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GASTROINTESTINAL BLEEDING
SIGNS & SYMPTOMS:
● or Gastrointestinal hemorrhage is
any bleeding that occurs in the
gastrointestinal system from the
mouth to the rectum
● Bleeding can occur either in the
upper or lower gastrointestinal tract
2 Classifications of GI bleeding:
1. Upper GI bleeding - this includes
the
esophagus, stomach and first part of
the small intestine
Further classified into 2 types:
1.1 Variceal bleeding - refers to the
bleeding of varices all throughout the GIT
such as in the esophagus, stomach, and
rectum.
1.2 Non-variceal bleeding - is
caused by an etiology of the UGIB other
than varices, bleeding proximal to the
ligament of treitz
● Varices - are veins that are enlarged
and swollen
2. Lower GI bleeding - includes much
of the small intestine, large intestine
or bowels, rectum and anus
Three types of Gastrointestinal Bleeding
1. Acute - sudden or overt
gastrointestinal bleeding is visible in
the form of hematemesis, melena or
hematochezia
2. Chronic or occult gastrointestinal
bleeding is not apparent to the
patient and usually presents as
positive fecal occult blood or iron
deficiency anemia.
3. Obscure is defined as recurrent or
persistent GIT bleeding from a
source that cannot be identified
using upper and lower endoscopy,
also known as GIT disease of
unknown cause.
○ EX: Small bowel tumor
● Signs and symptoms of GI bleeding
can be either obvious (overt) or
hidden (occult).
● It depends on the location of the
bleed, which can be anywhere on
the GI tract, from the mouth – to the
anus – and the rate of bleeding.
● Overt bleeding might show up as:
○ Vomiting blood, which might be
red or might be dark brown and
resemble coffee grounds in
texture
○ Black, tarry stool
○ Hematochezia/Rectal bleeding,
bright red blood usually in or
with stool
● Occult bleeding, you might have:
○ Hypotension and
Lightheadedness - d/t low BP
reading of 90/60 mmHg
○ Difficulty breathing
○ Fainting
○ Chest pain
○ Abdominal pain/cramps - d/t
gas, bloating or constipation
● Other Signs & Symptoms:
○ Febrile episodes - temp. Above
37.5 degrees Celsius
○ Dehydration
● Upper GI bleeding, causes can
include:
○ Peptic Ulcer. This is the most
common cause of upper GI
bleeding. Peptic ulcers are
sores that develop on the lining
of the stomach and upper
portion of the small intestine.
Stomach acid, either from
bacteria or use of
anti-inflammatory drugs,
damages the lining, leading to
formation of sores.

○ This may lead to bleeding,
perforation, or other
emergencies.
○ Tears in the lining of the tube
that connects your throat to
your stomach (esophagus)
known as Mallory-Weiss
Tears, can cause a lot of
bleeding. These are most
common in people who drink
alcohol to excess.
○ It is a tear in the mucosal layer
at the junction of the esophagus
and stomach.
○ Abnormal, enlarged veins in the
esophagus (esophageal
varices). This condition most
often occurs in people with
serious liver disease.
○ Esophagitis. This inflammation
of the esophagus is most
commonly caused by
gastroesophageal reflux
disease (GERD).
○ Gastritis. Inflammation on the
lining of the stomach. Leads to
damage of the stomach lining.
● Lower GI bleeding, causes can
include:
○ Diverticular disease.This
involves the development of
small bulging pouches in the
digestive tract (diverticulosis). If
one or more of the pouches
become inflamed or infected it's
called diverticulitis.
○ Inflammatory bowel disease
(IBD). This includes ulcerative
colitis which causes
inflammation and sores in the
colon and rectum, and crohn's
disease, and inflammation of
the lining of the digestive tract.
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● Tumors. Noncancerous (benign) or
cancerous tumors of the esophagus
stomach, colon or rectum can
weaken the lining of the digestive
tract and cause bleeding .
● Colon Polyps. Small clumps of cells
that form on the lining of your colon
can cause bleeding. Most are
harmless, but some might be
cancerous or become cancerous if
not removed.
● Hemorrhoids. These are swollen
veins in your anus or lower
rectum,similar to varicose veins.
● Anal Fissures. These are small
tears in the lining of the anus.
● Proctitis. Inflammation of the lining
of the rectum can cause rectal
bleeding.
COMPLICATIONS
● A gastrointestinal bleed can cause:
○ Shock
○ Anemia
○ Death
Symptoms of SHOCK
● If your bleeding starts abruptly and
progresses rapidly you could go into
shock signs and symptoms of shock
include:
○ drop in blood pressure
○ not urinating or urinating
infrequently, in small amounts
○ rapid pulse
○ Unconsciousness
● Lab tests to help diagnose the
cause of your GI bleeding include
stool tests to detect bleeding and
blood tests to detect whether you
have anemia.
● Endoscopy. This procedure
involves a doctor examining a hollow
passage in your body using a
special instrument. An endoscopy
procedure may help your doctor see

if and where you have GI bleeding
and the bleeding cause. Doctors
most often use upper GI endoscopy
and colonoscopy to test for acute GI
bleeding in the upper and lower GI
tracts.
IMAGING TESTS:
● Abdominal CT scan. An abdominal
computerized tomography (CT) scan
uses a combination of x-rays and
computer technology to create
images of your GI tract. An x-ray
technician performs the procedure in
an outpatient center or a hospital. A
radiologist reads and reports on the
images.
● Angiogram. It is a special kind of
x-ray in which a radiologist threads a
catheter through your large arteries.
The radiologist performs the
procedure and interprets the image
in a hospital or an outpatient center.
You may receive a light sedative to
help you stay relaxed and
comfortable during the procedure.
DIAGNOSIS:
● Ineffective tissue perfusion related to
active GI bleeding
● Fluid volume deficit related to fluid
volume loss secondary to GI
bleeding
● Acute pain related to abdominal
muscle spasm
● Fatigue related to low hemoglobin
level secondary to GI bleeding
● Anxiety related to deficient
knowledge of disease condition
PREVENTION:
● Limit your use of non-steroidal
anti-inflammatory drugs (NSAIDS)
it increases the risk of ulcers and GI
bleeding and take aspirin only when
necessary.
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● Limit your use of alcohol; it can
cause ulcers and esophageal
varices.
● If you smoke, quit - contains
nicotine and chemicals that can
cause ulcers.
● Getting treatment to keep
symptoms of GI conditions, like
diverticulitis under control.
● Checking for infections like
helicobacter pylori, which causes
ulcers.
● Reducing stress, which may
involve relaxation techniques, like
deep breathing.
● Maintaining an active lifestyle and
balanced diet, so you can achieve a
healthy weight.
PLANNING:
● Administering volume replacement
● Controlling the bleeding
● Maintaining surveillance for
complication
● Administering fluids, insulin, and
electrolytes
● Monitor response to therapy
● Survey for complications
● Normalize body temperature
● Patient education on rest, diet,
cessation from drinking of alcohol or
smoking, and seeking care if
symptoms return
TREATMENT FOR GI BLEEDING:
● Secure airway if needed - if with
active upper GI bleeding it can
cause aspiration of blood with
subsequent respiratory compromise,
endotracheal intubation should be
considered in patients who have
inadequate gag reflexes or are
unconscious.
● IV fluid resuscitation - healthy
adults are given normal saline IV in
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500 to 1,000 ml until signs of ○1-2 ml in lower GI bleeding

