4. Renal failure for nursing student imporatance.pdf

wsrsafs

1. Acute Renal Failure
(Acute Kidney Injury
AKI)

2. Educational learning outcomes
•Define acute and chronic kidney failure.
•List causes of acute and chronic renal failure.
•Describe phases of acute and chronic renal failure.
•Differentiate between clinical profile of acute and chronic renal failure.
•Outline management for acute and chronic renal failure.
•Recognize nursing management for patient with acute renal failure.
•List complications of end-stage renal disease.
•Outline complication of dialysis.
•List nursing diagnoses for patient with chronic renal failure.
•Discuss nursing intervention for patient undergoing kidney
transplantation.
•Enumerate contraindications for kidney transplantation.
•Discuss complications of kidney transplantation.

3. Renal Failure
Results when the kidneys cannot remove the body’s metabolic wastes
or perform their regulatory functions. The substances normally
eliminated in the urine accumulate in the body fluids as a result of
impaired renal excretion, leading to a disruption in endocrine and
metabolic functions as well as fluid, electrolyte, and acid–base
disturbances.
Renal failure is a systemic disease and is a final common pathway of
many different kidney and urinary tract diseases. Each year, the
number of deaths from irreversible renal failure increases (U.S. Renal
Data System, 2018).

4. Acute Kidney Injury (AKI)
•Reversible clinical syndrome whereby there is sudden and
pronounced loss of kidney function
•Is a sudden and almost complete loss of kidney function
(decreased GFR) over a period of hours to days.
•Results in kidneys failure to excrete nitrogenous wastes.
•Patient with ARF can be seen as a hospitalized and may see
in the outpatient setting as well.

5. Causes of Acute Renal Failure
Intra-renal actual parenchymal damage
•Prolonged renal ischemia from myoglobinuria (rhabdo, trauma,
burns), hemoglobinuria (transfusion reaction, hemolytic anemia)
•Nephrotoxic agents like aminoglycosides, radiopaque contrast,
heavy metals, solvents, NSAIDs, ACEIs, acute glomerulonephritis.
Pre-renal 60-70% of cases
•Volume depletion as seen in hemorrhage, renal losses from
diuretics, GI losses from vomiting, diarrhea
•Impaired cardiac output 2ndary to MI, heart failure, dysrhythmias,
cardiogenic shock
•Vasodilation from sepsis, anaphylaxis, antihypertensive meds
Post-renal
•Urinary tract obstruction by calculi, tumors, BPH, blood clots

6. Phases of Acute Renal Failure
1.Initiation occurs with the insult
2.Oliguria with urinary output less than 400ml/24h .
rising
potassium, BUN, Cr. Not responsive to fluid
challenges.
3.Diuresis period— gradual increase in urinary
output. Beginning recovery. Renal function
gradually improves
4.Recovery—may take 3-12 months. May have
permanent
reduction in functioning of 1%-3%.

7. •The patient may appear critically ill and lethargic with
persistent nausea, vomiting, and diarrhea.
• The skin and mucous membranes are dry from dehydration,
and the breath may have the odor of urine (uremic fetor.)
•Central nervous system signs and symptoms include
drowsiness, headache, muscle twitching, and seizures.
Clinical Manifestations

8. Laboratory Profile of ARF
•Elevated BUN and creatinine
•Sodium retention but may be deceptive due to water
retention
•Potassium increased
•Phosphorus increased
•Calcium decreased
•H&H decreased
•Sp. Gravity decreased and fixed

9. Management
(Medical &Pharmacological)
•Objectives : Restore normal chemical balance and prevent
complications until restoration of renal function
•Identify and treat underlying cause
•Maintain fluid balance—wts, serial CVP readings, BP, strict I&O
•May give Mannitol, Lasix or Edecrin
•May need temporary dialysis
•If prerenal, fluid challenges and diuretics to enhance renal blood
flow

10. Management )cont’d)
Oliguric renal failure, low dose dopamine. Calcium
channel blockers may be used to prevent influx of
calcium into kidney cells, maintains cell integrity and
increase GFR
Hyperkalemia—closely monitor electrolytes
Kayexalate/Sorbitol—may need Flexiseal
IV dextrose, insulin and calcium may help shift K+
Cautious administration of any medication that
can be nephrotoxic
Monitor ABGs and acid-base balance
Monitor phosphate levels

11. Nutritional Therapy
Azotemia and uremia are directly related to the rate of
protein breakdown
Dietary proteins are individualized to each patient. Is a
catabolic state and if insufficient intake, patient may lose up
to 0.5-1 pounds daily. Encourage high CHO. Protein needs
for non-dialysis patients need 0.6g/kg of body weight
Dialysis patients will need 1-1.5g/kg
Fluid restriction=urine volume plus 500ml

