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1600-1608 Acute Renal Failure (can be reversed) Kidneys do • Acid/base balance • FVO, FVE, -salt balance • Hormone balance • Filtering Rapid decrease in kidney function Types of acute renal failure include: Prerenal-reduced blood flow to the kidneys (before the kidneys) Intrarenal-damage to the glomeruli, interstitial tissue or tubules (inside the kidney) Postrenal-obstruction of renal flow (after the Kidneys) Prerenal • Prerenal azotemia—renal failure caused by poor blood flow to the kidneys • the kidneys compensates by constricting renal blood vessels, activating the renin-angiotension-aldosterone pathway and releasing ADH. • these responses increase blood volume and improve kidney perfusion • however these also reduce urine output (oliguria less then 400 ml/day) and build up of waste products (azotemia) • Toxins can cause blood vessels to constrict in the kidney, leading to reduced renal blood flow and renal ischemia Most commonly caused by hypovolemic shock and heart failure Can be reversed by correcting blood volume, increasing BP and improving cardiac output When reduced blood flow is prolonged the kidney is severely damaged and intrarenal failure results Intrarenal • • Other names- acute tubular necrosis and lower nephron nephrosis Causes- infections, drugs and invading tumors, inflammation of the glomeruli or of the small vessels of the kidneys or an obstruction of renal blood flow Postrenal • Obstruction of the urine collecting system anywhere from the calyces to the urethral meatus (out flow) (obstruction of the ureter must be bilateral to cause postrenal failure unless only one kidney is functional) •
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Health Promotion and Maintenance Severe blood volume depletion can lead to renal failure even in people who have no known kidney problems avoid dehydration drink 2-3L a day (2000-3000ml) Continual assessment of I&O.2).005 to 1. cool skin). weak pulse. blood volume depletion (low BP.030 • Renal tubular damage (intra) Imaging assessment Other diagnostic tests • • • • • • • • • • . • Ask about urination problems • Medications (where are they excrated?) Physical assessment/clinical manifestations Laboratory assessment • Specific gravity ↓ not concentrating 1. • Need 30ml/hr • oliguria =less then 400 ml/day • Micturation =urination • Anormia= no output Phases include: • Onset phase • Oliguric phase • Diuretic phase • Recovery phase Acute syndrome may be reversible with prompt intervention.contrast dye. laboratory values(BUN 5-25.5-1. use of nephrotoxic substances (medications. Lupus. gastroenteritis and sore throats) • medical history (hypertension. DM. Creat 0. dizzy. NSAIDS) Pg 1605 chart 71-2 Assessment chart 71-1 pg 1604 • History • Surgery • trauma • transfusions • recent exposure to nephrotoxins • acute illness (flu. colds.Phases of Acute Renal Failure • Phases of rapid decrease in renal function lead to the collection of metabolic wastes in the body.
RBC casts) ARF Diagnostics • • • • Flat plate X-rays Renal ultrasonography CT Renal Biopsy Drug Therapy.Hypotension. ↓central venous pressure • may look like a pt with dehydration or heart faliure • Intra. lethergy. starting of stream (oligura to intermittent anuria. distended neck veins.oligura. tachy. ↓ cardiac output.(intrinsic)rentention of fluid (edema) oligura(↓ urine output) to anureia(no urine output)hypertenstion. N/V. SOB.030 (concentrated –because not filtering) Urine sediment (common. weight gain. lethergy. fluid challenges and diuretics are often used to promote renal blood flow In patient without volume excess 500-1000 mL of normal saline may be infused over 1 hour The patient responds to the fluid challenge by producing urine soon after the initial bolus Diuretics like Lasix may be prescribed along with a fluid bolus If oliguric renal failure is dx the fluid challenges and diuretics are DC’d Constant CVP for accurate evaluation of their hemodynamic status Carefully monitor for signs of possible fluid overload .type of stream.Physical Assessment Pg 1604 chart 71-1 & pg 1603 • Manifestations of ARF are related to the build up of nitrogenous wastes (azotemia) as well as the underlying cause • Pre. anorexia. symptoms of uremia) lethergy ARF Labs • • • • • • Rising BUN and serum creatinine (↑ both) Abnormal blood electrolytes (↑ k+ & ↓calcium) ARF usually do not have the anemia associated with CKD Urine sodium levels (↓ or ↑) (10 to 20 mEq/L) Specific gravity greater than 1.pg 1605 • • • • Patients with ARF receive many drugs Drug dosages change with kidney function changes Be knowledgeable about the site of drug metabolism Constantly monitor for possible side effects and interactions of the drugs Fluid Challenges • • • • • • • In prerenal azotemia. ↓urine output. respiratory crackles. tachy. change in LOC & electrolyte imbalances (↑ K & ↓calcium) & ECG changes • Post.
