Renal

Assessment and
Diagnostic
Procedures
 Renal Failure
Is a severe impairment or a total lack of renal
function which leads to disturbances in all body
systems.
 Classification according to onset:
 Acute: Developing within hours to days with little time to
adjust to the biochemical changes, but is potentially
reversible. (sudden, rapid onset, reversible)
 Chronic: Insidious & progressive development over a
period of several years; allows for some adjustment to
biochemical changes, but is irreversible and always
necessitates some form of dialysis or transplantation for
long-term survival. (gradual, progressive, irreversible)
 General Symptoms
Weakness Metallic taste in mouth
Fatigue Loss of appetite
Dyspnea Rapid weight gains
Peripheral edema Pruritus
Nocturia Dry, scaly skin
Nausea
 Health History
The nurse elicits information regarding:
 Past medical and familial medical history
 Recent Changes:
 Urinary patterns

 General: nausea & vomiting, fatigue, lethargy or changes in

mentation
 Personal habits: sleep or work

 Recent weight gains or losses need to be explored

 Medications (current & recent)
 Over-the-counter and prescribed medications (NSAIDs e.g.,
ibuprofen) Antibiotics e.g., Aminoglycosides)
 Recent events:
 Trauma (presence of pain), infection, illicit drug use or expose
to nephrotoxic substances
 Laboratory Assessment
Serum Studies
 BUN (9-20mg/dl)
 Creatinine (0.7-1.5 mg/dl)
NB: the ratio of BUN to Creat. = 10:1
 Hgb (hemoglobin) & Hct (hematocrit)
 Albumin
 Electrolytes
 K+, Na+, Ca+, Magnesium & Phosphate
 Laboratory Studies Cont.,
Urine Studies:
 Urine Analysis (UA)
 Color, appearance, pH, specific gravity, glucose,
protein, WBC, RBC and casts.
 Culture & Sensitivity (C&S)
 Bacteria
 Urinary Collection:
 24 Hour Urine
 i.e. creatinine or electrolytes
 Spot / Random Urine
 First a.m. void preferred
Combination Studies:
 Creatinine Clearance (110-120 ml/min)
 24 hour urine and a serum sample
 Equivalent to GFR; best overall indicator of renal
function
Diagnostic Studies
Renal Radiological Examinations:
 Kidney-ureter-bladder (KUB)
 An X-ray; which identifies the position, size and
shape of the kidneys and the urinary tract
 Assist in identifying renal masses
 i.e. renal calculi, tumors or cysts
 Intravenous pyelogram (IVP)
 A series of x-rays following injection of radiopaque-
contrast dye.
 Allows visualization of the internal renal tissue.
 Check Allergies; watch contrast !!
 If there is evidence of renal impairment, it is contraindicated.
Diagnostics Cont.,
Other (Non-invasive) Renal Studies:
 Renal Ultrasound
 Size and shape of kidneys and urinary tract; may reveal fluid
accumulation, obstructions from masses (solid or fluid )
 Renal Computed Tomography (CT)
 I.V. radiopaque-contrast dye; can be done without

 Cross-sectional view of the kidneys and urinary tract

 Can assess renal perfusion and identify masses (fluid or solid),
tissue necrosis or hemorrhage
 Renal Magnetic Resonance Imaging (MRI)
 High-energy radiofrequency waves provide three-dimensional
views; clearer images
 Can assess: trauma, lesions, malformations of vessels or tubules
and necrosis
 Diagnostics Cont.,
More-Invasive Renal Studies:
 Renal Angiography
 Interventional radiology procedure

 Visualize renal blood flow

 Can also, detect stenosis, clots, cysts or necrosis

 Renal Biopsy
 Gold standard to diagnosis specific renal disease;
Last resort in critically-ill client
 Percutaneous: U/S guided / fluoroscopy
 Open
 Cautiously bleeding tendency
Renal
Disorders and
Therapeutic
Management
 Acute Renal Failure (ARF)
Sudden loss of kidney function over a period of
hours or days
 Characterized by:
 A rapid ↓ GFR
 Retention of metabolic waste
 A progressive ↑ BUN and ↑ Creatinine (Azotemia)
 Associated with:
 Classic finding of Oliguria (UO < 400ml/day)
 UO may also be normal or increased
 Fluid, electrolyte and acid-base imbalances
 Usually reversible with prompt treatment
 Classification of ARF
Acute renal failure is often classified according to
location of the insult:
 Prerenal
 Before the kidneys: ↓ Blood flow to kidneys

 Occurs in about 50-70% of all ARF cases

 Intrarenal
 Within the kidneys: actual damage to kidneys

 Occurs in about 20-30% of all ARF cases

 Postrenal
 After the kidneys: obstruction of urinary excretion

 Occurs in about 1-10% of all ARF cases

 Medical Management
Conservative Medical Management Goals
 Prevention of ARF
 Most effective is to prevent occurrence
 Eliminate underlying cause:
 Prerenal
 Optimize renal perfusion
 Intrarenal
 Supportive, remove causative ischemic or toxic agent
 Postrenal
 Removal of obstruction
 Support of Renal Function
 Prevent Complications
 Medical Management Cont.,
Fluid Balance
 Volume Deficit
 IVF or blood products

 Volume Excess:
 Fluid restriction
 All measurable output + 500-600ml/day (insensible losses)
 Daily weight, accurate I&O’s essential !!