12. Nursing management
•Monitor fluid and electrolyte balance
•Reduce metabolic demands
•Promote pulmonary function
•Prevent infection
•Provide skin care
•Provide support

13. Chronic Renal Failure (End-
stage renal disease)
Progressive, irreversibe deterioration in renal function
Causation: #1 diabetes mellitus, hypertension,
glomerulonephritis, pyelonephritis, polycystic
kidney disease, vascular disorders, others
Uremia---collection of nitrogenous wastes normally
excreted by the kidneys. S/S include: HA, seizures, coma,
dry skin, rapid pulse, elevated BP, scanty urine, labored
breathing

14. Kidney changes
•Nephrons hypertrophy and work harder until 70-80% of renal
function is lost
•Nephrons could only compensate by decreasing water reabsorption
thus:
•Hyposthenuria—loss of urine concentrating ability occurs
•Polyuria—increased urine output
•Then isosthenuria—fixed osmolality
•Gradual decline in urinary output

15. Stages of Renal Failure
1.GFR (Glomerular filtration rate) greater than or
equal to 90mL/min/1.73 m2.
Kidney damage w/normal or increased GFR
2.GFR = 60-89, mild decrease in GFR
3.GFR = 30-59, moderate decrease in GFR
4.GFR = 15-29. severe decrease in GFR
5.GFR < 15. Kidney failure

16. Clinical Manifestations
•Every body system is affected
•CV—hypertension, heart failure, pulmonary edema,
pericarditis, MI
•Pulm.—crackles, Kussmaul, pleuritic pain
•Derm—severe pruritus, uremic frost (urea crystals)
•GI—n/v, anorexia, uremic fetor (ammonia odor to breath),
constipation or diarrhea
•Neurologic—LOC changes, confusion, seizures,
agitation, neuropathies, RLS (restless leg syndrome) an
uncontrollable urge to move the legs
•Hematologic—anemia, thrombocytopenia
•Musculoskeletal—muscle cramps, renal osteodystrophy, bone pain,
bone fractures
•Metabolic changes—urea and creatinine, sodium, potassium, acid-
base, calcium and phosphorus

17. Diagnostic tests
•Decreased GFR can be detected by obtaining a 24-hour urinalysis for
creatinine clearance.
•The serum creatinine and BUN levels increase.
•SODIUM AND WATER RETENTION:Some patients retain sodium
and water, increasing the risk for edema, heart failure, and
hypertension.
•ACIDOSIS: metabolic acidosis occurs because the kidney cannot excrete
increased loads of acid. Decreased acid secretion primarily results from inability
of the kidney tubules to excrete ammonia (NH
−
) and to reabsorb sodium
bicarbonate (HCO
−
). There is also
3 3
decreased excretion of phosphates and other organic acids.
•ANEMIA: As a result of inadequate erythropoietin production, the shortened
life span of RBCs, nutritional deficiencies, and the patient’s tendency to bleed,
particularly from the GI tract.
•CALCIUM AND PHOSPHORUS IMBALANCE: as one rises, the other
decreases.

18. Potential complications of chronic renal failure that concern the
nurse and that necessitate a collaborative approach to care include
the following:
Hyperkalemia
Pericarditis, pericardial effusion, and pericardial tamponade.
Hypertension
Anemia
Bone disease and metastatic calcifications
Complications

19. Medical Management
•Calcium and phosphorus binders—Calcium
carbonate, calcium acetate
•Antihypertensives
•Antiseizure—valium or dilantin
•Erythropoietin
•Iron supplements
•Diet—CHO and fat, vitamins, restrict protein

20. Nutritional therapy
•Careful regulation of protein intake, fluid intake to balance fluid
losses, sodium intake to balance sodium losses, and some
restriction of potassium.
•Adequate caloric intake and vitamin supplementation must be
ensured.
•Protein is restricted because urea, uric acid, and organic acids.
•The allowed protein must be of high biologic value (dairy
products, eggs, meats). High-biologic-value proteins are those
that are complete proteins and supply the essential amino acids
necessary for growth and cell repair.
•the fluid allowance is 500 to 600 mL more than the previous
day’s 24-hour urine output.
•Calories are supplied by carbohydrates and fat to prevent
wasting. Vitamin supplementation is necessary.

