RENAL DISORDERS

MJ H. GONZLES RN, MSN

3/20/2012

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Urinary Tract Infections (UTI)
 A. Upper urinary tract  B. Lower urinary tract infection

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 Urinary tract infections occur in an ascending route up the urinary tract system.

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 Upper urinary tract infectionsPyelonephritis - an inflammation of the renal pelvis and the parenchyma of the kidney.

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 Acute pyelonephritis often occurs after bacterial contamination of the urethra or following an invasive procedure of the urinary tract 3/20/2012 5 .

 Chronic pyelonephritis most commonly occurs following chronic obstruction with reflux or chronic disorders 3/20/2012 6 .

 B.inflammation of the ureter that is commonly associated with pyelonephritis  Chronic pyelonephritis causes the ureter to become fibrotic and narrowed by strictures 3/20/2012 7 . Ureteritis . Lower urinary tract infection.  1.

 2. 3/20/2012 8 .  3. Cystitis.inflammation of the urethra.inflammation or infection of the bladder. Urethritis.

and reflux of urine back into the original reservoir are the primary factors in causing UTI.Causes  Stasis of urine in the bladder. 3/20/2012 9 .

Adult female urethra is short. in close proximity to the rectum and vagina which predisposes it to contamination from fecal material.Factors contributing to UTI  a. 3/20/2012 10 .

Ureterovesical reflux--the reflux of urine from the urethra into the bladder. 3/20/2012 11 . b. This causes a constant residual of urine in the bladder after voiding and precipitates UTI.

 c. Vesicoureteral reflux (ureterovesical reflux)-the reflux of urine from the bladder into one or both of the ureters and possibly into the renal pelvis. 3/20/2012 12 .

Instrumentation . 3/20/2012 13 . Stasis of urine in the bladder leading to urinary retention for any reason (clients with prostate disease). d.catheterization or cystoscopic examination.  e.

ureteral stones. urethral strictures. Obstruction to urinary flow congenital anomalies. 3/20/2012 14 . or contracture of the bladder neck. f.

hormone changes predispose the pregnant woman to increased urinary tract infections. Bladder hypotonia. mechanical compression of the ureters. 3/20/2012 15 . g.

Fecal contamination of the urethral meatus. Sexual intercourse promotes development of UTI. Metabolic disorders such as diabetes.  i. 3/20/2012 16 .  j. h.

E.  d. Staphylococcus saprophyticus (11% in women).  b. coli (80 to 90 percent).Causative bacterial organisms  a. Proteus mirabilia. Pseudomonas aeruginosa 3/20/2012 17 .  c.

Microorganism Antigen/Antibody complexes Toxins Renal Dysfunction Urinary tract Etiology in Renal Disease Pathways to renal damage and dysfunction Microorganism 3/20/2012 18 .

Bacterial gain Access to blood Hematogenous PN Systemic Arteries

Kidney Ureter and Bladder Etiology of Pyelonephritis Urethra Ascending PN

Interstitial Microorganism
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Exogenous microorganism

Vaginal Microorganism
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Clinical manifestations
 Cystitis:  (1) Frequency and urgency.  (2) Suprapubic pain.  (3) Burning on urination.  (4) Hematuria  (5) Fever, chills and body malaise,  (6) Nausea, vomiting.
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 7. Voiding in small amounts  8. Inability to void  9. Incomplete emptying of the bladder  10. Lower abdominal discomfort or back discomfort  11. Cloudy, dark, foul-smelling urine  12. Bladder spasms
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Causes of Cystitis
 Allergens or irritants, such as soaps, sprays, bubble bath, perfumed sanitary napkins  Bladder distention  Calculus  Hormonal changes influencing alterations in vaginal flora

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 Indwelling urethral catheters  Invasive urinary tract procedures  Loss of bactericidal properties of prostatic secretions in the male  Poor-fitting diaphragms  Sexual intercourse 3/20/2012 23 .

    Synthetic underwear and pantyhose Urinary stasis Use of spermicides Wet bathing suits 3/20/2012 24 .

Pyelonephritis  (1) Fever. flank pain.  (4) Symptoms of cystitis. chills.  (2) Painful urination (dysuria). 3/20/2012 25 .  (3) Pain and tenderness at the costovertebral angle.

3/20/2012 26 .000.colony count of at least 100.colonies per ml of urine on a clean catch midstream or catheterized specimen indicates infection. and RBCs found in the urine. Urinalysis-pus.  b.Diagnostics  a. bacteria. Urine test for culture and sensitivity.