 Diuretics
 Loop or osmotic diuretics
 Dialysis or hemofiltration
 Preferred method of fluid removal
 Watch I.V. placement
 Medical Management Cont.,
Serum Electrolytes
 Hyperkalemia
 I.V. Glucose accompanied by regular insulin
 Forces K out of serum and into cells
 I.V. Sodium Bicarbonate
 Creates temporary alkalemia moving H+ out of cells and allowing
K+ to shift into cells.
 I.V. Calcium Gluconate
 Supportive: raises threshold for cardiac dysrhythmias
 Polystyrene Sulfonate (Kayexalate)
 Cation exchanging resin; oral, rectal or down NG tube; resin binds
with K in bowel, promoting elimination in stool.
 Dialysis or hemofiltration
Medical Management Cont.,
Severe Metabolic Acidosis
 I.V. Sodium Bicarbonate
High Serum Phosphorous
 Phosphorous Binding Agents
 Aluminum-hydroxide preparations / antacids
 Bind to phosphate in bowel and promotes excretion in stool.
(i.e. Alternagel or Alu-cap)
 Calcium-based salts / antacids
 Calcium Carbonate or Calcium Acetate (PhosLo)

Low Serum Calcium

 Oral or I.V. Supplemental doses of Calcium
 Synthetic, active-form of Vitamin D (i.e. Calcitrol)
 Medical Management Cont.,
Pharmacological Considerations:
 Calcium Channel Blockers and ACE Inhibitors
 Hypertensive management
 Anemia
 RBC transfusions
 Epogen: Stimulate RBC production from bone marrow

 Ferrous Sulfate and folic acid supplements

 Other Pharmacologic Considerations:

 Anti-seizure medications
 Anti-emetic medications

 Anti-ulcer/ GI protective medications

 Anti-infective medications; renal dosing

 ARF Complications

Chronic renal failure HTN

Gastrointestinal bleeding Pulmonary edema
Convulsions (seizures) Pulmonary infection
Cardiac dysrhythmias Anemia
Cardiac arrest Metabolic Acidosis
Heart failure
 Nursing Interventions
Monitoring
 Vital signs
 Invasive Hemodynamics

 Fluid & Electrolyte Balances

 Essential assessment

 Laboratory
 CBC

 Urinalysis / Culture

 Electrolytes & Acid-Base Balances

 Be alert for signs/symptoms of imbalances
 Administer medications as ordered
 Provide support to client and significant others
 Encourage client to express feelings
Nursing Education
When to call the doctor
 Signs and symptoms of worsening renal function
Keep follow-up appointments
Smoking Cessation
Maintain normal weight
Medications: use, dose and side effects
Nursing Interventions Cont.,
Monitor Cont.,
 Signs and symptoms of infection
Maintain
 Diet & Fluids Restrictions
 Bed rest / Semi-fowler’s
 I.V. Fluids
 Quiet Environment
Prevent Infection
 Aspetic technique
 Invasive lines
 Foley catheters; avoid use when possible

Pulmonary Care
Skin & Mouth Care
Nursing Education
Infection Management
 Importance of good hygiene
 Recognize signs & symptoms
Rest-activity balance
Explain diet and/or FR
How to check daily weight
 Chronic Renal Failure
A progressive and irreversible loss of renal
function over a period of months to years
 The kidneys can loss up to 80% (overtime) of all
nephrons with relatively few overt changes in
functioning of the body
 Nephrons are destroyed and replace with scar
tissue; remaining nephrons become hypertrophied
and do not function as well.
 Resulting in systemic disease involving all of the body’s
organs (Uremic syndrome of CRF)
 Clinical Manifestations
Genitourinary System
 Renal insufficiency: polyuria, kidneys can no longer
concentrate urine
 Nocturia: frequent waking at night to urinate
 Specific gravity fixed at 1.010

