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Acute renal failure (ARF) presents as a rapid decline in renal function, may occur within a few hours or over a period of several weeks Detected by laboratory studies Evidenced by oliguria and elevated blood levels of BUN and creatinine electrolytes and acid-base homeostasis
Categories of ARF ETIOLOGY PRERENAL ARF ------------------------55% Due to diseases that cause renal hypoperfusion without affecting the renal parenchyma (dehydration from fluid loss ,cardiac failure)
Phases of ARF 1. Initiation Period - begins with initial insult to the kidney and ends when oliguria develops 2. OLIGURIC PHASE - Begins when the kidneys are damaged. Typically lasts 10- 15 days to several weeks. Cardinal sign is oliguria (urine output < 400 ml/day) During this phase urine output is low and fluid is retained. Protein is lost because of increased permeability of glomerular membrane, thus fluid diffuses into interstitial tissue Inability to excrete fluid loads Results in fluid overload and edema. This leads to CHF and pulmonary edema. Hypervolemia can lead to hypertension. Oliguria (urine output < 400ml/day) or anuria (< 100 ml/day) Electrolyte imbalances Retention of potassium Metabolic acidosis Potassium imbalance Hyperkalemia, the most sudden hazard in oliguric ARF, exists when the serum K reaches 5.5 or greater. K of 7-10 is incompatible with normal cardiac function In monitoring for signs of K toxicity, the EKG and lab results are the most reliable indicators. Sodium imbalance Hyponatremia develops with overhydration (occurs when the kidney cannot excrete fluid) When the volume of fluid and drugs cannot be reduced to a safe level, dialysis is required to remove excess fluid and restore sodium balance. Signs and sxs of hyponatremia: warm, moist, flushed skin muscle weakness and twitching confusion, delirium, coma, convulsions serum Na concentration < 130 mEq/L
INTRINSIC RENAL ARF ----------------40% Due to diseases that directly involve the renal parenchyma( Glomerulonephritis)
POSTRENAL ARF ------------------------ 5% Due to diseases associated with urinary tract obstruction (enlarged prostate gland, calculus)
Conditions that reduce blood flow to the kidney and impaired kidney function 1. Hypovolemia 2. Hypotension 3. Reduced cardiac output and heart failure 4. Obstruction of the lower urinary tract by tumor, stones, blood clot 5. Bilateral obstruction of the renal arteries or veins Pathophysiology Renal ischemia occurs when blood flow to the kidneys is reduced. The kidney responds with vasoconstriction, further increasing the problem of reduced renal blood flow. Damage to the cells leads to decreased glomerular permeability and tubular obstruction.
recovery) May excrete 2 L/day BUN & creatinine are high. anesthesia (fluorothane) Chronic Renal Failure A progressive and irreversible decline in renal function ranging from mild with nearly normal function to ESRD requiring renal replacement therapy. DIURETIC PHASE Marked by increased urine output Indicates the damaged nephrons are healing Within 1-2 days. BUN 2. 4. urine output up to or > 4-5 L/ day may occur ▪ ▪ ETIOLOGY 1. ▪ Pericarditis develops as a result of pericardial irritation from accumulated metabolic wastes. Recovery phase . Calcium decreases. sodium may be high or low Major complication of burns. Anemia 6. control serum electrolytes. Observe for UTI because infection is a major cause of death in ARF NON . 3. hypokalemia may occur 25% of deaths from renal failure occur during the diuretic phase (from dehydration & shock) This phase may last 10 days . asterixis. GI bleeding may result from uremic gastritis or colitis. ** If the oliguric phase lasts longer than 2 weeks. progressive and irreversible loss of nephron mass irregardless of cause Inability to excrete metabolic wastes . The lungs attempt to compensate with Kussmaul respirations . Creatinine 3. and excrete nitrogenous wastes. But remember it is not really "good" urine because the kidney can't concentrate urine as it should. Diagnostic Findings 1.4-5 L/day. prognosis for renal recovery is poor 3. 4. diuretic. producing signs and sxs of uremia. decreased Hgb hemodilution and Hct (from Complete recovery of renal function is slow (may take months) Metabolic acidosis This occurs when hydrogen ion secretion and bicarbonate ion production diminish in the tubules. (Normal 5-20) ▪ Signs and sxs: confusion. convulsions.Renal function is normal or near normal when the kidney can both concentrate and dilute urine.takes about 2. The pH of the blood decreases and CNS sxs of drowsiness progressing to stupor and coma may appear. BUN may increase at a rate of 30 mg/dl/day.the pt needs to avoid dietary protein. ▪ Decreased cellular immunity causes increased risk of infection. ▪ Bruising and bleeding from changes in coagulation factors. Phosphorus is increased PHARMACOLOGICAL THERAPY IN CRF Calcium carbonate . Urine is VERY diluted in this phase.Renal failure alters the body's ability to eliminate metabolic waste products.improvement of renal function . GFR 4.OLIGURIC RENAL FAILURE (High output renal failure) Represents 60% of all renal failures Does not follow the phases of ARF (oliguric. 2. ▪ N & V. Acidosis 5. results from a prolonged. BUN and creatinine values rise sharply. Factors affecting the progression of CRF: Modifiable Risk factors: Systemic hypertension Dyslipidemia Hyperglycemia Proteinuria BUN and creatinine may rise or remain elevated as urine volume increases Hyponatremia. coma.3 months of recovery . nephrotic drugs.