Acute pyelonephritis. 3/20/2012 27 .  (3) Intravenous pyelogramindicates enlargement of involved kidney and abscess into renal tissue.  (1) Elevated WBC count.  (2) Possible positive blood culture. c.

A lower urinary tract infection may result in an upper urinary tract infection.  b. Chronic pyelonephritis may occur after repeated bouts of acute pyelonephritis.Complications  a. 3/20/2012 28 .

Medical  2. Dietary 3/20/2012 29 .Treatment  1.

Nitrofurantoin 3/20/2012 30 . d. c.Medical       a. Sulfonamides. Urinary analgesics. b. Penicillins f. Antispasmodics. e. Urinary Antiseptics.

 (1) A diluted urine causes less irritation.Dietary  a. 3/20/2012 31 .  (2) The increase in flow of urine through the urinary tract system decreases the movement of bacteria up the urinary tract. Encourage fluid intake of 3.000 cc day.

 (3) Discourage carbonated beverages and foods or drinks containing baking powder or baking soda.  b. 3/20/2012 32 . An acid ash diet to increase the acidity of the urine.

dysuria. urgency.  2. and fever. Encourage eight to ten glasses of fluids daily.  1. Administer antimicrobial agent as prescribed. antibiotics need to he taken the entire course which is usually ten to fourteen days. 3/20/2012 33 .Nursing Intervention  Goal: to obtain relief of pain.

3/20/2012 34 . 3.  4. Teach importance of voiding every two to three hours during the day to completely empty the bladder. Sitz bath to decrease irritation of urethra.

If client prefers to take a tub bath she should avoid bubble bath additives. Goal: to prevent recurrence of infection. 3/20/2012 35 . Teach client to shower rather than bathe in tub.  1.

 2.  3. Explain importance of cleansing the perineal area from front to back after each bowel movement. 3/20/2012 36 . If intercourse seems to predispose to infection. encourage voiding immediately after intercourse.

 6. 4. Avoid caffeine and alcohol. 3/20/2012 37 . Teach importance of long-term antimicrobial therapy to prevent recurrences. Encourage and explain the need for follow-up care to prevent complications of chronic urinary tract infections.  5.

Prevention of Cystitis  Teach the female client good perineal care and to wipe from front to back  Instruct the female client to avoid bubble baths and tub  baths and avoid vaginal deodorants or sprays Instruct the client to void every 2 to 3 hours Instruct the female client to void and drink a glass of water after intercourse 3/20/2012 38 .

 Instruct the female client to wear cotton pants and to avoid wearing tight clothes or pantyhose with slacks. and to avoid sitting in a wet bathing suit for prolonged periods of time 3/20/2012 39 .

 Teach pregnant women to void every 2 hours Encourage menopausal women to use estrogen vaginal creams to restore pH  Instruct the female client to use water-soluble lubricants for coitus. especially after menopause 3/20/2012 40 .

URETHRITIS  An inflammation of the urethra commonly associated with sexually transmitted diseases (STD). it is most often caused by gonorrhea or chlamydial infection 3/20/2012 41 . and may be seen with cystitis  In men.

spermicidal jellies. In women. it is most often caused by feminine hygiene sprays. perfumed toilet paper or sanitary napkins. UTIs. or changes in the vaginal mucosal lining 3/20/2012 42 .

Nocturia e. Burning on urination b.Assessment/Male       a. Discharge from the penis 3/20/2012 43 . Difficulty voiding f. Frequency c. Urgency d.

Urgency c. Lower abdominal discomfort 3/20/2012 44 . Painful urination e. Nocturia d.Females       a. Difficulty voiding f. Frequency b.

Administer antibiotics as prescribed 3/20/2012 45 .Interventions  1. Prepare the client for testing to determine if an STD is present  3. Encourage fluids  2.

prepare the client for dilation of the urethra and instillation of an antiseptic solution 3/20/2012 46 . If stricture occurs. 4. Instruct the client in the administration of sitzbaths  5.

Instruct the client to avoid intercourse until the symptoms subside or treatment of the SID is complete  7. 6. Instruct the female client to avoid the use of perfumed toilet paper or sanitary napkins and feminine hygiene sprays 3/20/2012 47 .

UROSEPSIS  A gram-negative bacteremia originating in the urinary tract  The most common responsible organism is Escherichia coli 3/20/2012 48 .