Drug Therapy pg 1606 chart 71-3 • • • • • • Cardioglycosides-Digoxin Vitamins and minerals-folic acid.with specified amts of protein.5g/kg Nutrition Therapy • • • • • Sodium intake ranges from 60-90 mEq If potassium levels are high.protein levels of 1 to 1.use nutritional support -TPN Dialysis for ARF pg 1607 •Indicators: • Presence of uremia • Persistent high potassium levels • Metabolic acidosis • Continued fluid volume excess • Uremic pericarditis.6g/kg of body wt or 40 g/day of protein For patient who do require dialysis.Amphogel Diuretics Calcium Channel Blockers (improve the GFR by improving renal blood flow) Treatment-Nutrition Therapy • • • • With ARF there is a high rate of protein breakdown Nutritionist will calculate the patient’s caloric needs.bulid up of waste is affecting the heart • Encephalopathy Immediate Vascular Access •Dual or triple lumen catheter specific for hemodialysis •Outflow lumen •Inflow lumen •Lumen for access for drawing blood or giving drugs & fluid without interrupting dialysis •Subclavian or internal jugular vein-long term •Femoral-short term •xray to check placement . sodium and fluids For patients who do not require dialysis 0. dietary potassium is restricted to 60-70 mEq Amount of fluid permitted is equal to the urine volume plus the insensible loss volume of 500 mL Assess oral intake every shift Many patients are too ill or have a poor appetite. ferrous sulfate Synthetic erythropoietin.Epogen (intra renal) Phosphate binders.
chloride. glucose. potassium. bicarbonte) • Vascular access • Types • Continuous arteriovenoous hemodialysis (CAVH) • Continuous arteriovenous hemodialysis and filtration (CAVHD) Posthospital Care • If renal failure is resolving. • There may be permanent renal damage and the need for chronic dialysis or even transplantation. follow-up care may be done with the nephrologist or family MD that consults with the specialist. sodium.1608-1636 . fluid restrictions • prevention of complications • home care help • social work assistance Care of Patients with Chronic Kidney Disease Igg Chapter 71 pgs. magnesium. • Temporary dialysis is appropriate for some patients. calcium.Dialysis Therapies • Continuous renal replacement therapy (CCRT) (standard for ARF due to they are usually for short term) • Continuous arteriovenous hemofiltration (CAVH) • used for pt with FVO & resistant to diuretics. unstable BP & cardiac output • Continuous arteriovenous hemodialysis and filtration (CAVHD) • Hemodialysis • Peritoneal dialysis Continuous Renal Replacement Therapy • • Standard treatment Dialysate solution (composed of H2o. • Teaching • type of dialysis • care of the site • dietary restrictions.
