Ch 14 ppt renal


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Ch 14 ppt renal

  1. 1. Chapter 14 Care of the Patient with Acute Renal Failure
  2. 2. Learning Outcome 1
  3. 3. Prerenal (~60% of cases of ARF) <ul><li>Caused by decreased renal blood flow </li></ul><ul><ul><li>Decreased cardiac output </li></ul></ul><ul><ul><li>Severe hypotension </li></ul></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Severe vasoconstriction </li></ul></ul><ul><ul><li>Renal vascular disease </li></ul></ul><ul><ul><li>Obstruction of the renal artery </li></ul></ul>
  4. 4. Prerenal (~60% of cases of ARF) (cont.) <ul><li>Nephrons and glomeruli are structurally and functionally normal </li></ul><ul><li>↓ GFR is related to ↓ in renal blood flow </li></ul>
  5. 5. Nursing Management Assessment <ul><li>Common Causes </li></ul><ul><ul><li>Hypovolemia from hemorrhage </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Hypovolemic shock </li></ul></ul><ul><ul><li>Inadequate volume replacement prior to surgery </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul>
  6. 6. Nursing Management Assessment (cont.) <ul><li>Common Causes </li></ul><ul><ul><li>Excessive use of diuretics </li></ul></ul><ul><ul><li>Cardiovascular disorders (heart failure or dysrhythmias) </li></ul></ul><ul><ul><li>Vasodilation from sepsis or medications (antihypertensives) </li></ul></ul>
  7. 7. Patient Assessment for Hypovolemia <ul><li>Hypotension/orthostatic hypotension </li></ul><ul><li>Tachycardia </li></ul><ul><li>Dry mucous membranes </li></ul><ul><li>Poor skin turgor </li></ul><ul><li>Flat jugular veins </li></ul><ul><li>Weight loss </li></ul><ul><li>Low CVP or PAWP pressures </li></ul>
  8. 8. Patient Assessment For Extreme Vasodilation or Cardiovascular Disease <ul><li>Edema </li></ul><ul><li>Ascites </li></ul><ul><li>Weight gain </li></ul><ul><li>Increased CVP or PAWP pressures </li></ul>
  9. 9. Intrarenal (intrinsic) (~30–40% of cases of ARF) <ul><li>Due to disturbances within the glomerulus or renal tubules </li></ul><ul><li>Most commonly results from failure to promptly and adequately treat renal hypoperfusion that produces tubular hypoxia with dysfunction, inflammation, and possibly necrosis </li></ul>
  10. 10. Inflammatory Mediators <ul><li>Death of cells </li></ul><ul><li>Disrupts renal blood flow </li></ul><ul><li>Causes damage to the basement membranes and the renal tubules </li></ul><ul><li>Tubular dysfunction results in impaired sodium and water reabsorption </li></ul><ul><li>Can be differentiated from prerenal dysfunction by urinalysis </li></ul>
  11. 11. Postrenal (5–10% of cases of ARF) <ul><li>Due to obstruction of urinary outflow </li></ul><ul><li>Benign prostatic hypertrophy in older male—most common </li></ul><ul><li>Tubular obstruction from crystals (uric acid or acyclovir) </li></ul><ul><li>Bilateral ureteral obstruction </li></ul><ul><li>Prostatic cancer </li></ul>
  12. 12. Renal Failure <ul><li>Results when obstruction causes an increase in tubular pressure, which results in ↓ GFR </li></ul><ul><li>Commonly results in sudden onset of anuria </li></ul><ul><li>Quickly and accurately identified by renal ultrasound </li></ul><ul><li>Usually resolves quickly with removal of obstruction </li></ul>
  13. 13. Learning Outcome 2
  14. 14. Differential Testing—Urinalysis Urine Results Prerenal Dysfunction Intrinsic Dysfunction Urine osmolality > 500 mOsm/L < 350 mOsm/L Urine sodium < 20 mmol/L > 40 mmol/L Fractional excretion of: Sodium (FENa) Less than 1% Greater than 1% Casts Few ++ Sediment Little ++
  15. 15. Learning Outcome 3
  16. 16. Management of Prerenal Dysfunction <ul><li>Restore normal renal perfusion </li></ul><ul><ul><li>Reestablish normovolemia </li></ul></ul><ul><ul><li>Increase cardiac output </li></ul></ul><ul><ul><li>Relieve renal artery obstruction </li></ul></ul><ul><li>Reestablish normovolemia </li></ul><ul><ul><li>NSS challenges until CVP = 12 </li></ul></ul><ul><ul><li>Assess BP, HR, U/O, and CVP or PAWP </li></ul></ul><ul><ul><li>Identify and treat signs of fluid overload </li></ul></ul>
  17. 17. Management of Prerenal Dysfunction (cont.) <ul><li>Increase cardiac output </li></ul><ul><ul><li>MAP of 70 or greater </li></ul></ul><ul><ul><li>Norepinephrine for BP support if necessary </li></ul></ul><ul><li>Relieve renal artery obstruction </li></ul><ul><ul><li>Angioplasty </li></ul></ul><ul><ul><li>Stent placement </li></ul></ul>
  18. 18. Learning Outcome 4
  19. 19. Prevention of Further Renal Injury During Renal Failure <ul><li>Avoid nephrotoxic agents if possible </li></ul><ul><li>Administer drugs that must be excreted by the kidneys with caution </li></ul><ul><li>Monitor peak and trough levels of nephrotoxic drugs </li></ul><ul><li>Prophylactic acetylcysteine if contrast is necessary </li></ul><ul><li>Scrupulous aseptic technique </li></ul>
  20. 20. Learning Outcome 5
  21. 21. Management of Electrolyte Imbalance: Dilutional Hyponatremia <ul><li>Fluid restriction </li></ul><ul><li>Diuretics + saline infusion </li></ul>