 The most common cause is the presence of an indwelling urinary catheter or an untreated UTI in a client who is medically compromised 3/20/2012 49 .

 The major problem is the ability of this bacterium to develop resistant strains  Urosepsis can lead to septic shock if not treated aggressively

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Assessment
 Fever is the most common and earliest manifestation

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Nursing Interventions
 1. Obtain a urine specimen for urine culture and sensitivity  2. Administer IV antibiotics as prescribed, usually until the client has been afebrile for 3 to 5 days  3. Administer oral antibiotics as prescribed after the 3 to 5 day afebrile period
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Glomerulonephritis
 An inflammatory reaction in the glomerulus as a result of an antigenantibody response to the betahemolytic streptococcus.  Occurs more frequently in boys, usually between ages 6-7 years  Usually resolves in about 14 days, self-limiting
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 The inflammation of the glomeruli results from an antigen-antibody reaction produced from an infection elsewhere in the body  An immune complex is formed as a result of the antigen-antibody formation. the complex becomes trapped in the glomeruli. 3/20/2012 54 .

3/20/2012 55 . the GFR is significantly decreased. It results in proliferative and inflammatory changes within the glomerular structure  As a result of the edema in the glomeruli.

inflammation. and sclerosis of the glomeruli of both kidneys occur  Loss of kidney function develops 3/20/2012 56 . Destruction.

Pathogenesis of GN Immune Complex Deposition Complement Activation Infiltrating Leukocytes Mesangial Cells Aggregate Platelets Growth factor Proliferation of glomerular elements Proteases And Free Radicals Microthrombi Blocked Capillaries BM Exposed 3/20/2012 Defective Filtration Glomerular Damage 57 .

Causes  Immunological or autoimmune diseases  Streptococcal infection. group A betahemolytic  History of pharyngitis or tonsillitis 2 to 3 weeks prior to symptoms 3/20/2012 58 .

but all age groups can be affected. Scarlet fever and impetigo.  Most common in children. 3/20/2012 59 .

Types  Acute: Occurs 2 to 3 weeks after a streptococcal infection  Chronic: Can occur after the acute phase or slowly over time 3/20/2012 60 .

Complications     Heart failure Hypertensive encephalopathy Pulmonary edema Renal failure 3/20/2012 61 .

 Facial edema.Clinical manifestations  a.  Headache and malaise.  Disease may be mild with proteinuriaasymptomatic hematuria. periorbital edema. Acute glomerulonephritis. 3/20/2012 62 .

 Mild to severe hypertension.  Tea or cola colored urine due to hematuria. 3/20/2012 63 .  Tenderness over the costovertebral angle. Decrease in urine output (oliguria).

 Feet are slightly swollen at night.Chronic glomerulonephritis  Proteinuria and hematuria. or uremic convulsions. retinal hemorrhages.  Hypertension-nose bleeds. 3/20/2012 64 .

 Occurs over months to years. 3/20/2012 65 . A yellow grayish pigmentation of the skin along with pale mucous membranes and anemia.

 1. cola-colored or redbrown urine  3. Proteinuria that produces a persistent and excessive foam in the urine  4. Dark. Urinary debris 3/20/2012 66 . smoky. Gross hematuria  2.

Low urinary pH  7. Oliguria or anuria  8. Chills and fever 3/20/2012 67 . Headache  9. 5. Moderately elevated to high specific gravity  6.

and vomiting 12. Pallor 13. periorbital area. pleural effusion and CHF     3/20/2012 68 . Anorexia. Edema in the face. and generalized  14. nausea. Shortness of breath. Fatigue and weakness 11. ascites. feet.10.

Hypertension 17. Abdominal or flank pain 16. Increased antistreptolysin 0 titer (used to diagnose disorders caused by streptococcal infections)     3/20/2012 69 .15. Reduced visual acuity 18. Increased BUN and creatinine levels  19.

Nephrotic syndrome 3/20/2012 70 . Chronic renal failure  b.Complications  a.

Diagnostics a. Urinalysis.  (2) Increased specific gravity.   (4) Urine specific gravity increased 3/20/2012 71 .  (1) Proteinuria.  (3) Hematuria.

ESR elevated 3/20/2012 72 .  c.  d.  e. Positive complement studies and ASO titer. CBC-decreased hemoglobin and hematocrit. and albumin.  b. Elevated BUN. creatinine. (4) Red cell casts.

