nursing and kidneys

2. RENAL FAILURE 2008
ACUTE RENAL FAILURE
CHRONIC RENAL FAILURE

3. OBJECTIVES
• Identify normal functioning of the kidney and laboratory
tests that assess kidney function
• Define renal failure
• Discuss the causes of acute renal failure and compare
those with chronic renal failure
• Compare prerenal, intrarenal and postrenal conditions
• Identify the alterations seen in patients, explaining why
they exist
• Identify nursing measures appropriate to the
alterations

4. NORMAL KIDNEY
FUNCTION
What does the kidney do in terms of?
• wastes and water balance?
• Acid base balance?
• Controlling BP?
• Controlling anemia?

5. RENAL FAILURE DEFINED
• Kidneys no longer function properly
• Kidneys unable to excrete waste
• kidneys cannot concentrate urine
• Kidneys cannot conserve electrolytes

6. HORMONES WHICH
INFLUENCE THE KIDNEY
• ALDOSTERONE
– Produced:
– Action:
• RENIN/ANGIOTENSIN
– Produced:
– Action:

7. HORMONES WHICH
INFLUENCE THE KIDNEY
• ANTIDIURETIC HORMONE
– Produced:
– Action:
• ERYTHROPOIETIN (EPO)
– Produced:
– Action:

8. IDENTIFYING THE THREE
PRIMARY RENAL FUNCTIONS
• GLOMERULAR FILTRATION:glucose, amino acids,
creatinine, urea, phosphates, uric acid
• GLOMERULAR REABSORPTION:bicarbonate,
phosphates, sulfates, 65% of Na and water, glucose,
K, amino acids, H ions, urea
• GLORMERULAR SECRETION: hydrogen and
potassium, remove acids (hydrogen) to maintain
appropriate acid base balance, potassium, urea

9. ASSESSMENTS OF RENAL
FUNCTION
• u/a: negative for glucose, protein, blood,
leukocytes, nitrites, ketones
• Specific gravity: measures concentration of
the urine; normal values: 1.010-1.025
• Urine osmolality: normal 300-900 mOsm/
kg/24
• Serum creatinine: 0.6-1.2mg/dl
• BUN: 7-18mg/dl
• BUN to creatinine ratio: about 10:1

10. DIAGNOSTIC ASSESSMENTS
CONTINUED
• STANDARD FOR RENAL FUNCTION:
assess glomerular filtration rate (GFR)
• Norm for this assessment is the
creatinine clearance test done over 24
hours: normal rate is 80-125ml/min

11. DEFINITIONS
• OLIGURIA: urine output is less than 30
ml/hr
• ANURIA: no urinary output
• NORMAL URINARY OUTPUT: 1500-
1800ml/day

12. CAUSES OF ACUTE RENAL
FAILURE
• PRERENAL or factors external to the kidney
which interferes with renal perfusion (55%
cases of ARF)
• INTRARENAL: conditions that cause direct
damage to renal tissue (35-40% cases of
ARF)
• POSTRENAL: mechanical obstruction in the
urinary tract (5% cases of ARF)

13. CAUSES OF RENAL FAILURE
CONTINUED
• Multiple problems may exist at same
time
• AGING

14. RENAL FAILURE DEFINED
• To define renal failure ask yourself: How
is the kidney functioning with regard to?
• Excreting nitrogenous wastes
• Concentrating urine
• Conserving electrolytes

15. PROBLEMS FOR PATIENT
• Retention of metabolic wastes
• Imbalance of fluid and electrolytes
• Alterations of sensorium

16. 3 phases of acute renal failure
• Oliguria
• Diuresis
• Recovery

17. OLIGURIC PHASE (lasts 10-14
days)
• Urinary changes
• Fluid volume excess
• Metabolic acidosis
• Sodium balance
• Potassium excretion

18. OLIGURIC PHASE (lasts 10-14
days)continued
• Hematologic disorders
• Calcium deficit and phosphate excess
• Waste product accumulation
• Neurologic disorders

19. DIURETIC PHASE (lasts 1-3
wks)
Gradual increase of urine output as a
result of osmotic diuresis
• Why does this happen?
• What is the state of nephron?
• Can the kidney excrete wastes?
• Can the kidney concentrate urine?
• What would we see in the patient during
this stage?