edema.to view pulmonary status ECG. and skin changes NUTRITION Nurse must asses markers of nutrition Restrictions on fluids/ salts Restriction on protein intake Dialysis Purpose: Remove the end products of protein metabolism from blood Maintain safe levels of electrolytes Correct acidosis and replenish blood bicarbonate system Remove excess fluid from the blood RENAL REPLACEMENT THERAPIES Hemodialysis DIALYZER Nursing Care: femoral/subclavian cannulation Palpate peripheral pulses in cannulized extremity Observe for bleeding/hematoma formation Position catheter properly to avoid dislodgement during dialysis AV FISTULA NURSING CARE: AVF Confirm patency by palpating thrills and bruits along course of AVF Nephrology precautions Teach patient to avoid constrictive clothing and to check fistula patency daily. Vit C & B) Antihypertensive medications Anti seizure agents Avoid magnesium containing antacids Drug dose or interval adjustment is necessary for most drug dependents on renal clearance Schedule daily drugs after dialysis to prevent dialysis loss DIALYSIS 1. CRRT KIDNEY TRANSPLANTATION Continuous Renal Replacement Therapies (CRRT) .Removes waste product slowly . ureters and bladder (KUB).to determine calculi or renal vascular calcification Renal ultrasound. altered taste sensation Anxiety related to major health. Teach patient to handle post treatment bleeding at cannula site: apply direct pressure for several minutes to control bleeding then apply dry dressing VASCULAR ACCESS .determines presence of severe hyperkalemia Diffusion is the process used to remove toxin and wastes in the blood Ultrafiltration – water moves from high pressure to an area of lower pressure . nausea & vomiting.Hemodynamic stability is easily attained Hemodialysis DIAGNOSTIC TEST Abdominal X-ray of the kidneys.Used when uric acid needs to be aggressively managed .Requires more time . lifestyle.Similar to hemodialysis .Rocaltrol) Water soluble replacement for dialysis loss (Folate. Hemodialysis 2. Recombinant erythropoeitin (Epogen or Procrit) Dihydroxyvitamin D3 (Calcitriol.Offers lower fluid removal and solute clearance rates . DIALYSATE fluid is a special solution containing a premixed concentrate of electrolytes HD treatment lasts for 3-4 hours NURSING DIAGNOSIS Excess fluid volume related to inability of the kidneys to excrete excess fluid Imbalanced nutrition. less than body requirements. role and financial income Disturbed body image related to visible dialysis access. Peritoneal Dialysis 3.applies suctioning force to the dialysis membrane HEMODIALYZER has Dialysis coil which acts as the semipermeable membrane. related to anorexia.to identify renal vascular blood flow and to rule out obstruction Bladder scan – to detect urinary retention Blood chemistries 24-hour urine collection Chest X-ray.
