This document discusses chronic renal failure and hydronephrosis. It defines chronic renal failure as irreversible kidney dysfunction resulting in an inability to excrete fluids and waste. It stages chronic renal failure based on glomerular filtration rate. Hydronephrosis is an abnormal dilation of the kidneys caused by urinary tract obstruction. Common causes include benign prostatic hyperplasia and kidney stones. Treatment involves relieving obstruction through surgery or stents and managing complications like infection or fluid imbalance.

1. CHRONIC RENAL FAILURE
&
HYDRONEPHROSIS

2. CHRONIC RENAL FAILURE
ALBERT BLESSON V

3. CHRONIC RENAL FAILURE
Chronic renal failure (CRF) refers to irreversible renal dysfunction as manifested by the
inability of the kidneys to excrete sufficient fluid and waste products from the body to maintain
health.
CRF is a progressive process; stages are defined by categorizing how much renal
function remains. CRF may begin with subtle renal deterioration, followed by renal
insufficiency, and then ultimately,
ESRD also referred to as end-stage kidney disease (ESKD). When patients reach ESRD,
treatment with dialysis is indicated.

4. One classification of renal failure has been derived from the National Kidney
Foundation and is based on GFR (the flow rate of filtered fluid through the kidney) as
follows:
Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)
Stage 2: Mild reduction in GFR (60 to 89 mL/min/1.73 m2)
Stage 3: Moderate reduction in GFR (30 to 59 mL/min/1.73 m2)
Stage 4: Severe reduction in GFR (15 to 29 mL/min/1.73 m2)
Stage 5: Kidney failure (GFR less than 15 mL/min/1.73 m2 or dialysis)

5. CAUSES OF CHRONIC RENAL FAILURE
• Failure to halt progression of ARF
• Diabetes mellitus
• Hypertension
• Chronic urinary obstruction
• Renal artery occlusion
• Autoimmune disorders

6. SIGNS AND SYMPTOMS
• Hypertension
• Dysrhythmias
• Jugular venous distension
• Pericardial friction rub
• Hyperventilation
• Kussmaul patterned breathing
• Dyspnea
• Orthopnea
• Crackles (breath sounds)
• Pink frothy sputum
• Urine-like odor on breath
• Altered skin color (yellow or gray tint)
• Dilute urine
• Presences of casts or crystals in urine
• Dry skin and pruritus
• Uremic frost on the skin
• Bruising, petechiae
• Brittle nails
• Dry brittle hair
• Gum ulcerations
• Difficulty with ambulation because of altered motor
function, gait abnormalities, bone and joint pain, and
peripheral neuropathy
• Altered level of consciousness
• Electrolyte imbalances
• Apathy
• Irritability
• Fatigue

7. TREATMENT
• Hemodialysis
• Peritoneal dialysis
• Kidney transplant

8. NURSING CONSIDERATIONS
• Measure and record intake and output of all fluids, including wound drainage,
nasogastric tube output, and diarrhea.
• Be sure to weigh the patient daily especially before and after dialysis.
• Evaluate all drugs the patient is taking to identify those that may affect or be affected by
renal function.
• Assess hematocrit and hemoglobin levels and replace blood components as ordered.
• Monitor vital signs.
• Watch for and report signs of pericarditis (pleuritic chest pain, tachycardia, and
pericardial friction rub), inadequate renal perfusion (hypotension), and acidosis.
• Maintain proper electrolyte balance.
• Strictly monitor potassium levels.
• Watch for symptoms of hyperkalemia and report them immediately.
• Avoid administering medications that contain potassium.

9. • Maintain nutritional status
• Provide a diet high in calories and low in protein, sodium, and potassium, with vitamin supplements.
• Monitor the patient for signs and symptoms of developing acidosis, such as decreased level of
consciousness, development of cardiac arrhythmias, and changes in the rate and depth of respirations.
• Prevent complications of immobility by encouraging frequent coughing and deep breathing and by
performing passive range-of-motion exercises.
• Provide mouth care frequently to lubricate dry mucous membranes.
• Monitor GI bleeding by testing all stools for occult blood.
• Provide meticulous perineal care to reduce the risk of ascending UTI (in women) and to protect skin
integrity.
• If the patient requires hemodialysis, check the vascular access site (arteriovenous fistula or graft, subclavian
or femoral catheter) every 2 hours for patency and signs of clotting. Do not use the arm with the graft or
fistula for measuring blood pressure, inserting IV lines, or drawing blood.

10. • During hemodialysis, monitor vital signs, clotting times, blood flow, vascular access site
function, and arterial and venous pressures.
• After hemodialysis, monitor vital signs, check the vascular access site, weigh the patient,
and watch for signs of fluid and electrolyte imbalances.
• Provide emotional support to the patient and family.
• Collaborate with a health care provider to ascertain which medications should be given
prior to hemodialysis and which should be administered after hemodialysis is completed.
Many medications are removed from the blood during treatment.
• Refer patient and family to support groups and community resources.
• Encourage compliance with antirejection medications (immunosuppressant therapy) when
renal transplant has been performed.