21. Other Therapies: Dialysis
Indications:
1.Uremia
2.Persistent hyperkalemia
3.Uncompensated metabolic acidosis
4.Fluid volume excess
5.Uremic encephalopathy
6.Remove toxic substances

22. Dialysis
•Based on principles of diffusion, osmosis and
ultrafiltration
•Diffusion—removal of toxins and wastes. Move
from blood to dialysate.
•Osmosis—excess water is removed. Goes from area
of higher solute concentration (blood) to lower
concentration (dialysate)
•Ultrafiltration—water moves from high pressure
area to lower pressure. Applied by negative pressure,
more efficient than just by osmosis

23. Complications of dialysis
▣ ASHD (atherosclerotic heart disease)
▣ Disturbances of lipids worsened by dialysis
▣ Anemia and fatigue
▣ Gastric ulcers
▣ Renal osteodystrophy
▣ Sleep problems
▣ Hypotension
▣ Muscle cramps
▣ Dysrhythmias
▣ Dialysis equilibrium from cerebral fluid shifts

24. Dialysis Disequilibrium Syndrome
•Caused by rapid decrease in fluid volume and blood
urea nitrogen levels during HD
•Change in urea levels can cause cerebral edema and
increased ICP (intracranial pressure).
•Neurologic complications include: HA (headache) ,
vomiting, restlessness, decreased LOC (level of
consciousness), seizures, coma or death
•Can be prevented by starting HD for short periods
and low blood flows

25. Forms of dialysis
•Hemodialysis
•In ICUs where patient is too unstable to have
hemodialysis, can have CRRT(continuous renal
replacement therapy)
•Peritoneal dialysis

26. Nursing management:
The patient with chronic renal failure requires astute nursing care to avoid
the complications of reduced renal function and the stresses and anxieties
of dealing with a life-threatening illness. Examples of potential nursing
diagnoses for these patients include the following:
1.Excess fluid volume related to decreased urine output, dietary excesses, and
retention of sodium and water.
2.Imbalanced nutrition: less than body requirements related to anorexia,
nausea and vomiting, dietary restrictions, and altered oral mucous membranes.
3.Deficient knowledge regarding condition and treatment regimen.
4.Activity intolerance related to fatigue, anemia, retention of waste products,
and dialysis procedure.
5.Low self-esteem related to dependency, role changes, changes
in body image, and sexual dysfunction.

27. Organs transplantation
Kidney Transplantation
•More successful if done before dialysis
•HLA (human leukocyte antigen) and ABO
compatibility
•Donor kidney placed in iliac fossa
•Patient must be free from infection
•Similar care for patient post-operative as any surgery

29. Kidney Transplantation
Advantages of kidney transplantation over dialysis:
•Reverses many of the pathophysiologic changes associated
with renal failure
•Eliminates dependence on dialysis
•Less expensive than dialysis after the first year.
Kidney Transplantation(Recipient Selection:)
•Candidacy determined by a variety of medical and
psychosocial factors that vary among transplant centers
•Preemptive transplantation (before dialysis is required) is
possible if the recipient has a living donor

30. Kidney Transplantation
Recipient Selection
Contraindications to transplantation
•Disseminated malignancies
•Untreated cardiac disease
•Chronic respiratory failure
•Extensive vascular disease
•Chronic infection
•Unresolved psychosocial disorders

31. Kidney Transplantation
Donor Sources
•Deceased donors with compatible blood type
•Blood relatives
•Emotionally related living donors
•Altruistic living donors
•Paired organ donation

32. Kidney Transplantation
•Post-operative assessment for s/s of rejection such as
oliguria, edema, fever, increasing blood pressure,
weight gain and swelling or tenderness over
transplanted area
•Monitor creatinine level, in those on cyclosporine,
may be the only s/s
•Monitor WBCs
•Monitor urinary output, may need hemodialysis
temporarily (2-3 weeks may initially have ATN
[acute tubular necrosis])
•Addressing psychological concerns
•Monitoring & management potential complication.

33. PROMOTING HOME AND
COMMUNITY -BASED CARE
Teaching Patients Self-Care: The nurse works closely with the patient
and family to be sure that they understand the need for continuing the
immunosuppressive therapy as prescribed. Additionally, the patient and family
are instructed to assess for and report signs and symptoms of transplant
rejection, infection, or significant adverse effects of the immunosuppressant
regimen.
Continuing Care: follow-up care after transplantation is a lifelong
necessity. Individual verbal and written instructions are provided concerning
diet, medication, fluids, daily weight, daily measurement of urine,
management of intake and output, prevention of infection, resumption of
activity, and avoidance of contact sports in which the transplanted kidney may
be injured

34. Kidney transplantation
complications
•Rejection
•Chronic rejection
•Process that occurs over months or years and is irreversible
•Infection
•Most common infections observed in the first
month
•Pneumonia
•Wound infections
•IV line and drain infections
•Urinary tract infections
•Fungal infection
•Viral infection

35. Kidney transplantation complications
(cont’d(
•Cardiovascular disease
•Transplant recipients have increased incidence of
atherosclerotic vascular disease
•Immunosuppressant can worsen hypertension
and hyperlipidemia
•Patients need to adhere to antihypertensive
regimen
•Malignancies
•Recurrence of original renal disease
•Corticosteroid-related complications