diet • Urea is protein metabolism Electrolytes changes: • Sodium • Potassium Acid-base balance changes.Chronic Kidney Disease • • • • • Progressive. kidney function does not recover End-stage renal disease (ESRD) Azotemia (build up of waste ) Uremia.metabolic Calcium ↑ and phosphorus ↓ changes • Early hypo .inflamed by the uremic toxins or infection • Hematologic changes-anemic due to the ↓ erythropoietin level that ↓ RBC production GI changes • halitosis-bad breath • stomatitis-mouth inflammation • • • • • • .S&S in chart 71-4 azotemia with clinical symptoms Uremic syndrome -table 71-1 Five Stages of Chronic Kidney Disease • • • • • At Risk Reduced renal reserve (GFR ↑ 90ml/min) Mild Chronic Kidney Disease (GFR 60-89ml/min) Moderate Chronic Kidney Disease (GFR 30-59ml/min) Severe Chronic Kidney Disease (GFR 15-29ml/min) End-stage Kidney disease (GFR ↓15ml/min Stages of Chronic Kidney Disease Changes . activity.late hyper Cardiac changes: • Hypertension cause or result of • Hyperlipidemia • Heart failure ↑workload due to ↑fluid = death because of the CKD • Pericarditis.pg 1609 & 1610 • Kidney changes • abnormal urine production • poor water excreation • electrolyte imbalances • metabolic abnormalitlies Metabolic changes: • Urea and creatinine (↑) • creatinine is derived from proteins present in skeletal muscle and depends on muscle mass. irreversible kidney injury.
• peptic ulcer Etiology and Genetic Risk • • • • • Many causes Two main causes HTN and DM Complex Table 71-6 pg 1611 African Americans patients are 4X more likely to develop ESKD and 7X more likely to have HTN Incidence/Prevalence • 2008 US Renal Data System more than 340.000 people in the US are receiving dialysis treatment for ESKD • More than 24% of patients with ESKD die within the first year of treatment • ESKD occurs more often in men than in women Health Promotion and Maintenance • • • • • • • • • • • Focus on controlling the diseases that lead to CKD development-like DM and HTN Identify patients at risk Teach adherence to drug and diet therapy Regular physical exercise Keep blood glucose levels within normal Compliance with drug therapy Yearly testing for microalbuminuria for DM and HTN patients Treat renal and urinary infections Avoid abusing NSAIDs Drink 3 liters of water daily Chart 71-5 History Assessment • • • • • • • • Focus on manifestations of CKD Patient’s age and gender Accurately measure wt and ht-asking about usual wt and any recent gains or losses Renal or urologic disorders. long term health problems. drug use and current health problems Current OTC and prescription drug use and past hx Dietary habits Energy levels Urine elimination Clinical Manifestations chart 71-6 pg 1613 • Neurologic .
• Assess for manifestations of volume excess: • Crackles in the bases of the lungs • Edema • Distended neck veins • Drug therapy includes diuretics.• • • • • • • Cardiovascular Respiratory Hematologic Gastrointestinal Skeletal Urinary Skin Assessments • • • Psychosocial assessment Laboratory assessment • BUN 10-20 • Creat 0.2 • Potassium 3.0-10.0 • Mag 1.3-2.5 Imaging assessment Imbalanced Nutrition: Less Than Body Requirements • Interventions include: • Dietary evaluation for: • Protein • Fluid • Potassium • Sodium • Phosphorus • Vitamin supplementation Excess Fluid Volume • Interventions: • Monitor intake and output.5-1.1 • Sodium 135-145 • calcium 9. Decreased Cardiac Output .5-5. • Promote fluid balance.
• Interventions: • Control hypertension with calcium channel blockers (improve renal blood flow & GFR). oxygen saturation levels. anemia. Anxiety • Interventions include: • Health care team involvement • Patient and family education • Continuity of care • Encouragement of patient to ask questions and discuss fears about the diagnosis of renal failure Potential for Pulmonary Edema • Interventions: • Assess the patient for early signs of pulmonary edema.and beta-adrenergic blockers. • Monitor serum electrolyte levels. pathologic fractures. diet. • Administer vitamin and mineral supplements. • Give iron supplements as needed. alpha. and vasodilators. hypertension. Risk for Infection ← • Interventions include: • Meticulous skin care • Preventive skin care • Inspection of vascular access site for dialysis • Monitoring of vital signs for manifestations of infection • HAND WASHING Risk for Injury • Interventions include: • Drug therapy • Education to prevent fall or injury. and drug therapy. ACE inhibitors(slow the progression). and buildup of urea. • Instruct patient and family to monitor blood pressure. and toxic effects of prescribed drugs Fatigue Interventions: • Assess for vitamin deficiency. patient’s weight. • Administer erythropoietin therapy for bone marrow production. Hemodialysis • Patient selection • presence of irreversible kidney failure • • . bleeding. vital signs.