20. RECOVERY PHASE
• When does this begin?
• Do all patients recover?

21. GOALS OF TREATMENT
• Restore renal function
• Identify cause
• Eliminate cause

22. MAINTAINING FLUID AND
ELECTROLYTE BALANCE
• How do we assess fluid excess?
• How can we control fluid intake?
• What physical assessments would be
done?
• What would you expect to see?
• What laboratory tests would be used to
assess client status?

23. NURSING CARE FOR:
• Elevated serum phosphate:
• Hypocalcemia:
• Hypermagnesemia:
• Hypovolemia:
• Fluid retention: diuretics:
• Hypertension:
• Metabolic acidosis:

24. TREATING HYPERKALEMIA
• Regular insulin IV
• Sodium bicarbonate
• Calcium gluconate IV
• Dialysis
• Kayexalate
• Dietary restriction

25. DIET FOR ACUTE RENAL
FAILURE
• dietary protein
• calories
• K and phosphorus
• Na
• Fe

26. CHRONIC RENAL FAILURE
DEFINED
• Progressive deterioration in renal
function resulting in fatal uremia (excess
of urea and other nitrogenous wastes in
the blood)
• Irreversible destruction of nephrons
• Called ESRD (end stage renal disease)
• Dialysis or transplant

27. TERMS ASSOCIATED WITH
CHRONIC RENAL FAILURE
• Azotemia: collection of nitrogenous
wastes in blood
• Uremia: azotemia
• Uremic syndrome: systemic clinical and
laboratory manifestations of ESRD

28. Alterations: Chronic Renal
Failure
• Metabolic Disturbances:
– elevated BUN,
– creatinine,
– hyponatremia,
– hyperkalemia,
– metabolic acidosis,
– hypocalcemia,
– hyperphosphatemia
• Reproductive Disturbances:
– For woman: menstrual irregularities, amenorrhea, infertility,
decreased libido
– For men: impotence, reduced sperm motility
• Integumentary Disturbances: pruritus,dry,hair brittle,
nails thin, UREMIC FROST: white/yellow crystals of
urate on skin

29. ALTERATIONS OF CHRONIC
RENAL FAILURE CONTINUED
• Gastrointestinal Disturbances: Anorexia, N&V,
metallic taste in mouth, breath smells like
ammonia, stomatitis, ulcers/GI bleeding,
constipation
• Neurological Distrubances: uremic
encephalopathy progresses to seizures &
coma
• CHF: from increased workload on heart from
anemia, hypertension and fluid overload
• Uremic pericarditis: pericardium becomes
inflammed from toxins

30. ALTERATIONS OF CHRONIC
RENAL FAILURE CONTINUED
• Respiratory:
– breath smells like urine: uremic fetor or
uremic halitosis
– Metabolic acidosis: see tachypnea
(increased rate) and hyperpnea (increased
depth) indicates worsening metabolic
acidosis
• See Kussmaul respirations extreme
hyperventilation

31. NURSING CARE FOR PT WITH
CHRONIC RENAL FAILURE
FOR ANEMIA:
FOR HYPOCALCEMIA
FOR FLUID RETENTION AND HYPERTENSION
FOR SKIN ITCHING

32. DIETARY RESTRICTIONS FOR
CHRONIC RENAL FAILURE
• calorie
• protein
• Na
• K
• calcium
• Phosphorus
• Magnesium

33. DIALYSIS: peritoneal and
hemodialysis

36. PERITONEAL DIALYSIS
• Diffusion of solute molecules through a semi-
permeable membrane passing from the side of higher
concentration to that of lower concentration
• Fluids passing through the semi-permeable
membrane via osmosis
• Renal Failure pt has dialysis to remove waste
products and to maintain life until kidney function can
be restored
• Dialysis indicated for high levels of K and fluid
overload