 As renal failure progresses…Oliguria→ Anuria

 Urine findings: casts, WBC & hematuria

Psychological Changes
 Personality and behavior changes
 Decreased ability to concentrate
 Emotional lability
 Anxiety and Depression
 Clinical Manifestations Cont.,
Neurologic System
 General CNS depression
 Lethargy, apathy & fatigue → alterations in mental status →
convulsions → LOC → coma
 Peripheral Neuropathy
 Restless leg syndrome →paresthesias → motor involvement
foot drop & muscle weakness → paralysis
 Need dialysis or transplant; should improve CNS
symptoms
 Clinical Manifestations Cont.,
Cardiovascular System
 Hypertension
 Increased sodium and fluid retention
 Peripheral Edema
 Cardiac Dysrhythmias
 Hyperkalemia & Hypocalcemia
 Heart failure
 Uremic pericarditis
 Friction rub, chest pain and low-grade fever
 May progress to pericardial effusion & tamponade
Clinical Manifestations Cont.,
Respiratory System
 Kussmaul’s respirations
 Usually less prominent in CRF versus ARF
 Pulmonary edema and dyspnea
 Secondary to heart failure or overload
 Uremic pleuritis
 Pleural effusion
 Predisposed to respiratory infections
 Thick sputum & decreased cough reflex
 Clinical Manifestations Cont.,
Gastrointestinal System
 Excessive urea causes inflammation of mucosa
along the entire GI tract:
 Anorexia, hiccups, nausea & vomiting
 Oral mucosal ulcerations

 Stomatitis

 Metallic taste in mouth

 Ammonia odor to breath (uremic fector)

 Diarrhea

 Constipation
 Clinical Manifestations Cont.,
Anemia
 Inadequate erythropoietin production
 Decreased life span of RBC
 Nutritional deficits
 S/SX: fatigue, shortness of breath and even angina
Renal Osteodystrophy
 A syndrome of skeletal changes found in CRF from
alterations in calcium & phosphate metabolism and
elevated PTH levels:
 ↑ PTH reabsorbs calcium & phosphorous from bone stores
in an attempt to increase serum calcium levels.
 Long term effects: bone deformity and weakness
 Clinical Manifestations Cont.,
Integumentary System
 Yellowish-bronze discoloration to skin
 Retention of urinary chromogens (pigment)
 Pallor
 Result of anemia
 Dry, scaly skin
 Decreased oil and sweat glands
 Pruritus
 Calcium-phosphate deposits on skin / dry skin
 Petechiae and ecchymosis
 Abnormal platelet function and coagulation factors
 Uremic frost
 White crystals on skin as a result of urea
 Clinical Manifestations Cont.,
Other Considerations
 Increased triglyceride levels
 Occurs in 30-70% in CFR
 Increased blood sugars
 Usually moderate; alterations cellular use of glucose
 Increased tendency to bleed
 Altered platelet function and coagulation factors
 Increased risk of Infection
 Impaired leukocyte function and immune responses
 Reproductive Dysfunction
 Infertility and decreased libido
Parmacologic Management
Conservative Therapies
 Severe Hyperkalemia
 I.V. Glucose & Regular Insulin
 I.V. Calcium Gluconate

 I.V. Sodium Bicarbonate

 Kayexalate

 Dietary Restrictions

 Hypertension
 Na+ and fluid restrictions
 Antihypertensive medications
 Ace Inhibitors & Calcium Channel Blockers
Medical Management Cont.,
Renal Osteodystrophy
 Treatment of Increased Phosphate
 Dietary Restrictions
 Phosphate binders with daily meals
 Often accompanied by stool softeners
 Avoid magnesium containing antacids
 Magnesium toxicity and anemia
 Treatment of Decreased Calcium
 Supplements
 Active form of Vitamin D: i.e. Calcitrol (Rocaltrol)
 Calcium and Vitamin D
 Parathyroid (PTH) Management
 Possible partial- parathyroidectomy
Medical Management Cont.,
Metabolic Acidosis
 Sodium bicarbonate
Anemia
 Epogen
 Ferrous Sulfate
 Folic Acid
Other Pharmacologic Considerations
 Anti-seizure medications
 Anti-emetic medications
 Anti-ulcer / GI protectors
 Medical Management Cont.,
Nutrition (Conservative Management)
 High-carbohydrate, Low-protein Diet
 Dietary Restrictions:
 Protein
 0.6-0.8 g/kg; with dialysis may increase to 1-1.5 g/kg
 Sodium, Potassium & Phosphate
 Fluid Restriction:
 All measurable output + 500-600ml/day (insensible losses)
 Manage
 Glucose levels if necessary
 Supplements
 Vitamins
Nursing Management
Maintain
 Dietary & Fluid Restrictions
 Dietician consult

Administer
 Medications as prescribed
Monitor/Assess
 Fluid / electrolyte balances
 Vital signs
 Bruising /bleeding
 Laboratory results
Nursing Management
 Provide
 Skin care and mouth care
 Pulmonary Toileting
 Protect from infection
 Quiet environment

 Provide support
 To client and significant others
Nursing Education
Keep follow-up appointments
Avoid OTC medications
 Magnesium cont. laxatives or antacids
 NSAIDS etc.
S/Sx of worsening renal function
 Edema, hyperkalemia and other electrolyte
imbalances
When to notify doctor
 n/v more than once
 Rapid weight gains
Thank
You
For
Active
Listening