D. Biliary cirrhosis Stages of Hepatic Coma . giving injections. allowing it to dwell for a prescribed period of time.Dysrhythmias . hepatotoxic drugs Vitamin therapy: especially the fat soluble vitamins A.painful muscle cramping .Chest Pain Advantages of Hemodialysis short treatment time minimal interruption of lifestyle in between treatments more efficient than PD performed by trained health personnel contact with similarly treated patients THERAPEUTIC INTERVENTIONS Rest Restriction of alcohol. E and K and vitamin B (thiamine chloride and nicotinic acid).A chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver 3 types 1.most common protein loss malnutrition inguinal or abdominal hernias KIDNEY TRANSPLANTATION HEPATIC CIRRHOSIS . administering IV infusions.Dialysis disequilibrium syndrome – due to cerebral fluid shift . Post necrotic cirrhosis 3.exsanguination Complications .Hypovolemic shock: may occur as a result of rapid removal or ultrafiltration of fluid from intravascular compartment .Air embolism . and vasodilators to prevent hypotensive episodes (unless ordered otherwise) Ensure bed rest with frequent position changes for comfort Inform client that headache and nausea may occur Monitor closely for signs of bleeding since blood has been heparinized for procedure Nursing Care: Postdialysis Chart client’s weight Assess for complications: Fluid removal is by osmotic gradient with dialysate dextrose concentration providing the higher osmotic pressure PD requires filling the peritoneal cavity with a prescribed volume dialysate. Nursing Care: for AV Graft Auscultate for a bruit and palpate for a thrill to ensure patency Assess for clotting (color change of blood. sedatives. zinc and calcium supplements Diuretics to control ascites and edema lactulose may be prescribed for elevated blood ammonia levels (2-4 soft stools) Paracentesis if respiratory distress occurs as a result of ascites LABORATORY ALTERATIONS Serum Albumin Total CHON Cholinesterase SGOT/SGPT Alkaline phosphatase Bilirubin (total & direct) Prothrombin time (PT) Partial thromboplastin time (PTT) Serum ammonia Urine urobilinogen Na & K Hemoglobin Hematocrit Sengstaken-Blakemore tube PERITONEAL DIALYSIS The capillaries of the peritoneal membrane allow solute clearance down a concentration gradient between the instilled dialysate and the plasma . or taking a blood pressure with a cuff on the shunt arm Nursing Care: before and during hemodialysis Have client void Chart client’s weight Assess vital signs before and every 30 minutes during procedure Withhold antihypertensives. Alcoholic cirrhosis 2. absence of pulsations in tubing Change sterile dressing over shunt daily Avoid performing venipuncture. then draining and discarding the effluent (waste materials) Complications of Peritoneal Dialysis peritonitis .
0 meq/L Etiology Undiagnosed diabetes Laboratory Plasma glucose level 350 – 1500 mg/dl Ketonuria – large ketone bodies Serum bicarbonate <9meq/dl Serum potassium (Low) Treatment Correct volume depletion .Trauma . prevents danger of rupture and bleeding Alcohol is contraindicated to prevent further damage DIETARY (HEPATIC COMA) Protein: reduced according to tolerance. and electrolyte supplements Low sodium (500-1000mg daily). ensure proper placement. usually of abrupt onset . vitamin. dryness.10 units of Regular insulin + 100cc saline Potassium replacements Base medications . elevate bed 30-45 degrees Maintain the esophageal balloon at inflated level (30-35mm Hg) up to 48 hrs Deflate gastric balloon for a few minutes at specific intervals if ordered to prevent necrosis Gastric lavage as ordered Suction orally as necessary because the client is unable to swallow saliva Missed anti diabetic drug Physical stress . abdominal girth. petechiae. and palmar erythema Signs of hepatic coma such as confusion. flapping of extremities Observe for bleeding Provide special skin care and keep nails trimmed because pruritus is associated with jaundice Maintain the client in a semi-Fowler’s position to prevent ascites from causing dyspnea Monitor intake and output. and daily weight to assess fluid balance DIETARY (CIRRHOSIS) High carbohydrate. Sengstaken-Blakemore Tube Management If the gastric balloon is inflated.NaHCO3 NURSING CONSIDERATION Monitor fluid status Monitor blood glucose levels Prevent aspiration pneumonia Monitor potassium Monitor mental status HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA HHNK HONK A complication of diabetes No ketoacidosis (+) history of non insulin dependent DM HHNK Has the same pathogenesis with DKA the only difference is that there is no Acidosis due to fat metabolism.9% saline used in general Insulin Drip . helps control increasing ascites Soft foods if esophageal varices are present. provides for energy. mineral.Surgery . spider angiomas. ecchymoses.0.Illness PATHOPHYSIOLOGY NURSING CARE Abdominal girth measurements for baseline data relative to ascites. Skin for presence of jaundice. It is said that a little insulin is available so glucose is available for the muscles leaving fat in its place Management and consideration are the same with DKA THYROID CRISIS Thyroid Crisis/ Thyroid Storm/ Thyrotoxic Crisis . moderate fat.Is a form of severe hyperthyroidism. 1530g High calorie (1500-2000g) Fluid carefully controlled according to output DIABETIC KETO ACIDOSIS DKA Develops as a result of severe insulin deficiency Cardinal symptom is Severe HYPERGLYCEMIA >350mg/dl Elevated Ketone Acidosis (bicarbonate <9.