11. TEACHING ABOUT CHRONIC RENAL FAILURE
• Teach patient and family some strategies to increase the patient’s comfort and compliance with fluid
restrictions. Use ice chips, frozen lemon swabs, hard candy, and diversionary activities. Give medications
with meals or with minimal fluids to maximize the amount of fluid that is available for patient use.
• Instruct the patient to keep the fingernails short and file nail tips so that they are smooth and will not cause
skin breakdown.
• Teach the patient to use skin emollients liberally, to avoid harsh soaps, and to bathe only when necessary

12. • If the patient undergoes a renal transplantation, provide preoperative teaching and postoperative care as
for any patient with abdominal surgery.
• Monitor patients for signs of rejection which may include a decrease in urine output, weight gain, edema,
pain over the site, hypertension, fever, and increased WBC count.
• Teaching about immunosuppressive drugs is essential before discharge.
TIP: Teach the patient and family to monitor for signs of infections. The immunosuppressive drugs place the patient at
risk for infection. Steroids can mask the signs of infections.

13. • The patient needs to plan the week’s activities to incorporate the level of fatigue, the dialysis routine, and any
desired activities. The patient may also find that cognitive activities are more easily accomplished on certain
days in relationship to dialysis treatments.
• Reassure the patient that this is not unusual but is caused by the shift of fluid and waste products. Counseling
relative to role function, family processes, and changes in body image is important.
• Sexuality counseling may be required.
• Reassure the patient that adaptation to a chronic illness with an uncertain future is not easy for either the
patient or significant others.
• Participate when asked in discussions related to feasibility of home dialysis, placement on the transplant list,
and decisions related to acceptance or refusal of dialysis treatment. Encourage decisions that increase feelings
of control for the patient.

15. HYDRONEPHROSIS
Hydronephrosis is an abnormal dilation of the renal pelvis and the calyces of one or both
kidneys. It is caused by an obstruction of urine flow in the genitourinary tract.
A partial obstruction and hydronephrosis may not produce symptoms initially, but pressure that
builds up behind the area of obstruction eventually results in symptoms of renal dysfunction.
The most common causes of hydronephrosis are benign
prostatic hyperplasia (BPH), urethral strictures, and calculi.
Less common causes include strictures or stenosis of the ureter or bladder outlet;
congenital abnormalities; bladder, ureteral, or pelvic tumors; blood clots; and neurogenic bladder.

17. SIGNS AND SYMPTOMS
Dependent upon cause of obstruction, including:
• Mild pain and slightly decreased urine flow
• Severe, colicky renal pain or dull flank pain radiating to the groin
• Gross urinary abnormalities, such as hematuria, pyuria, dysuria, alternating oliguria
and polyuria, and anuria
• Nausea
• Vomiting
• Abdominal fullness
• Pain on urination
• Dribbling
• Urinary hesitancy
• Pain on only one side, usually in the flank area, signaling unilateral obstruction

18. TREATMENT
• Dilatation (for urethral stricture)
• Ureteral stents to maintain patency
• Prostatectomy (for BPH)
• Diet low in protein, sodium, and potassium to stop renal failure progression before
surgery (if renal function has already been affected)
• Decompression and drainage of the kidney, using a temporary or permanent
nephrostomy tube placed in the renal pelvis (for inoperable obstructions)
• Antibiotic therapy (for concurrent infection

19. NURSING CONSIDERATIONS
• Administer prescribed pain medication as needed and evaluate response.
• Monitor renal function studies daily, including BUN, serum creatinine, and serum potassium levels. Specific
gravity tests can be done at the bedside.
• Postoperatively, closely monitor intake and output, vital signs, and fluid and electrolyte status. Watch for a
rising pulse rate and cold, clammy skin, which can indicate impending hemorrhage and shock.
• Keep in mind that postobstructive diuresis may cause the patient to lose great volumes of dilute urine over
hours or days. If this occurs, administer IV fluids at a constant rate, as ordered, plus an amount of IV fluid
equal to a percentage of hourly urine output to safely replace intravascular volume.
• If a nephrostomy tube was inserted, frequently check it for bleeding and patency. Irrigate the tube only as
ordered and do not clamp it. Provide meticulous skin care to the area surrounding the tube; if urine leaks,
provide a protective skin barrier to decrease excoriation. Observe for signs of infection.

20. UNDERSTANDING POSTOBSTRUCTIVE DIURESIS
Polyuria—urine output that exceeds 2,000 mL in 8 hours—and excessive electrolyte losses characterize
postobstructive diuresis. Although usually self-limiting, this condition can cause vascular collapse, shock, and death if
not treated with fluid and electrolyte replacement.
Prolonged pressure of retained urine damages renal tubules, limiting their ability to concentrate urine.
Removing the obstruction relieves the pressure, but tubular function may not significantly improve for days or weeks,
depending on the patient’s condition.
Although diuresis typically abates in a few days, it persists if serum creatinine levels remain high. When these
levels approach the normal range (0.7 to 1.4 mg/dL), diuresis usually subsides.

21. HEALTH EDUCATION
• Explain hydronephrosis to the patient and family. Also explain the purpose of diagnostic tests and how they are
performed.
• If the patient is scheduled for surgery, explain the procedure and postoperative care.
• If the patient is to be discharged with a nephrostomy tube in place, provide teaching on how to care for it, including how
to thoroughly clean the skin around the insertion site.
• If the patient must take antibiotics after discharge, tell him to take all of the prescribed medication even if he feels better.
• To prevent the progression of hydronephrosis to irreversible renal disease, urge the patient (especially a male patient with
a family history of BPH or prostatitis) to have routine medical checkups. Teach him to recognize and report symptoms of
hydronephrosis, such as colicky pain or hematuria, or UTI.

22. Pray for the mentally ill
Thank you
REFERANCE
LippincottVISUAL NURSING
A Guide to Diseases, Skills, and
Treatments
Third Edition