hypovolemia. ○ Endoscopic hemoclips -
● Blood transfusion if needed - application of hemoclips to control
packed RBCs, check hematocrit nonvariceal bleeding in the upper
level GIT.
○ men - 41 to 50% ○ Angiographic embolization - in
○ women - 36 to 48% arterial GI bleeding can be
● Platelet count should be controlled by selective
monitored closely. embolization of the bleeding
○ Patients who are taking artery with coils or particulate
antiplatelet/ anticoagulant matter, selective arterial infusion
drugs (clopidogrel, aspirin) of vasoconstrictive drugs, or by a
have platelet dysfunction, often combination of these techniques.
resulting in increased bleeding. ○ Electrocautery - heat treating
○ Acute or chronic bleeding of using a heat probe used to stop
internal hemorrhoids stop bleeding.
spontaneously in most cases. ○ Hemostatic spray - used to stop
DRUGS/MEDICATIONS: rapid bleeding.
● IV proton pump inhibitors should ■ It works by coming in
be started (omeprazole contact with an actively
/pantoprazole) inhibits acid secretion bleeding site then it
and prevents recurrent bleeding. absorbs water and acts
● H2 blocker (histamine H2-receptor both cohesively and
antagonists) - used as prophylaxis adhesively forming a
to treat stress ulcers. Esophagitis, mechanical barrier over the
gastritis, GIT hemorrhage or urticaria bleeding site. Hemospray
and prevent their return. does not affect the clotting
○ EX: Ranitidine (Zantac), cascade.
Cimetidine (Tagamit), NURSING INTERVENTIONS:
Famotidine (Pepsid). ● Independent Nursing Intervention
● Vasoconstrictor - are often used as ○ Assess and monitor color and
first-line therapy for acute characteristics of vomitus and
esophageal variceal hemorrhage or stool.
after endoscopic therapy to prevent ○ Monitor vital signs and compare
early rebleeding. them with baseline vital signs.
● Epinephrine - used in lower GIT ○ Monitor intake and output -
bleeding causing vasoconstriction. observe for weight changes.
OTHER MEDICAL/SURGICAL ○ Schedule rest and activity,
TREATMENTS: allowing clients to have an
● Endoscopic therapies: uninterrupted schedule of nap
○ Injection sclerotherapy - and sleep time.
endoscopic injection of ● Dependent and Collaborative
epinephrine reduces blood flow ○ Monitor laboratory studies.
○ 15-20 ml for upper GI bleeding

○ Assist in insertion of nasogastric
lavage - used to remove food
residue, blood clots from the
stomach to facilitate endoscopy.
○ Administer fluids, blood, and
electrolytes as prescribed.
○ Prepare clients for endoscopy
or surgery and collaborate with
an interdisciplinary team to
create a plan of care.
CLIENT EDUCATION/HEALTH
TEACHINGS:
● Educate patients and family for signs
and symptoms of GI bleeding and
inform them to seek help
immediately.
● Encourage adequate rest and sleep
and scheduled activities.
● Instruct patients to follow a special
diet, avoid or limit caffeine and spicy
food, avoid food that causes
heartburn, nausea or diarrhea.
Eating small meals more often while
the digestive system heals.
● Teach patients on different
nonpharmacologic treatments to
relieve pain like deep breathing
exercises, providing the diversional
activities to reduce stress levels.
● Discuss with the patient in modifying
activities or lifestyle changes to
further avoid complications and
bleeding.
PANCREATITIS
PANCREAS
● An organ and a gland.
● The pancreas performs two main
functions:
○ Exocrine function: produces
substances as (enzymes) that
help with digestion.
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○ Endocrine function: sends out
hormones that control the
amount of sugar in your
bloodstream.
● Your pancreas releases the following
enzymes:
○ Lipase: works with bile (a fluid
produced by the liver) to break
down fats.
○ Amylase: breaks down
carbohydrates for energy.
○ Protease: breaks down
proteins.
● The endocrine glands in your
pancreas release hormones that
control blood sugar (glucose). These
hormones are:
○ Insulin: reduces high blood
sugar levels ,produced by the
beta cells.
○ Glucagon: increases low blood
sugar levels, produced by the
alpha cells.
PANCREATITIS
● Inflammation of the pancreas.
● The pancreas is a large organ
located in the upper abdomen and
behind the stomach, it plays a very
important role in digestion as well as
in controlling blood sugar.
● A normal pancreas secretes
digestive enzymes that do not
become active until they reach the
small intestine. However, when the
pancreas becomes inflamed the
digestive enzymes begin to attack
the pancreas itself commonly
described as auto digestion of the
pancreas.
● It can be acute or chronic in nature.
● It may be caused by edema necrosis
or hemorrhage.

● In men this disease is commonly
associated with alcoholism, peptic
ulcer or trauma.
● In women it's associated with biliary
tract disease.
CLASSIFICATION:
1. Acute Pancreatitis
● Occur suddenly as one
attack or can be recurrent
with, resolves within a week.
● Acute pancreatitis does not
usually lead to chronic
pancreatitis unless
complication develops.
● Inflamed pancreas and
gallstones block the
pancreatic duct.
2. Chronic Pancreatitis
● An inflammatory disorder
characterized by progressive
destruction of the pancreas,
with scar tissue replacing
pancreatic tissue.
● Inflamed pancreas,
gallbladder with stones, and
gallstones and calcification in
dilated pancreatic duct.
PATHOPHYSIOLOGY
● Self-digestion of the pancreas
caused by its own proteolytic
enzymes, particularly trypsin, causes
acute pancreatitis.
○ Entrapment. Gallstones
enter the common bile duct
and lodge at the ampulla of
vater.
○ Obstruction. The gallstones
obstruct the flow of
pancreatic juice or cause
reflux of bile from the
common bile duct into the
pancreatic duct.
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○ Activation. The powerful
enzymes within the pancreas
are activated.
○ Inactivity. Normally, these
enzymes remain in inactive
form until the pancreatic
secretions reach the lumen
of the duodenum.
○ Enzyme activities.
Activation of enzymes can
lead to vasodilation,
increased vascular
permeability, necrosis
erosion, and hemorrhage.
○ Reflux. These enzymes
enter the bile duc,t where
they are activated and
together with bile, backup
into the pancreatic duct,
causing pancreatitis.
CAUSES:
● Mechanisms causing pancreatitis
are usually unknown but it is
commonly associated with
autodigestion of the pancreas.
○ Alcohol abuse. 80% of the
patients with pancreatitis
have biliary tract disease or a
history of long-term alcohol
abuse.
○ Bacterial or viral infection.
Pancreatitis occasionally
developed as a complication
of mumps virus.
○ Duodenitis. Spasm and
edema of the ampulla of
vater can probably cause
pancreatitis.
○ Medications. The use of
corticosteroids, thiazide
diuretics, oral contraceptives,
and other medications have
been associated with