Treatment  Medical  Dietary 3/20/2012 73 .

Antibiotics--penicillin. Diuretics are usually not effective.  b.  c. 3/20/2012 74 . if cultures indicate. Antihypertensives. Medical. May be utilized if the child is severely edematous.  a.

 Fluid restriction if renal insufficiency  Peritoneal dialysis if severe renal or cardiopulmonary problems develop 3/20/2012 75 .

The anorexia the child experiences frequently limits the protein sufficiently. Decrease sodium intake.  b.  a. 3/20/2012 76 . Protein restriction if child is azotemic from prolonged decrease in urinary output. Dietary.

3/20/2012 77 . c. Foods containing high potassium are generally restricted during the oliguria phase.

 1. 3/20/2012 78 . activity as tolerated.Nursing Intervention  Goal: to protect client's poorly functioning kidneys by preventing secondary infections. otherwise. Bedrest for severe hypertension and significant edema. Administer antibiotic therapy.  2.

Monitor renal function-cheek characteristics and color of urine. and cheek blood pressure q 2 to 4 hours. maintain diet and fluid restrictions as ordered. Monitor intake and output. 3/20/2012 79 .  2.  1. Goal: to maintain fluid balance. weigh client daily.

3/20/2012 80 . then may progress to profuse diuresis. Frequently the first sign of improvement is an increase in the urine output.  4. 3. Administer antihypertensives as ordered.

Decrease anxiety by explaining treatments.  1. Goal: to prevent complications and promote comfort. and chronic renal failure.  2. Assess for complications related to hypertension. congestive heart failure.  3. pulmonary edema. 3/20/2012 81 . Encourage verbalization of fears.

Nephrotic Syndrome  A set of clinical manifestations arising from protein wasting secondary to diffuse glomerular damage 3/20/2012 82 .

 Primarily occurs in children and is the outcome of other renal problems in which there is proteinuria.  Commonly affects preschoolers. hypoalbuminemia. boys more often than girls 3/20/2012 83 . hyperlipedemia and edema.

 Changes occur in the basement membrane of the glomeruli that allows the large protein molecules to pass through the membrane and he excreted. 3/20/2012 84 .

 The loss of the albumin from the serum decreases the oncotic pressure in the capillary bed and allows fluid to pass into the interstitial tissues and into the abdominal cavity (ascites). 3/20/2012 85 .

the renin-angiotensin response is stimulated. aldosterone secretion is increased. 3/20/2012 86 . and the tubules begin to conserve sodium and water to increase the circulating volume. The interstitial fluid shift causes hypovolemia.

frequently there is no evidence of renal dysfunction or systemic disease. the etiology is unknown. 3/20/2012 87 . In the majority of children with the syndrome.

 Course of the disease consists of exacerbations and remissions over a period of months to years 3/20/2012 88 .

 b. Protein shift causes altered oncotic pressure and lowered plasma volume. 3/20/2012 89 . Plasma proteins enter the renal tubule and are excreted in the urine.Pathophysiology  a. causing proteinuria.

aldosterone increases reabsorption of water and sodium in distal tubule. Hypovolemia triggers release of renin and angiotensin. c. 3/20/2012 90 . which stimulates increased secretion of aldosterone.

3/20/2012 91 . results in edema. d. together with a general shift of plasma into interstitial spaces. Lowered blood pressure also stimulates release of ADH. further increasing reabsorption of water.

 (1) Glomerulonephritis.Risk factors/etiology  a. 3/20/2012 92 .  (2) Systemic lupus erythematosus.  (3) Congestive heart failure. History of renal dysfunction or systemic disease.

 c. bay fever and urticaria. Increased incidence in children with allergic disorders such as asthma. 3/20/2012 93 . b. Majority of children are male and between ages of 2 and 7 years.

Glormerular damage Pathogenesis of Nephrotic Syndrome Fluid retention reflex Protein loss Hypoalbuminemia Inc. plasma volume Reduce blood Osmotic pressure Hepatic lipoprotein production Reduce Antibody levels Reduced Anticoagulants Systemic edema 3/20/2012 Hyperlipedemia Proteinuria Infections Thrombosis 94 .

May be more pronounced in the morning. (1) Facial edema. may increase during the day. 3/20/2012 95 . Edema. and subside some during the day.Clinical manifestations  a. (2) Generalized edema of the lower ext. especially periorbital edema.

