RENAL FAILURE

1. RENAL FAILURE ACUTE RENAL FAILURE CHRONIC RENAL FAILURE

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

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

4. 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

5. 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

6. DEFINITIONS OLIGURIA: POLYURIA: ANURIA: NORMAL URINARY OUTPUT:

8. 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)

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

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

11. 3 phases of acute renal failure Oliguria Diuresis Recovery

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

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

14. DIURETIC PHASE (lasts 1-3 wks) Gradual increase of urine output as a result of osmotic diuresis

15. RECOVERY PHASE Do all patients recover?

16. GOALS OF TREATMENT Restore renal function Identify cause Eliminate cause

17. 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?

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

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

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

21. 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

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

23. Alterations: Chronic Renal Failure • Metabolic Disturbances: • elevated BUN, • creatinine, • hyponatremia, • hyperkalemia, • metabolic acidosis, • hypocalcemia, • hyperphosphatemia • Integumentary Disturbances: pruritus,dry,hair brittle, nails thin, UREMIC FROST: white/yellow crystals of urate on skin

24. 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

25. 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

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

27. DIETARY RESTRICTIONS FORCHRONIC RENAL FAILURE calorie protein Na K calcium Phosphorus Magnesium

28. Thank You

29. DIALYSIS: peritoneal and hemodialysis

30. 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

32. 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

33. 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

34. 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

35. 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

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

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

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

39. 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

40. 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

42. COMPLICATIONS Hemodialysis vascular access BLEEDING INFECTION CLOTTING

43. 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

44. Nursing care pre dialysis Vasoactive drugs which cause hypotension are held until after treatment CHECK WITH PHYSICIANABOUT WHICH DRUGS TO BE HELD Know pt’s BP pre-dialysis

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

46. 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

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

48. NURSING 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

49. Thank You