increased incidences of
pancreatitis.
SIGNS & SYMPTOMS
● Severe Abdominal pain. Abdominal
pain is the major symptom of
pancreatitis that causes the patient
to seek medical care and this results
from irritation and edema of the
inflamed pancreas.
● Boardlike abdomen. A rigid or
brown like abdomen may develop
and cause abdominal guarding
● Ecchymosis. Ecchymosis or
bruising in the flank or around the
umbilicus may indicate severe
pancreatitis.
● Nausea and vomiting. Both are
also common in pancreatitis and the
emesis is usually gastric in origin but
may also be bile stained.
● Hypotension. It is typical and reflex
hypovolemia and shock caused by
the large amounts of protein-rich
fluid into the tissue and peritoneal
cavity.
COMPLICATIONS
● Fluid and electrolyte
disturbances. These are common
complications because of nausea,
vomiting, movement of fluid from the
vascular compartment to the
peritoneal cavity, diaphoresis, fever,
and use of gastric suction
● Pancreatic necrosis. This is a
major cause of morbidity and
mortality in patients with pancreatitis
because of resulting hemorrhage,
septic shock, and multiple organ
failure.
● Septic shock. It may occur with
bacterial infection of the pancreas.
DIAGNOSTIC PROCEDURES
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● Abdominal ultrasound: an
ultrasound will indicate whether the
pancreas is swollen or inflamed.
● Magnetic resonance imaging
(MRI) scan: this can help rule out
other causes of abdominal pain.
● Computed tomography (CT) scan:
may also be used to help rule out
other causes of abdominal pain.
● Endoscopic retrograde
cholangiopancreatography
(ERCP): a test that combines
fluoroscopy (x-ray technique) with
flexible endoscopy.
ASSESSMENT: ACUTE PANCREATITIS
● Abdominal pain, sudden onset at
mid epigastric or left upper quadrant
location with radiation to the back
● Pain aggravated by a fatty meal,
alcohol or lying in recumbent
position
● Abdominal tenderness and guarding
behavior
● Nausea and vomiting
● Weight loss
● Absent or decreased bowel sounds
● Elevated white blood cell count
● Elevated bilirubin - elevation is
common (may be caused by
alcoholic liver disease or
compression of common bile duct).
● Elevated serum lipase and amylase
levels - increased because of
obstruction of normal outflow of
pancreatic enzymes.
● Alkaline phosphatase - usually
elevated if pancreatitis is
accompanied by biliary disease
period.
● Urinary amylase levels - can
increase dramatically within 2 to 3
days after onset of attack .

● Cullen’s sign - discoloration of the
abdomen and periumbilical area
period
● Turner’s sign - bluish discoloration
of the flanks
ASSESSMENT: CHRONIC PANCREATITIS
● Abdominal pain and tenderness
● Left upper quadrant mass
● Steatorrhea and foul - smelling
stools that may increase in volume
as pancreatic insufficiency increases
● Weight loss
● Muscle wasting
● Jaundice
● S&S of diabetes mellitus
DIAGNOSIS
● Acute pain related to edema,
distention of the pancreas, and
peritoneal irritation.
● Imbalanced nutrition: less than body
requirements related to inadequate
dietary intake, impaired pancreatic
secretion, and increased nutritional
needs.
● Ineffective breathing pattern related
to splinting from severe pain,
pulmonary infiltrates, pleural
effusion, and atelectasis.
PLANNING
● Relief of pain and discomfort.
● Improvement in nutritional status.
● Improvement in respiratory function.
● Improvement in fluid and electrolyte
status.
INTERVENTIONS: ACUTE
PANCREATITIS
● Withhold food and fluid during the
acute period and maintain hydration
with IV fluids as prescribed.
● Administer parenteral nutrition for
severe nutritional depletion.
● Administer vitamins and minerals to
increase caloric intake as
prescribed.
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● A nasogastric tube may be inserted
if the client is vomiting or has biliary
obstruction or paralytic ileus.
● Instruct the client in the importance
of avoiding alcohol.
● Administer H2-receptor antagonist
or proton pump inhibitors to
decrease hydrochloric acid
production.
● Administer Opiates as prescribed
for pain (Morphine).
INTERVENTIONS:CHRONIC
PANCREATITIS
● Instruct patients to limit intake of fat
and protein.
● Instruct clients to avoid heavy meals.
● Instruct clients the importance of
avoiding alcohol.
● Provide vitamins and minerals to
increase caloric intake.
● Administer pancreatic enzymes
medications (Creaon, Pancreaze,
Zenpep) as prescribed to aid in the
digestion and absorption of fat and
protein
SURGICAL MANAGEMENT
● Side-to-side pancreatic
jejunostomy (ductal drainage).
Indicated when dilation of pancreatic
ducts is associated with septa and
calculi. This is the most successful
procedure with a success rate
ranging from 60 to 90%.
● Caudal pancreatic jejonostomy
(ductal drainage). Indicated for
uncommon causes of proximal
pancreatic ductal stenosis not
involving the ampulla.
● Pancreaticoduodenal (right-sided)
resection (ablative) (with
preservation of the pylorus)
(Whipple procedure). Indicated
when major changes are confined to
the head of the pancreas.

Preservation of the pylorus avoids
usual sequelae of gastric resection.
● Pancreatic surgery. A patient who
undergoes pancreatic surgery may
have multiple drains in place
post-operatively, as well as a
surgical incision that is left open for
irrigation and repacking every 2 to 3
days to remove necrotic debris.
EVALUATION OF CARE
GOAL MET:
● Relieved pain and discomfort.
● Improved nutritional status.
● Improved respiratory function.
● Improved fluid and electrolyte status.
FUNCTION OF THE LIVER
LIVER FAILURE
LIVER
● It is the largest solid organ in the
body
● Which consists of 4 lobes, which are
made up of eight sections and
thousands of lobules (small lobes)
● It is reddish-brown and shaped like a
cone or a wedge, with the small end
above the spleen and stomach and
the large end above the small
intestine.
● The entire organ is located below
the lungs in the right upper
abdomen.
● It weighs between 3 - 3.5 pounds
PARTS OF THE LIVER
● Common Hepatic Duct: a tube that
carries bile out of the liver. It is
formed from the intersection of the
right and left hepatic ducts.
● Falciform Ligament: a thin, fibrous
ligament that separates the two
lobes of the liver and connects it to
the abdominal wall.
● Glisson’s Capsule: a layer of loose
connective tissue that surrounds the
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liver and its related arteries and
ducts.
● Hepatic Artery: the main blood
vessel that supplies the liver with
oxygenated blood.
● Hepatic Portal Vein: the blood
vessel that carries blood from the
gastrointestinal tract, gallbladder,
pancreas, and spleen to the liver.
● Lobes: the anatomical sections of
the liver.
● Lobules: microscopic building
blocks of the liver.
● Peritoneum: a membrane covering
the liver that forms the exterior.
● Albumin Production: it is a protein
that keeps fluid in the bloodstream
from leaking into surrounding
tissues; it also carries hormones,
vitamins, and enzymes through the
body.
● Bile Production: bile is a fluid that
is critical to the digestion and
absorption of fats in the small
intestine.
● Filters Blood: all the blood leaving
the stomach and intestines passes
through the liver, which removes
toxins, by-products, and other
harmful substances, such as alcohol
and drugs.
● Regulates Amino Acids: the
production of protein depends on
amino acids. The liver makes sure
amino acid levels in the bloodstream
remain healthy.
● Regulates Blood Clotting: Blood
clotting coagulants are created using
vitamin k which can only be
absorbed with the help of bile, a fluid
the liver produces.
● Resists Infections: as part of the
filtering process, the liver also