5 C Extreme tachycardia .rapid respiration .>130beat/min Gastrointestinal.extreme emotional stress . palpitations Altered mental state. abd’l pain Cardiovascular.above 38. hyperexcitability Low Self esteem Altered Body Temperature Management For fever ice packs cool environment TSB Paracetamol Oxygen Therapy D5 containing IV fluids Medulla Cortex ADRENAL CRISIS ALTERNATIVE NAMES: Adrenal crisis. Radioactive Iodine d. For patients with cardiac problem. dyspnea. Precipitating Factors STRESS . somnolence.rapid.edema. coma NURSING DIAGNOSIS Imbalanced Nutrition Less than Body Requirements Ineffective Coping rt irritability.Insulin Reaction .90% cases) Infection .weight loss.Tuberculosis .Histoplasmosis Inadequate secretion of ACTH Therapeutic use of Corticosteroid MANIFESTATIONS Muscle weakness Anorexia Gastrointestinal Symptoms Fatigue Emaciation Hyperpigmentation of the skin Hypotension Low blood glucose Low sodium High potassium Cyanosis Circulatory shock .Corticosteroids . weak pulse . PTU or Methimazole b.DKA .infection .Administer fluids .tooth extraction .Abrupt withdrawal of anti thyroid medications .Digitalis Intoxication . Addisonian crisis. Causes: Autoimmune or idiopathic atrophy of the Adrenal Gland ( 80.Vigorous palpation of the thyroid CLINICAL MANIFESTATIONS High fever. chestpain.injury . Acute adrenal insufficiency Addison’s Disease ( Adrenocortical Insufficiency) . diarrhea.low blood pressure Management Control of Circulatory shock Place the patient in Trendlenburg position Oral intake of fluids if tolerated Medications a.delirium psychosis.pallor .Occurs when adrenal cortex function is inadequate to meet the patient’s need for cortical hormones.Propanolol combined with digitalis ADRENAL CRISIS Adrenal Gland Dependent . Hydrocortisone c.Vasopressin .Antibacterial meds .Thyroid and non Thyroid Surgery .Pregnancy Precipitating Factors .
25% ( 750. Fluid and blood replacement . Treatment of the underlying cause 2. Anti emetic Nursing Management 1. hypotension b. tachycardia c. Adequate Cardiac pump 2.1300ml) of blood in a 70 kg person Pathophysiology Pulmonary Congestion decrease systemic tissue perfusion decrease Coronary Artery perfusion Signs and Symptoms: Decrease blood volume (Intracellular or extracellular) Decrease venous return Decrease stroke volume Decrease Cardiac Output a.occurs when there is a decrease in the intravascular volume by 15.SHOCK A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular functions Components of Adequate Blood Flow 1. Desmopressin c. pain of angina b. HYPOVOLEMIC SHOCK Decrease SV and CO . paleness d.It maybe coronary or non coronary event in origin Pathophysiology Inadequate blood flow to the tissue Poor delivery of O2 and nutrients to the cell Cellular starvation Cell Death Organ Dysfunction Organ failure Death MEAN ARTERIAL PRESSURE The average pressure at which the blood moves through the vasculature Normal= > 65mmHg Formula: MAP= systolic BP + 2(diastolic) -------------------------------3 Classifications of Shock Decrease cardiac contractility I. Antidiarrheal d. CARDIOGENIC SHOCK . Redistribution of Fluid Medical Management 4. Effective Circulatory System 3. cold clammy skin e.Dextran is not to be given to patient with Hemorrhage 3.It occurs when the heart has an impaired pumping ability . dizziness Medical Management 1.Crystalloids/ Colloids . Pharmacology a. Implementing other measures .Safety and comfort of the patient II. dysrhythmias c. Sufficient Blood Volume Decrease tissue perfusion Signs and Symptoms: a. Insulin b. Administration of blood and fluids safely 2. Hemodynamic Instability .Oxygen therapy .