(3) Labia and scrotum may become very edematous. 3/20/2012 96 . (4) Edema may progress to the level of severe generalized edema (anasarca).

Inc. Permeability Dev. of edema in neprhosis Loss of albumin. circulating blood volume 97 . other protein in urine Dec. colloid osmotic pressure of blood Fluid loss to interstitial spaces Edema (anasarca) 3/20/2012 Dec.

Volume of urine is decreased and may be dark or tea-colored 3/20/2012 98 . Hypoalbuminemia. f. Gradual increase in weight. Hyperlipidemia e. c. Proteinuria. d.     b.

Waxy pallor to the skin 99 3/20/2012 . Body malaise m. Irritability. Hematuria h. Anorexia n. l. Anemia i. lethargy. fatigue.       g. Amenorrhea or abnormal menses j.

Child is malnourished due to decreased intake as well as loss of protein in the urine but may not appear so due to edema.  q. Skin is pale and is prone to break down during the edematous stage  p. Depending on the severity of the condition. o. the child may experience episode of hypertension. 3/20/2012 100 .

 c. Renal failure.Complications  a. Anasarca.  b. Hypertension. 3/20/2012 101 .

Creatinine clearance may he decreased with normal serum creatinine.density lipoproteins (LDL) are elevated followed later by increased triglyceride level. 3/20/2012 102 . Urinalysis-proteinuria. Increase serum lipids-cholesterol and low. Decrease serum albumin.  d.  c.  b.Diagnostics  a.

Treatment  Medical  Dietary 3/20/2012 103 .

Or some used Thiazide diuretics 3/20/2012 104 . may be used when the edema is severe or the child is hypertensive) spironolactone (ALDACTONE) in combination with furosemide (LASiX).Medical  a. Corticosteroid-prednisone. Diuretics-(frequently child is not responsive to the diuretics.  b.

Salt-poor human albumin for vascular insufficiency and severe edema. Prophylactic broad spectrum antimicrobial agents. 3/20/2012 105 .  d. c.

 e. 3/20/2012 106 . Immunosuppressant therapy. usually cyclophosphamide (CYTOXAN) may be administered for up to two months to reduce the relapse rate and induce long-term remission.

 b. Decreased sodium intake. There is usually no fluid restriction. If there is any indication of renal failure or azotemia. 3/20/2012 107 . There controversy regarding the benefits of decreased protein intake.Dietary  a. Protein intake depends on stage of disease. then protein is restricted.  c.

 Bed rest 3/20/2012 108 .

 1. Provide and encourage a saltrestrictive diet. Support edematous organs such as scrotum.  2. 3/20/2012 109 .Nursing Intervention  Goal: to reduce edema and excess fluid retention.

Provide meticulous skin care. 3/20/2012 110 . 3. change position frequently and monitor good body alignment.  4. Administer salt-poor albumin as ordered and monitor closely for circulatory overload during and after administration.

accurate intake and output measure abdominal girth. 5. 3/20/2012 111 . Daily weights.  6. Cleanse and powder opposing skin surfaces frequently.

asses carefully for indications of infection.  3.  2. Protect child from upper respiratory infections good pulmonary hygiene. Prevent skin excoriation and breakdown. 3/20/2012 112 .Goal: to prevent infection  1. Child susceptible to infection due to decreases immune state from steroid therapy.

3/20/2012 113 . Serve small quantities to children.  2. Encourage adequate protein intake.Goal: to promote nutrition  1.  3. Encourage input from child in selecting foods from prescribed diet.

Reassure parents of the course of the disease so that they do not become discouraged with the frequent relapses.  2.  1. Goal: to assist parents to cope with chronic disease and teach them home care. Instruct as to medical regimen. 3/20/2012 114 .

3/20/2012 115 . 3.  4. Impress upon them the importance of long-term care and to obtain medical assistance when relapse occurs. Social isolation is often a problem due to frequent hospitalizations or confinement (high risk of infection which could precipitate an exacerbation).

3/20/2012 116 .Nephritic Syndrome  It is dominated by inflammatory damage that restricts glomerular filtration and allows erythrocytes to escape to the urine (hematuria).

systemic HPN. and the accumulation of nitrogenous wastes in the blood (azotemia). The decreased filtration causes reduced urinary output (oliguria). 3/20/2012 117 .

Pathogenesis of Nephritic Syndrome Glomerular Damage RBC loss to filtrate Variable Low level Proetinuria Reduced Glomerular Filtration Hematuria Azotemia 3/20/2012 Fluid Retention Oliguria 118 .