removes bacteria from the
bloodstream.
● Stores vitamins and minerals: the
liver stores significant amounts of
vitamins A,D,E,K and B12, as well
as iron and copper.
● Processes Glucose: the liver
removes excess glucose or sugar
from the bloodstream and stores it
as glycogen. As needed, it can
convert glycogen back into glucose.
IMPORTANT NOTES
● Liver Failure can be a entirely
life-threatening emergency.
● It can be acute or chronic.
● Liver failure is when the liver loses
some or all of its functionality, occurs
through damage that is caused by
liver disease.
● Liver disease refers to any condition
that causes inflammation or damage
to your liver. Damage occurs in
several stages.
STAGES OF LIVER FAILURE
● Inflammation. In this early stage,
the liver is enlarged or inflamed. If
the inflammation continues,
permanent damage can occur.
○ Increase liver d/t fat deposits
● Fibrosis. Scar tissue begins to
replace healthy tissues in the
inflamed liver, but scarred tissue
cannot perform the same functions.
○ Formation of scar tissue
within the liver
● Cirrhosis. Severe scarring has built
up, making it difficult for the liver to
function properly.
○ Scarred tissue replaces
healthy tissue in the liver
● Liver cancer. The development and
multiplication of unhealthy cells in
the liver can occur at any stage of
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liver failure, although people with
cirrhosis are more at risk.
○ Formation of malignant tumor
in the liver
● End-stage liver disease (ESLD).
The liver function has deteriorated,
with associated complications such
as ascites and hepatic liver
encephalopathy, to the point where
the damage cannot be reversed
other than with a liver transplant.
○ Liver function has ceased
SYMPTOMS OF LIVER FAILURE
● Unexpected weight loss
● Abdominal pain or swelling
● Loss of appetite or feeling full after
eating a small amount of food
● Nausea or Vomiting
● Yellowing of the skin and eyes
(jaundice)
● Skin itching
TYPES OF LIVER FAILURE
1. Acute Liver Failure
● ALF occurs rapidly, cause may be
d/t a variety of things or unknown.
● Possible causes include:
○ Viral infections, such as Hep
A, B or E
○ Overdose of Acetaminophen
(Tylenol)
○ Reactions to prescription
medications such as
antibiotics, NSAIDS, or anti
-epileptic drugs
○ Reaction to herbal
supplements.
○ Metabolic conditions, such as
Wilson’s disease (a rare
inherited disorder that
causes copper to accumulate
in the liver, brain and other
vital organs).

○ Autoimmune conditions such
as Autoimmune hepatitis
(occur when the body's
immune system which
normally attacks viruses,
bacteria, and pathogens
instead attack the liver).
○ Conditions that affect the
veins of the liver, such as
Budd-Chiari syndrome
(hepatic veins are blocked or
narrowed by a blood clot).
○ Exposure to toxins, such as
those found in industrial
chemical or poisonous wild
mushrooms.
SYMPTOMS:
● Body malaise
● Feeling tired and sleepiness
● Nausea or vomiting
● Right upper abdominal pain
● Ascites (swollen belly)
● Jaundice (skin & eyes)
● Confusion or disorientation
● Breath may be musty or sweet odor
● Tremors
❖ Fulminant hepatic failure is
used to describe the
development of
encephalopathy within 8 wks.
of the onset of symptoms in
patients with previously
healthy liver.
❖ Subfulminant hepatic
failure reserved for patients
with liver disease for up to 26
wks. before the development
of hepatic encephalopathy.
2. Chronic Liver Failure
● Occurs d/t liver damage that
develops slowly over time
● This leads to cirrhosis, in which the
large amount of scar tissue on the
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liver prevent the organ from
functioning properly
CAUSES:
● Chronic hep B or C infection
● Alcohol-related liver disease
● Nonalcoholic fatty liver disease
● Autoimmune hepatitis
● Disease that affect the bile ducts,
such as Cholangitis
SYMPTOMS:
● Early S/S
○ Fatigue
○ Loss of appetite
○ Nausea or vomiting
○ Mild abdominal discomfort or
pain
● Advance Stage S/S
○ Jaundice
○ Easy bruising or bleeding
○ Confusion or disorientation
○ Build-up of fluid in the
abdomen, arms and or legs
(Ascites, Edema)
○ Darkening color of the urine
○ Severe skin itching
DIAGNOSING LIVER FAILURE:
● Liver blood test. Assess the levels
of various proteins and enzymes in
the blood that indicate liver function.
● Complete blood count. Test for
viral hepatitis or genetic condition
that causes liver damage.
● Imaging test : ultrasound, CT scan,
MRI scan - helps to visualize the
liver
● Biopsy. Taking a tissue sample from
the liver to see if scar tissue is
present.
TREATMENT:
● Antiviral medications - used to
treat a viral hepatitis infection.
● Immune suppressing medications
- given to treat autoimmune
hepatitis.

● Lifestyle changes - abstaining from
alcohol, losing weight, avoiding
taking certain medications.
● Liver transplant - for severe
cirrhosis coming from a healthy
donor.
MAINTAINING A HEALTHY LIVER:
● Avoid Illicit drugs - these are toxins
that the liver must filter out, taking
these drugs can cause long-term
damage.
● Drink alcohol moderately - ecchymosis, bleeding from one or
excessive use can cause liver
damage.
● Exercise regularly - this routine
helps promote general health for the
liver.
● Eat healthy foods - avoid fatty
foods which can make it difficult for
the liver to function and lead to fatty
liver disease.
● Practice safe sex - use protection
to avoid sexually transmitted
diseases such as hepatitis C.
● Vaccine - get vaccination against
Hep A & B
NURSING DIAGNOSIS:
● Ineffective Breathing Pattern
● Fluid volume excess
● Imbalanced nutrition: less than body
requirements
● Risk for impaired skin integrity
● Risk for injury
● Disturbed body image
NURSING INTERVENTIONS:
● Auscultate breath sounds - crackles,
wheezes, rhonchi
● Note rate & depth of respirations
● Elevate head of the bed at least 30%
● Deep breathing exercises
● Coughing exercises
● Monitor ABG and O2 saturation
● Change to position of comfort
12
● Provide supplemental oxygen as
ordered by physician
● Monitor intake & output
● Measure abdominal girth - Ascites
● Monitor serum albumin and
electrolytes - edema, use of diuretics
● Give medications such as
Loop-diuretics, Aldosterone receptor
antagonist, Potassium Positive
Inotropic drugs and Vasodilators.
● Observe the presence of petechiae,
more sites - d/t altered clotting
factors in the blood like prothrombin,
fibrinogen, etc.
● Inspect skin for dryness, break, &
wounds.
● Use calamine lotion, baking soda
baths or give antihistamine as
needed.
● Use emollient lotions to massage
bony prominences.
● Utilize alternating mattresses such
as egg-crate mattresses.
● Monitor patient’s daily calorie intake
● Weigh the patient daily.
● Encourage them to eat small,
frequent meals as tolerated.
● Assist patients to cope with
biophysical changes, suggest
clothing choices that do not focus on
altered appearance.
CLIENT EDUCATION:
● Eat a healthy diet, low sodium, low
fat.
● Have adequate fluid intake, or limit if
fluid retention is manifested.
● Cessation of alcohol intake.
● Maintain a healthy weight.
● Follow instructions on medication
regimen.
● Avoid contact with other people’s
blood and body fluids.
● Avoid infections.
 13

