patency
and appropriate precautions, such as avoiding venipuncture and
blood pressure measurements on the arm with the access device.
• Teach patient and family what problems to report: signs of
worsening renal failure, hyperkalemia, access problems.
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38. • Continuing Care
• Stress the importance of follow-up examinations and
treatment.
• Refer patient to home care nurse for continued
monitoring and support.
• Reinforce the dietary restrictions required, including
fluid, sodium, potassium, and protein restriction.
• Remind the patient about the need for health promotion
activities and health screening.
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39. References
-Hinkle, j., & Cheever, K. (2020). Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing. (15th edition). Wolters Kluwer
- Lewis L. SH,. RN, Bucher, L,. Heitkemper, M.M., , Harding, M.,,
Kwong, ND Roberts,D . (2017). Medical-Surgical Nursing, 10th
Edition, Mosby company
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