PHILIPPIANS 4:13  I CAN DO ALL THINGS THROUGH CHRIST WHO STRENGTHENS ME! 3/20/2012 119 .

RENAL FAILURE
 The loss of kidney function  Sudden interruption of kidney function to regulate fluid and electrolyte balance and remove toxic products from the body

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 The signs and symptoms of renal failure are caused by the retention of wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes

Most important manifestation: OLIGURIA
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Kidney function
The Nephron produces urine to eliminate waste Impaired urine production and azotemia Secretes Erythropoietin to ANEMIA increase RBC Metabolism of Vitamin D Calcium and Phosphate imbalances

Produces bicarbonate and Metabolic ACIDOSIS secretes acids Excretes excess POTASSIUM
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HYPERKALEMIA

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Kinds of Renal Failure
 Acute renal failure  Chronic renal failure

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Acute Renal Failure  Prerenal  Intrarenal  Postrenal 3/20/2012 124 .

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Prerenal(renal ischemia)  Serious cardiovascular disorders  Peripheral vasodilation  Severe vasoconstriction 3/20/2012 126 .

Hemorrhage Shock Burns Hypovolemia Renal vascular obstruction -(A/V)thrombosis      3/20/2012 127 .

Heart Failure Vasodilatation Hypovolemia Systemic Hypotension Atherosclerois Renal Ischemia Nephrosclerosis Renal artery stenosis Inadequate filtration Prerenal Disease 3/20/2012 Prerenal disease 128 .

acute vasoconstriction. septicemia. and oliguria. ischemia. include CHF. cardiogenic shock. anaphylaxis 3/20/2012 129 . hypotension. burns. hemorrhage.Acute renal failure -PATHOPHYSIOLOGY Prerenal CAUSE:  Factors interfering with perfusion and resulting in diminished blood flow and glomerular filtrate.

lead.Renal/Intrarenal(kidney tissue pathology)  Acute tubular necrosis  Nephrotoxins  Aminoglycosides or NSAIDs  Heavy metals -(carbon tetrachloride. arsenic. mercury 3/20/2012 130 .

Intrarenal  Ischemic damage from poorly treated renal failure  Acute glomerulonephritis and pyelonephritis 3/20/2012 131 .

 Diseases that precipitate micro and microvascular changes (atheroselerosis. diabetes mellitus. hypertension). 3/20/2012 132 .

3/20/2012  Eclampsia. postpartum renal failure or uterine hemorrhage  Crush injury. myopathy. sepsis or transfusion reaction 133 .

nephrotoxins (certain antibiotics. blood transfusion reactions. hypercalcemia. pesticides.Acute renal failure -PATHOPHYSIOLOGY Intrarenal CAUSE:  Conditions that cause damage to the nephrons. acute glomerulonephritis. malignant hypertension. include acute tubular necrosis (ATN). anesthetics) 3/20/2012 134 . endocarditis. diabetes mellitus. x-ray dyes. tumors.

Postrenal(obstructive problems)  Bladder obstruction  Ureteral(stones) obstruction  Urethral obstruction  BPH  Trauma resulting to obstruction 3/20/2012 135 .

strictures. BPH. tumors.Acute renal failure -PATHOPHYSIOLOGY Postrenal CAUSE:  Mechanical obstruction anywhere from the tubules to the urethra. includes calculi. blood clots. and anatomic malformation 3/20/2012 136 . trauma.

PRERENAL CAUSES INTRARENAL CAUSES Acute tubular necrosis (ATN) POSTRENAL CAUSES Calculi Tumors Blood clots BPH Strictures Hypotension Cardiogenic shock Acute vasoconstriction Diabetes mellitus Malignant hypertension Acute glomerulonephritis Hemorrhage Burns Tumors Blood transfusion reactions Septicemia CHF Trauma Anatomic malformation Nephrotoxins 3/20/2012 137 .

Diuretic phase 4.Phases of Acute Renal Failure  1. Recovery or convalescence Four phases of acute renal failure (Brunner and Suddarth) 1. Initiation phase 2. Oliguric phase  2. Convalescence or recovery phase 3/20/2012 138 . Oliguric phase 3. Diuretic phase  3.

Oliguric phase
 a. Urinary output decreases to less than 400 ml per day.  b. Increase in BUN, creatinine, uric acid, potassium, magnesium, and presence of metabolic acidosis.  c. Can last for 1 to 8 weeks.