EVALUATION OF CARE ● SIGNS & SYMPTOMS

GOAL MET: ○ It usually develops slowly.
● Absence of edema. Early symptoms include:
● Maintained efficient breathing - Being very thirsty.
pattern, and have satisfactory ABG - Urinating a lot more
and O2 saturation readings. than usual.
● Normal fluid volume is maintained. ○ If untreated, more severe
● Maintained vital signs at normal symptoms can appear
levels. quickly, such as:
● Client expresses understanding of - Fast, deep breathing
disease conditions and lifestyle - Dry skin & mouth
modification and takes part in the - Flushed face
care. - Fruity - smelling breath
● Determine coping mechanisms for - Headache
negative self-perception. - Muscle stiffness or
aches
- Being very tired
DIABETIC KETOACIDOSIS - Nausea & vomiting
- Stomach pain
● Is a serious complication of diabetes ● CAUSES
that can be life-threatening. ○ Very high blood sugar & low
● DKA is most common among people insulin levels lead to DKA.
with type 1 diabetes. People with The two most common
type 2 diabetes can also develop causes are:
DKA. - Illness. When you get
● It develops when your body doesn’t sick,
have enough insulin to allow blood - Missing insulin shots, a
sugar into your cells for use as clogged
energy. ○ Other causes include:
● Insulin plays a key role in helping - Heart attack or stroke
sugar - a major source of energy - Physical injury, such as
and other tissue to enter cells in the from a car accident.
body. - Alcohol/drug use.
● Without enough insulin, the body - Certain medications,
begins to break down fat as fuel. such as some diuretics
This causes a buildup of acids in the (water pills) and
bloodstream called ketones. If left corticosteroids (used to
untreated, it builds up to dangerous treat inflammation in
levels in the body and can lead to the body).
diabetic ketoacidosis.
● Sometimes DKA is the 1st sign of TEST FOR KETONES
diabetes in people who have not ● Anytime you're sick or your blood
been diagnosed yet. sugar is 240 mg/dL or above, use an
ASSESSMENT over-the-counter ketone test kit to

check your urine or a meter to test
your blood for ketones every 4 to 6
hours.
● You should also test for ketones if
you have any symptoms of DKA.
● Call your doctor if your ketones are
moderate or high. Elevated ketones
are a sign of DKA which is a medical
emergency and needs to be treated
immediately.
● Go to the emergency room right
away if you can't get in touch with
your doctor and experiencing any of
the following:
○ Your blood sugar stays at
300 mg/dL or above.
○ Your breath smells fruity.
○ You are vomiting and can't
keep food or drinks down
○ You're having trouble
breathing.
○ You have multiple signs and
symptoms of dka.
Result of your ketone:
● Negative: reduce carbohydrate
intake or increase exercise.
● Trace/small/moderate: your health
is satisfactory and you’re burning
fats.
- Trace: 0.5 mmol/L
- Small: 1.5 mmol/L
- Moderate: 4.0 mmol/L
- Large: 8.0 - 16 mmol/L
TREATMENT
● Replacing fluids you lost through
frequent urination and to help dilute
excess sugar in your blood.
● Replacing electrolytes such as
sodium, potassium and chloride
(minerals in your body that help your
nerves, muscles, heart, and brain to
work the way they should). Too little
insulin can lower your electrolyte
levels.
14
● Receiving insulin. Insulin reverses
the condition that causes it in DKA.
● Taking medicine for any underlying
illness that causes DKA, such as
antibiotics for an infection.
PREVENTION
● Check your blood sugar often,
especially if you are sick.
● Keep your blood sugar levels in your
target range as much as possible.
● Take medicines as prescribed even
if you feel fine.
● Talk to your doctor about how to
adjust your insulin based on what
you eat, how active you are, or if
you're sick.
NURSING DIAGNOSIS
● Risk for unstable blood glucose level
● Risk for fluid volume deficit
● Risk for infection
● Deficient knowledge
● Imbalanced nutrition: less than body
requirements
❖ Related to:
➢ Lack of diabetic diagnosis
➢ Poor diabetes management
➢ Illness causing unstable
glucose levels
➢ Nonadherence to insulin
regimen
➢ Physical injury such as a
motor vehicle accident
➢ Alcohol or drug use
INTERVENTIONS:
1. Observe the patient using their
glucometer.
- Have the patient
demonstrate using their
glucose monitoring device.
The nurse can also calibrate
devices to ensure accuracy.
2. Use a ketone test kit.
- Patients can be advised to
purchase over-the-counter

ketone testing kits. Patients
can test for ketones in their
urine when their blood sugar
is >240.
3. Educate on the causes of KDA.
- Provide education on
instances that affect insulin in
may lead to decay a such as
illnesses affecting fluid or
food and take alcohol intake
and medication
4. Coordinate with a diabetes
educator.
- These are usually nurses
trained to help patients
manage and understand their
diabetes and medications.
5. Assess skin turgor, mucous
membranes, and thirst.
- To provide baseline data for
further comparison. Skin
turgor will decrease and
tenting may occur. The oral
mucous membrane will
become dry and a client may
experience extreme thirst.
6. Monitor hourly I&O.
- Oliguria or anuria results
from reduced glomerular
filtration and renal blood flow.
7. Monitor BP especially for
orthostatic hypotension.
- Decreased blood volume
may be manifested by a drop
in systolic blood pressure
and orthostatic hypotension.
8. Monitor respirations, e.g., acetone
breath, Kussmaul’s respirations.
- Acetone breath is due to the
breakdown of acetoacetic
acid. Kussmaul’s respiration
(rapid and shallow breathing)
represents a compensatory
mechanism by the
15
respiratory buffing system to
raise arterial pH by excelling
more carbon dioxide.
9. Monitor temperature.
- Fever with flushed, dry skin
may indicate dehydration.
10. Monitor heart rate.
- Compensatory mechanism
results in a period for
vasoconstriction with a weak,
thready pulse that is easily
obliterated.
11. Assess neurological status every
two(2) hours.
- Decreased level of
consciousness results from
blood volume depletion,
elevated or decreased
glucose level, hypoxia or
electrolyte imbalances.
12. Weigh clients daily.
- Provides baseline data of
current fluid status and
adequacy of fluid
replacement. A weight loss of
2.2 lbs over 24 hours
indicates a 1 L of fluid loss.
13. Monitor ABG for metabolic
acidosis.
- Clients with DKA have
metabolic acidosis with
arterial bicarbonate level less
than 18 mEq/L and a pH less
than 7.30.
14. Insert indwelling urinary catheter
as indicated.
- To provide accurate
measurement of urinary
output especially for client
with neurogenic bladder
15. Administer IV potassium and
other electrolytes as indicated.
- Potassium is added to the IV
once serum potassium drops
 16