  22. 22. Management of Electrolyte Imbalance: Hyperkalemia <ul><li>Limit potassium intake </li></ul><ul><li>Increase potassium loss via the urine with diuretics </li></ul><ul><li>IV calcium to patients not on digitalis </li></ul><ul><li>Shift potassium intracellularly (insulin with dextrose or bicarb) </li></ul><ul><li>Kayexalate </li></ul><ul><li>Dialysis </li></ul>
  23. 23. Management of Electrolyte Imbalance: Hypocalcemia <ul><li>Oral supplementation if mild </li></ul><ul><li>IV replacement if serious </li></ul>
  24. 24. Management of Electrolyte Imbalance: Hyperphosphatemia <ul><li>Adequate hydration </li></ul><ul><li>Dietary restriction of phosphate </li></ul><ul><li>Calcium supplementation </li></ul><ul><li>Phosphate binders </li></ul>
  25. 25. Learning Outcome 6
  26. 26. Fluid Volume Management <ul><li>Fluid volume excess </li></ul><ul><ul><li>Fluid restriction </li></ul></ul><ul><ul><li>Renal replacement therapies </li></ul></ul>
  27. 27. Learning Outcome 7
  28. 28. Disadvantages of Peritoneal Dialysis for Treatment of Acute Renal Failure <ul><li>Treatment occurs slowly </li></ul><ul><li>Dysfunction progresses quickly </li></ul><ul><li>Ineffective for removal of urea </li></ul><ul><li>Peritoneal “dwell” fluid impairs respiratory function </li></ul><ul><li>Poorer patient outcomes than other modalities </li></ul>
  29. 29. Learning Outcome 8
  30. 30. Continuous Renal Replacement Therapies <ul><li>Advantages </li></ul><ul><ul><li>Can be used for patients who are hemodynamically unstable. Allows for controlled removal of fluid over 24 hours or more </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Very time-intensive for the critical care nurse </li></ul></ul>
  31. 31. Hemodialysis <ul><li>Advantages Can be used daily for 1–2 hour sessions </li></ul>
  32. 32. Hemodialysis (cont.) <ul><li>Disadvantages </li></ul><ul><ul><li>Fluid overload, waste accumulation, and electrolyte imbalances develop between treatments </li></ul></ul><ul><ul><li>May precipitate hemodynamic instability </li></ul></ul><ul><ul><li>Difficulties with vascular access </li></ul></ul><ul><ul><li>Problems with anticoagulation </li></ul></ul><ul><ul><li>Dialysis membrane incompatibility </li></ul></ul><ul><ul><li>Dialysis disequilibrium syndrome </li></ul></ul>
  33. 33. Learning Outcome 9
  34. 34. Nursing Management of Patients Requiring Hemodialysis <ul><li>When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by: </li></ul><ul><ul><li>Palpating for the thrill or auscultating the bruit over the access </li></ul></ul><ul><ul><li>Checking the CSM in the access extremity </li></ul></ul>
  35. 35. Nursing Management of Patients Requiring Hemodialysis (cont.) <ul><li>When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by: </li></ul><ul><ul><li>Avoiding any obstruction of blood flow in that extremity such as: </li></ul></ul><ul><ul><ul><li>BP measurement </li></ul></ul></ul><ul><ul><ul><li>IV placement </li></ul></ul></ul><ul><ul><ul><li>Phlebotomy </li></ul></ul></ul><ul><ul><ul><li>Positioning the patient so there is pressure on the access </li></ul></ul></ul>
  36. 36. Nursing Measures for a Patient Prior to Hemodialysis <ul><li>The nurse determines if there is a “dry weight” for the patient on record and determines the patient’s current weight </li></ul><ul><li>Other measurements of fluid balance the nurse should assess before dialysis include BP, skin turgor, intake and output, breath sounds, and CVP or PAWP if available </li></ul>
  37. 37. Nursing Measures for a Patient Prior to Hemodialysis (cont.) <ul><li>The nurse also reviews the patient’s laboratory results and identifies the goals the nephrologist has established for correction of electrolyte and acid-base abnormalities </li></ul><ul><li>Care of the critically ill patient during the dialysis session requires specialized knowledge and experience </li></ul>
  38. 38. Nursing Measures for a Patient Prior to Hemodialysis (cont.) <ul><li>The patient’s BP may be measured as frequently as every 2 to 5 minutes at the start of dialysis but may be taken every 15 to 30 minutes after the patient has stabilized </li></ul><ul><li>The entire dialysis session will usually take between 2 and 4 hours </li></ul>
  39. 39. Nursing Measures for a Patient Prior to Hemodialysis (cont.) <ul><li>The nurse will hold certain medications prior to hemodialysis </li></ul><ul><ul><li>The doses of medications that may cause hypotension such as beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers that are due to be administered 2 to 4 hours prior to dialysis are usually held until dialysis has been completed. </li></ul></ul>
  40. 40. Nursing Measures for a Patient Prior to Hemodialysis (cont.) <ul><li>Medications that are removed from the body by dialysis (a current list is usually available from the dialysis center) are also held until the end of dialysis. </li></ul><ul><li>Finally, prior to dialysis, the nurse may check the patient’s temperature and should assess the patient’s access. </li></ul>
  41. 41. Nursing Management of Patients Requiring CRRT <ul><li>Vital signs, hemodynamics, and fluid status every ½ hour </li></ul><ul><li>Assessment of ultrafiltration rate hourly </li></ul><ul><li>Administration of replacement fluid </li></ul><ul><li>Obtain and review lab results every 4–6 hours </li></ul><ul><li>Maintain the patency of the system </li></ul>