• check for bruit or thrill Complications • thrombosis or stenosis • infection • aneurysm • ischemia • heart failure • Subclavian Dialysis Catheters . dual or triple lumen.• • • • absence of illness that would seriously complicate HD • expectation of rehabilitation • pt acceptance of the regimen Dialysis settings • many settings Hospital. or arteriovenous shunt for temporary access • due to need for large blood flow 250-300ml/min for 3-4 hr Precautions • AV fistulas • need adequate circulation in the area and the lower arm. home Procedure • diffusion Anticoagulation • needed for HD • Heparin is used to prevent clots from forming when blood comes in to contact with foreign surfaces • protamine sulfate antidote for heparin Hemodialysis Circuit Vascular Access • • • Arteriovenous fistula or arteriovenous graft for long-term permanent access Hemodialysis catheter. clinic.
graft or shunt Table 71-10 Prevention of Complications Hemodialysis Nursing Care • • Drugs table 71-11 Post-dialysis assess for hypotension.Caring for the Vascular Access • • • • • Assess for adequate circulation in the fistula or graft and in the lower portion of the arm Check for a bruit or a thrill by auscultation or palpation over the access site Avoid repeated compression Chart 71-8 Caring for fistula. pt home) • Automated peritoneal dialycan be done at night • Intermittent peritoneal dialysis • Continuous-cycle peritoneal dialysis (done at night while pt sleeps) . out pt. vomiting. and muscle cramps or bleeding Complications of Hemodialysis • Dialysis disequilibrium syndrome • rapid ↓ in fluid volume and BUN levels durning HD • can cause cerebral edema. HIV • Peritoneal Dialysis • Procedure involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate. ↑ intracranial pressure Infectious disease • Hepatitis B & C. nausea. • Types of peritoneal dialysis: • Continuous ambulatory peritoneal dialysis (CAPD) sis (acute care setting. malaise. headache. dizziness.
and discomfort. weight. evaluate baseline vital signs. and initiate outflow. kink in tubing.cold solution can cause pain) Exit site and tunnel infections . Monitor prescribed dwell time. Observe the outflow amount and pattern of fluid. constipation • Dialysate leakage • Other complications.bleeding.due to not maintaining an clean dry area. pain. Continually monitor the patient for respiratory distress. pulling or twisting of the catherter • Poor dialysate flow -position. dwell & outflow Renal Transplantation table 71-13 • • • • • • Candidate selection criteria Donors Preoperative care Immunologic studies Surgical team Operative procedure . • one PD exchange is a fill.Peritoneal Dialysis Exchange Continuous Ambulatory Peritoneal Dialysis (CAPD) Automated Peritoneal Dialysis Complications of Peritoneal Dialysis • • • Peritonitis (connection site contamination) (cloudy outflow= infection) Pain (at the start is common. and laboratory tests. leakage of solution. perforation Nursing Care Durning Peritoneal Dialysis • • • • Before treating.
Transplanted Kidney Postoperative Care • • • Urologic management Assessment of urine output hourly for 48 hr Complications include: • Rejection • Acute tubular necrosis • Thrombosis • Renal artery stenosis • Other complications Immunosuppressive drug therapy • cyclosporin • long term to protect the kidney • increased risk for infection (viral. protozoal) Community-Based Care pg 1635 • • • • Home care management Health teaching Psychosocial preparation Health care resources • . bacterial.
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