below 5.5 mEq/L to prevent - Continuation of IV

hypokalemia, the administration depends on
administration of insulin to the degree of fluid deficit,
lower blood glucose urinary output, and serum
promotes the movement of electrolyte values.
potassium intracellularly. 20. Add dextrose to IV fluid when
16. Administer bicarbonate as serum blood level is less than 250
indicated. mg/dL in DKA.
- This is given in clients with - Dextrose is added to prevent
severe hyperkalemia and the occurrence of
severe acidosis with ph of hypoglycemia and an
less than 7.1 excessive decline in plasma
17. Administer IV bolus dose of osmolality that can result in
regular insulin, followed by a cerebral edema.
continuous infusion of regular ● Blood glucose levels
insulin. - Diagnostic criteria: DKA =
- Regular insulin has a rapid blood glucose level greater
onset and therefore than 250 mg/dL.
immediately helps move ● Serum ketones
glucose intracellularly. IV - Elevated ketones are
route is the initial route associated with DKA.
because subcutaneous ● Potassium
injection of insulin may be - Initially, hyperkalemia occurs
absorbed unpredictably. in response to metabolic
While a continuous infusion acidosis. As the fluid volume
is an optimal way to deficit progresses,
consistently administer ● Sodium
insulin to prevent - Increased blood sugar
hypoglycemia. causes water to
18. Administer fluid as indicated : ● Blood urea nitrogen & creatinine
Isotonic solution (0.9% NaCl). - Elevated BUN and creatinine
- Initial goal of therapy is to indicate
correct circulatory fluid EVALUATION OF CARE:
volume deficit. Isotonic GOAL MET:
normal saline will rapidly ● Patient will verbalize factors causing
expand extracellular fluid unstable blood glucose
volume without causing a ● Patient will verbalize the correct
rapid fall in plasma administration of insulin
osmolality. Clients typically ● Patient will maintain blood glucose
need 2 - 3 L within the first 2 levels within an acceptable range
hours of treatment.
19. Administer succeeding IV
therapy : Hypotonic solution such
as 0.45% normal saline.

RENAL FAILURE
URINARY SYSTEM
● Kidneys.They filter your blood and
make urine, which your body
eliminates. The kidneys are a pair of
bean-shaped organs on either side
of your spine, below your ribs and
behind your belly. Each kidney is
about 4 or 5 in long, roughly the size
of a large fist.
● Ureters.This two thin tubes inside
your pelvis carry urine from your
kidneys to your bladder.
● Bladder. It holds urine until you’re
ready to empty it. It’s hollow, made
of muscles, and shaped like a
balloon. Your bladder expands as it
fills up. Most bladders can hold up to
2 cups of urine.
● Urethra. This tube carries urine from
your bladder out of your body. It
ends in an opening to the outside of
your body in the penis (in men) or in
front of the vagina (in women).
● The kidneys, ureters, bladder and
urethra make up the urinary system.
They all work together to filter, store
and remove liquid waste from your
body.
FUNCTION
● It filters your blood to get rid of what
your body doesn’t need. It eliminates
extra water and salt, toxins, and
other waste products. Different parts
of urinary system performs tasks
including:
○ Filtering blood
○ Separating the toxins you
don’t need from the nutrients
you do need.
○ Storing and carrying urine
out of your body.
17
● Your kidneys are an essential part of
filtering your blood. Here’s how the
urinary system works:
1. Your blood enters each
kidney through lots of little
arteries.
2. Your kidneys filter your blood,
separating toxins from
nutrients.
3. Vitamins, minerals, nutrients
and proteins return to your
bloodstream.
4. Waste products and urine
move through your ureters to
your bladder. Your bladder
stores urine until you use the
toilet.
5. Urine leaves your body
through your urethra.
URINE FORMATION
KEY:
A. Glomerular Filtration: water and
solutes smaller than proteins are
forced through the capillary walls
and pores of the glomerular capsule
into the renal tubule.
B. Tubular Filtration: water, glucose,
amino acids, and needed ions are
transported out of the filtrate into the
tubule cells & then enter the capillary
blood.
C. Tubular secretion: H+, K+,
creatinine, and drugs are removed
from the peritubular blood &
secreted by the tubule cells into the
filtrate.
ASSESSMENT
● NURSING HISTORY: Subjective
data
* Current Health Status
○ Urinary frequency and urgency
○ Pain on urination
○ Difficulty urinating

○ Flank pain (area on the sides
and back of your abdomen
between the lower ribs and
hips)
* Previous Health Status
○ Previous major and minor
illnesses
○ Accidents or injuries
○ Surgical procedures
○ Allergies - drugs, food or other
products
○ Urologic related disorders such
as hypertension
○ Sexual history - pain on
intercourse
○ Urinary tract infection
○ Taking of herbal medications or
prescription or recreational drugs
* Family history - ask if family
members or relatives have been
treated with renal or cardiovascular
disorders, diabetes, cancer or other
chronic illness.
Objective Data
● PHYSICAL EXAMINATION
○ Take the basal vital sign
○ Weigh the patient
○ Assess patient’s urine for color,
odor and clarity
● Inspection - examines client’s
abdomen & urethral meatus
● Auscultation - auscultate the renal
arteries (left & right upper abdominal
quadrants), listen for systolic bruits
(whooshing sounds) or other
unusual sounds.
● Percussion - percuss the kidneys to
detect any tenderness or pain and
percuss the bladder to evaluate
tympanic or dull sound (urine-filled
bladder).
● Palpation - palpate kidneys &
bladder to detect any lumps, masses
or tenderness.
18
● DIAGNOSTIC ASSESSMENT
○ Urinalysis: A routine test of the
urine by a machine and often by
a person looking through a
microscope. Urinalysis can help
detect infections, inflammation,
microscopic bleeding, & kidney
damage.
○ Blood Studies: Blood urea
nitrogen (BUN) and Serum
Creatinine.
■ BUN, urea, the chief product
of protein metabolism, is
formed from ammonia in the
liver, filtered by the glomeruli,
reabsorbed in the tubules
and excreted. Insufficient
urea excretion elevates the
BUN level.
■ Normal BUN ranges from
8-16 mg/dL.
■ Creatinine, another
nitrogenous waste, results
from muscle metabolism of
creatinine.
■ Normal serum creatinine
values for males from (0.8 to
1.2 mg/dL), and (0.6 to 1.1
mg/dL) for women.
■ Persistent renal impairment
causes creatinine levels to
rise, creatinine greater than
1.5 mg/dL indicates 66% or
greater loss renal function,
levels greater than 2 mg/dL
indicates renal insufficiency.
○ Kidney Ultrasound: a probe
placed on the skin reflects sound
waves off the kidneys, creating
images on a screen. Ultrasound
can reveal blockages in urine
flow, stones, cysts, or suspicious
masses in the kidneys.