37. PERITONEAL DIALYSIS
• Sterile dialyzing fluid is introduced into
the peritoneal cavity
• Peritoneum is an inert semipermeable
membrane
• The dialyzing solution promotes
osmosis leading to diuresis
• Urea and creatinine are removed

38. NURSING CARE OF PT ON
PERITONEAL DIALYSIS
• Baseline VS and wgt
• Assess for fluid overload
• Maintain highly accurate inflow and outflow
records
• When PD starts the outflow may be bloody
or blood tinged
• This clears within a week/two
• Effluent should be clear and light yellow

39. Nursing care during PD
• Drainage bag is lower than the client’s
abdomen to enhance gravity drainage
• Avoid kinking or twisting, ensure
clamps are open
• Reposition client to stimulate inflow or
outflow
• Sitting/standing/coughing: increases
intraabdominal pressure

40. COMPLICATIONS OF
PERITONEAL DIALYSIS
• Respiratory difficulties
• Hypotension
• Infection:
– peritonitis: see cloudy or opaque dialysate outflow
(effluent), fever, abdominal tenderness, pain, malaise, N&V
• Hypo-albuminemia
• Bowel perforation:
• Bladder perforation:
• Catheter may get clogged

41. COMPLICATION OF PD: Fibrin
Clot formation
• Fibrin Clot formation
• Milking the tubing
• Xray

42. COMPLICATION OF PD:
LEAKAGE
• Dialysate leakage
• See with obese, diabetic, older clients,
those on long term steroids

43. HEMODIALYSIS
• Process by which the uremic toxins and
accumulated waste products are
removed from the blood

44. HEMODIALYSIS
CONTINUED
• A synthetic semi-permeable membrane
replaces the renal glomeruli and tubules
and acts as a filter for the impaired
kidneys
• Must have 3 times/week for 4 hours per
treatment for rest of life

45. Access to pt’s circulation via:
• AV shunt (less common): external silastic
tubing placed in an adjacent artery and vein
• AV Fistula: internal access using pts own
vessels (artery and vein)
• AV Graft: internal access using a foreign
material

46. COMPLICATIONS Hemodialysis
vascular access
• BLEEDING
• INFECTION
• CLOTTING

47. Assessment during Hemodialysis
– Assess for disequilibrium reaction
– CAUSE:
• due to rapid decrease in fluid volume and BUN levels
• Change in urea levels can cause cerebral edema and
increased intracranial pressure
• Neurologic complications: HA, N&V, restlessness,
decreased LOC, seizures, coma, death
• PREVENTION: starting HD for short periods
with low blood flows

48. Nursing care pre dialysis
• Vasoactive drugs which cause
hypotension are held until after
treatment
• CHECK WITH MD ABOUT WHICH
DRUGS TO BE HELD
• Know pt’s BP predialysis

49. Post dialysis nursing care
• BP and wgt
• Hypotension
• Temperature may also be elevated:
• If client has a fever
• Bleeding risk:

50. KIDNEY TRANSPLANT
• Involves transplanting a kidney from a
living donor or human cadaver to a
recipient who has end-stage renal
disease and requires dialysis to live

51. POSTOPERATIVE CONCERNS
AFTER TRANSPLANT
major concern is rejection
• Drugs given to suppress immunologic
reactions: Imuran, prednisone,
cyclosporin (Cyclosporin A)
Next concern is infection

52. NRSG CARE POST KIDNEY
TRANSPLANT
TO DETECT REJECTION:
• Assess for increased temp, pain or
tenderness over grafted kidney
• Assess for decrease in urine output,
edema, sudden wgt gain
• Assess for rise in serum creatinine and
BUN values