Dobutamine.Caused by spinal cord injury.Relieves angina . Tachycardia 4. Nursing Management Hand Hygiene Aseptic technique Obtaining appropriate specimen for culture and sensitivity d.caused by widespread infection Pathophysiology Medical Management Any potential route for infection is eliminated Fluid replacements Pharmacology Therapy a.replacement of a faulty cardiac valve. Medical Management 1. CIRCULATORY SHOCK 1. IABP b. Implementing mechanical cardiac support Medical Management 3. Pharmacology Therapy a. Providing Selected Fluid Control d. Hypotension 3.increases blood flow to the kidneys and mesentery . Septic shock. Oxygen Therapy b.vasodilator which reduces preload and afterload c. CABG. Coronary cardiogenic shock . Monitor hemodynamic status 3. Hypotension 3.Thrombolytics. Prevent Cardiogenic Shock . Monitoring of pertinent blood test 2. acidosis and electrolyte imbalance Medical Management Permeability / fluid shifting Poor Tissue Perfusion Signs and symptoms: 1. Control of chest pain c. Initiation of First line treatment a.anti inflammatory. Correction of underlying cause a. Dopamine . Confusion 2.Spinal Anesthesia Microorganisms invade body tissues Activation of inflammatory mediators Increased capillary Mediators activate . coagulation system 2. Fluid Therapy Nursing Management 1. 2. Recombinant human activated protein C (rhAPC)-antithrombotic. antibiotics b. Enhancing safety and comfort III. correction of dysrhythmia. b.has an inotropic effect b. Non Coronary Cardiogenic Shock . Administer medications and intravenous fluids safely 4. profibrinolytic 4. c.Administer supplemental O2 2. bradycardia Medical Management Stabilization of a spinal cord injury Glucose for hypoglycemia Proper positioning . spinal anesthesia and nervous system damage Pathophysiology Parasympathetic stimulation Prolonged vasodilation Blood volume is displaced Hypotensive state Decrease vascular resistance Insufficient perfusion of tissues and cells Signs and symptoms: (parasympathetic effect) 1. Nitroglycerin.conserve patient’s energy . 3. Aggressive nutritional supplementation a. Dry. Maintaining Mechanical Assistive Devices 5. Antiarrhythmic medications e. warm skin 2. Tachypnea 1. Angioplasty.inotropic and slight chronotropic effect d. Neurogenic Shock .
Occurs when patient is already exposed to an antigen and who have developed antibodies to it. hyperlacticacidemia.Severe organ damage . 2. polyuria 4. Hypermetabolic state. Medical Management Controlling the initiating event Promoting adequate organ perfusion Providing nutritional support Nursing management a. Renal failure a.Liver and Renal failure . Hypotension 2.bronchodilator Nursing Management Assess patient for allergies Advise patient to wear identification of what kind of allergies he has Stages of Shock I.Metabolic Acidosis MULTIPLE ORGAN DYSFUNCTION SYSTEM/ MULTISYSTEM ORGAN FAILURE . Nursing Management Elevate the bed at 30 degrees Immobilize the patient to prevent further damage to the spinal cord Application of elastic compression stockings/ elevate foot of the bed Passive range of motion exercises Watched out for signs of internal bleeding if patient has spinal cord injury Signs and symptoms: 1.Hypotension Due to: 1. Promoting Communication 3.Cardiac and respiratory failure .vasoconstrictive effect Diphenhydramine. c. Irreversible Stage . Liver failure 5. Anaphylactic Shock .Increase RR II. Compensatory Stage .Decrease MAP . Medical Management Removal of causative antigen Epinephrine. Respiratory failure 3.Altered organ function in acutely ill patients .Metabolic acidosis . b.hyperglycemia.A complication of any state of shock .antihistamine Albuterol. Progressive Stage . 4. Direct tissue insult SIRS Sepsis shock III.Hypotension . 3.