○ Computed tomography (CT)
scan: a CT scanner takes a
series of X-rays, and a computer
creates detailed images of the
kidneys.
○ Magnetic resonance imaging
(MRI) scan: A scanner uses
radio waves in a magnetic field
to make high-resolution images
of the kidneys.
○ Urine and blood culture: if an
infection is suspected, cultures of
the blood and urine may identify
the bacteria responsible. This
can help target antibiotic therapy.
○ Ureteroscopy: an endoscope
(flexible tube with a camera on
its end) is passed through the
urethra into the bladder and
ureters. It generally cannot reach
the kidneys but can help treat
conditions that also affect the
ureters.
○ Kidney biopsy: Using a needle
inserted into the back, a small
piece of kidney tissue is
removed. Examining the kidney
tissue under a microscope may
help diagnose a kidney problem.
KIDNEY TREATMENTS
● Antibiotics:Kidney infections
caused by bacteria are treated with
antibiotics. Often, cultures of the
blood or urine can help guide the
choice of antibiotic therapy.
● Ciprofloxacin, Cefalexin,
Co-amoxiclav or Trimethoprim
○ Nephrostomy: A tube (catheter)
is placed through the skin into
the kidney. Urine then drains
directly from the kidney,
bypassing any blockages in urine
flow.
19
○Lithotripsy: Some kidney stones
may be shattered into small
pieces that can pass in the urine.
Most often, it is done by a
machine that projects ultrasound
shock waves through the body.
○ Nephrectomy: Surgery to
remove a kidney. It is performed
for kidney cancer or severe
kidney damage. The following
are the types of Nephrectomy:
■ Bilateral
■ Simple
■ Radical
■ Partial
○ Dialysis: artificial filtering of the
blood to replace the work that
damaged kidneys can’t do.
○ Hemodialysis: a person with
complete kidney failure is
connected to a dialysis machine,
which filters the blood and
returns it to the body. It is
typically done 3 days per week in
people with ESRD.
○ Peritoneal dialysis: placing
large amounts of a special fluid
in the abdomen through a
catheter allows the body to filter
the blood using the natural
membrane lining the abdomen.
After a while, the fluid with the
waste is drained and discarded.
○ Kidney transplant: transplanting
a kidney into a person with
ESRD can restore kidney
function. A kidney may be
transplanted from a living donor,
or from a recently deceased
organ donor.
NURSING DIAGNOSIS
● Deficient Fluid Volume
○ Associated with dialysis,
renal failure, ingestion of

large amounts of diuretics or
metabolic acidosis.
● Expected Outcomes:
○ Patient exhibits normal skin
color and temperature.
○ Patient produces adequate
urine volume.
○ Patient’s urine specific
gravity remains between 1.0
05 and 1.0 30.
● Nursing Interventions
○ Monitor vital signs every 2 or
4 hrs. until stable, monitor for
signs of tachycardia,
dyspnea, or hypotension.
- This indicates fluid
volume deficiency or
electrolyte imbalance.
○ Measure intake and output
every 1 to 4 hours. Record
and report significant
changes. Include urine,
stools, vomitus, wound
drainage, and any other
output. Low urine output and
high specific gravity indicate
hypovolemia.
○ Administer fluids, blood or
blood products, or plasma
expanders to replace fluids
and whole blood loss and to
promote fluid movement into
vascular space.
○ Weight the patient at the
same time daily to give more
accurate and consistent data.
Weight loss or gain is a good
indicator of fluid status.
○ Assess skin turgor and oral
mucous membrane every 8
hrs. to check for dehydration.
Give meticulous mount care
every 4 hours to avoid
20
dehydrating mucous
membranes.
● Excess Fluid Volume
○ Associated with
● Expected Outcomes:
○ Patient’s blood pressure is no
higher than 130/80 mmHg
patient demonstrates no signs of
hyperkalemia on ECG
○ Patient maintains fluid intake
● Nursing Interventions:
○ Monitor blood pressure, pulse
rate, cardiac rhythm,
temperature, and breath sound
once every 4 hours, changes
may indicate altered fluid or
electrolyte status.
○ Monitor intake and output and
urine specific gravity once every
4 hours, intake greater than
output and elevated specific
gravity indicate fluid retention or
overload.
○ Monitor BUN, creatinine,
electrolyte, ang hemoglobin (Hb)
levels as well as hematocrit
(HCT) - BUN and creatinine
levels indicate renal function.
Electrolyte Hb and HCT levels
reflect fluid status.
○ Weigh patients daily before
breakfast - check for signs of
fluid retention, such as edema,
sacral edema or Ascites.
○ Give fluids as ordered. Monitor
flow of IV fluids - in excess
worsens patients condition.
○ Help patients create a schedule
for fluid intake - if allowed.
○ Assess skin turgor to monitor
dehydration.
● Urge Urinary Incontinence
○ Associated with conditions as
acute bladder infection, bladder

obstruction and interstitial
cystitis.
● Expected Outcomes:
○ Patient has decreased frequency
of incontinence episodes
○ Patient states increase comfort
○ Patient demonstrates skill in
managing incontinence
● Nursing Interventions
○ Observe voiding patterns and
document intake and output to
ensure correct fluid replacement
therapy and provide information
about the patient's ability to void
adequately.
○ Unless contraindicated, maintain
fluid intake of 2 - 3 L/day to
moisten mucous membrane and
ensure hydration.
○ Explain condition to patient and
family and include instructions on
bladder schedule.
2 TYPES OF RENAL FAILURE
1. ACUTE RENAL FAILURE
● Is the sudden interruption of
kidney function from obstruction
reducing circulation or renal
parenchymatous disease.
● Reversible with treatment or
progress if untreated to
end-stage renal disease, uremic
syndrome or death.
● ARF may be classified as
prerenal, intrarenal and
postrenal.
PATHOPHYSIOLOGY
● Prerenal Failure - results from
conditions that damage blood
flow to the kidneys
(hypoperfusion).
○ When renal blood flow is
interrupted so is oxygen
supply, which results in
hypoxemia and ischemia &
21
irreversibly damage the
kidney.
○ Sudden and severe drop in
the blood pressure (shock)
or interruption of blood flow
to the kidneys from severe
injury or illness.
● Intrarenal Failure - results
from damage to the filtering
structures of the kidneys.
○ Causes of which are
classified as nephrotoxic,
inflammatory, or ischemic.
○ If caused by nephrotoxicity
or inflammation, the
delicate layer under the
epithelium (the basement
membrane) becomes
irreparably damaged,
typically leading to chronic
renal failure.
○ Severe or prolonged lack of
blood flow by ischemia may
lead to renal damage
(ischemic parenchymal
injury) & excess nitrogen in
the blood (intrinsic renal
azotemia).
○ Direct damage to the
kidneys by inflammation,
toxins, drugs, infection, or
reduced blood supply.
● Postrenal Failure - caused
by bilateral obstruction of
urine outflow.
○ This cause may be in the bladder,
ureters or urethra.
○ Sudden obstruction of urine flow
d/t enlarged prostate, kidney
stones, bladder tumor, or injury.
S&S OF ARF
● Oliguria (earliest sign)
● Anorexia
● Nausea & vomiting

● Diarrhea or Constipation
● Stomatitis
● GI bleeding
● Hematemesis
● Dry mucous membranes
● Uremic breath
● Hypotension
TREATMENT
● Major Goals of ARF:
○ To reestablish effective renal
function if possible.
○ To maintain the constancy of the
internal environment despite
transient renal failure.
● Supportive measures:
○ Diet high in calories, low protein,
low sodium, low potassium with
supplemental vitamins
restricted fluids.
○ Electrolyte monitoring
essential to detect hyperkalemia.
- If it occurs: dialysis,
- Sodium polystyrene
sulfonate (Kayexalate) can
be given
○ If these measures fail to control
uremic symptoms, hemodialysis
or peritoneal dialysis is required.
EVALUATION OF CARE
GOAL MET:
● Patient has no weight gain.
● Stable vital signs.
● Exhibits no complications or signs of
infection.
● Patient has normal blood values.
● Patients are prepared to follow a
high calorie, low protein, low sodium
and low potassium diet with vitamin
supplements.
● For anorectic patients, give small
frequent meals.
2. CHRONIC RENAL FAILURE
● The progressive loss of renal
function.
22
●75% of glomerular filtration is
lost.
● Remaining normal parenchyma
deteriorates progressively and
signs and symptoms are sent as
renal function decreases.
● If unchecked, uremic toxins
accumulate and cause changes
in all major organ systems.
● The estimated glomerular
filtration rate (eGFR) can be
calculated from the concentration
of creatinine in a blood sample to
estimate the volume of blood that
is filtered through the glomeruli in
the kidneys per minute.
● A healthy person typically has an
& eGFR greater than 90 mL/min.
● An eGFR that is less than this
is may be an indicator of impaired
kidney function.
5 STAGES OF CKD
● STAGE 1
○ 90 % kidney function
○ Most people may not experience
any symptoms. However, factors
such as abnormally high levels of
creatinine or urea in the blood,
blood in the urine or evidence of
kidney damage in an MRI, CT
scan or ultrasound could show
stage 1 CKD.
● STAGE 2
○ 60% to 89% kidney function
○ Patients may still be
symptom-free during stage 2, but
some people start having
problems with high blood
pressure
○ There are no specific symptoms
but kidney function can slowly
decline.
● STAGE 3
○ 40% to 59% kidney function

○ Symptoms such as fluid
retention, swelling of the
extremities, changes in urination
& kidney pain may appear during
stage 3.
● STAGE 4
○ 15% to 29% kidney function
○ It involves severely reduced
kidney function. During stage 4,
a person may develop
complications such as high blood
pressure, anemia, bone disease
or cardiovascular diseases.
○ Kidney function is very low &
treatment for kidney failure may
be needed soon.
● STAGE 5
○ Less than 15% kidney function
○ It is also referred to as end-stage
renal disease (ESRD). When a
patient's CKD has reached stage
5, his or her kidneys cannot
absolutely function without
dialysis or a kidney transplant.
○ Kidneys can no longer keep up
with removing waste products
and extra water. This is called
kidney failure. Although there is
no cure, treatment options are
available.
PATHOPHYSIOLOGY
● Nephron damage is progressive,
function diminishes.
● Healthy nephrons compensate for
damaged nephrons by enlarging and
increasing their clearance capacity.
● The kidneys can maintain normal
function until about 75% of the
nephrons are nonfunctional.
● Eventually, healthy glomeruli are
overburdened and become sclerotic
and stiff, leading to their destruction.
23
● If untreated, toxins accumulate and
produce fatal changes in all major
organ systems.
TREATMENT
● GOAL: To preserve existing kidney
function and to correct specific (early
treatment).
● Conservative measures, give a low -
protein diet to reduce the production
of end product of protein metabolism
that the kidneys cannot excrete.
● However, patients on continuous
peritoneal dialysis should have a
high - protein diet.
● High-calorie diet is provided to
prevent ketoacidosis and negative
nitrogen balance that results in
catabolism and tissue atrophy.
● Sodium and potassium are
restricted.
● To maintain fluid balance, monitor
vital signs and weight changes, and
urine output.
DRUG THERAPY
● Antipruritic-Diphenhydramine
(Benadryl) to relieve itching.
● Calcium carbonate - to lower serum
phosphate levels.
● Vitamin supplements (Vit. D & B)
and essential amino acids to relieve
deficiencies caused by inadequate
intake or loss during dialysis.
● Loop diuretics (Furosemide) along
with fluid restriction to reduce fluid
retention.
● Digoxin (Lanoxin) to mobilize edema
fluids.
● Antihypertensives to control blood
pressure and associated edema.
● Antiemetic taken before meals to
● Famotidine (Pepcid) to decrease
gastric irritation.
● Anemia - give iron and folate
supplements.
 24

● Epoetin alfa may be given to which is termed

increase RBC production.
MEDICAL & SURGICAL MANAGEMENT
● Peritoneal Dialysis
○ A cleansing fluid flows
through a tube (catheter) into
part of your abdomen. The
lining of your abdomen
(peritoneum) acts as a filter
and removes waste products
from your blood. After a set
period of time, the fluid with
the filtered waste products
flows out of your abdomen
and is discarded.
● Hemodialysis
○ A machine that filters waste,
salts and fluids from your
blood when your kidneys are
no longer healthy enough to
do this work adequately.
Hemodialysis is one way to
treat advanced kidney failure
and can help you carry on an
active life despite failing
kidneys.
● Continuous Renal Replacement
Therapy (CRRT)
○ It is a type of blood
purification therapy used with
patients who are
experiencing AKI.
○ During this therapy, a
patient's blood passes
through a specific filter that
removes fluid and uremic
toxins, returning clean blood
to the body.
○ The slow and continuous
nature of the process,
typically performed over a
24-hour period, allows
patients with unstable blood
pressure and heart rates,
hemodynamically unstable,
to better tolerate this
process.
○ CRRT is a slower type of
dialysis that puts less stress
on the heart.
○ Instead of doing it over 4
hours, CRRT is done 24
hours a day to slowly and
continuously clean out waste
products and fluid from the
patients.
○ It requires special
anticoagulation to keep the
dialysis circuit from clotting.
○ There are six medical
products required to perform
CRRT on a patient.
■ Blood purification
machine: the machine
pumps the blood,
controls the rate of blood
flow and includes
software to safely
monitor therapy delivery.
■ Dialysate: a fluid that
carries toxins away from
the filter.
■ Replacement fluid: a
specialized, sterile fluid
also used to flush toxins
from the body but also to
replace electrolytes,
other blood elements
and volume lost during
the filtration process.
■ Filter: machine
component that removes
fluid and uremic toxins.
■ Anticoagulation
method: a type of drug
that helps the blood flow
through the system,
 25

lessening the likelihood

that the blood will clot in
the filter.
■ Blood warmer:
efficiently maintains a
patient's blood
temperature during
blood purification.
INTERVENTION
● Provide a low protein diet and avoid
food high in sodium and potassium
and phosphate.
● Follow fluid restrictions as ordered.
● Provide electrolyte replacement.
● Prepare clients for dialysis or kidney
transplantation.
● For other interventions - the same
for acute renal failure.
EVALUATION
● Patients will verbalize understanding
of the disease process and medical
regimen.
● Exhibits no signs of complications,
with controlled signs and symptoms
by dialysis or transplantation.
● Patient has normal BUN, creatinine
and electrolyte levels.