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 d. Often the patient may excrete two or more liters of urine daily-this is referred to as high output failure; occurs predominately after nephrotoxic antibiotics, burns, or traumatic injury.

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 d. Urine specific gravity of 1.010 to 1.016  e. Anorexia, nausea, and vomiting  f. Hypertension  g. Decreased skin turgor  h. Pruritus  i. Tingling of the extremities
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 i. Drowsiness progressing to disorientation to coma  k. Edema  l. Dysrhythmias  m. Signs of congestive heart failure (CHF) and pulmonary edema  n. Signs of pericarditis  o. Signs of acidosis
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Laboratory       Glomerular filtration rate decreases Hyperkalemia Sodium level normal or decreased Fluid overload Elevated BUN and creatinine 3/20/2012 143 .

3/20/2012 144 .  c.three to five liters per day. Decreased urinary creatinine clearance. Excessive urine output indicates recovery of damaged nephrons  b. A low gradual increase in urine output. BUN.Diuretic phase  a. Elevated serum creatinine.

May last for two to three weeks.  e. Tachycardia  h. d. and water. Decrease in sodium.  f. Hypotension  g. Improvement in level of consciousness (LOC) 3/20/2012 145 . potassium.

Laboratory  Glomerular filtration rate begins to increase  Hypokalemia  Hyponatremia  Hypovolemia  Gradual decline in BUN and creatinine 3/20/2012 146 .

3/20/2012 147 .  c. complete recovery may take 1 to 2 years  b. Usually some type of permanent reduction occurs in glomerular filtration rate. Complications-secondary infection which is the most common cause of death.Recovery/Convalescent  a. May last from three to twelve months or slow process.

Increase in LOC e. Urine volume is normal c.     d. Client can develop chronic renal failure 3/20/2012 148 . BUN is stable and normal f. Increase in strength d.

Laboratory  BUN is stable and normal  Complete recovery may take 1 to 2 years 3/20/2012 149 .

3/20/2012 150 . very little proteinuria. Urinary-decreased urinary output (Oliguria. "muddy brown" casts. except in elderly may be 600-700 cc/day). less than 400 cc per day. or increased sodium in the urine.  (1) Intrarenal and postrenal failurefixed specific gravity is decreased.Clinical manifestations (multiple body systems affected)  a.

high sodium concentration. urine specific gravity may be high. 3/20/2012 151 . There is high urinary output. the urine is diluted and does not contain waste products from the filtering. however. (2) Prerenal failure-history of precipitating event. and proteinuria  (3) High output renal failure-the kidney no longer filters the urine.

 (4) Pericarditis.  (3) Dysrhythmia.  (2) Congestive heart failure. pericardial effusion.Cardiovascular  (1) Initially hypotension followed by hypertension after fluid overload. frequency secondary to the increase in potassium. 3/20/2012 152 .

3/20/2012 153 . c.  (2) Kussmaul breathing due to metabolic acidosis.  (1) Pulmonary edema due to congestive heart failure. Respiratory.

and diarrhea. vomiting. d. anorexia.  (1) Nausea. 3/20/2012 154 . Gastrointestinal.  (2) Stomatitis and GI bleeding.

 (2) Leukocytosis. 3/20/2012 155 .  (3) Inadequate platelet functioning. e. Hematologic  (1) Anemia occurring within the first two days.

(2) Memory impairment. 3/20/2012 156 .    f. (1) Change in level of consciousness. Neurologic. (3) Convulsions.

3/20/2012 157 . (3) Hyponatremia (usually dilution). (4) Metabolic acidosis from accumulation of acid waste products. Fluid and electrolyte balance. (2) Hyperkalemia.     g. (1) Fluid retention.

CLINICAL FINDINGS OLIGURIC PHASE DIURETIC PHASE CONVALESCENT PHASE Hypernatremia Hypocalcemia Hyperkalemia Hyponatremia Hypokalemia Hypovolemia Normal Urine Volume Increase in LOC BUN stable and normal May develop CRF Hyperphosphatemia Hypermagnesemia Metabolic acidosis 3/20/2012 158 .

BUN. 3/20/2012 159 .  b.proteinuria. Urinalysis. and potassium. RBC. casts. and specific gravity is decreased. Elevated scrum creatinine.Diagnostics  a.

Dialysis 3/20/2012 160 .  2.Treatment  1.  3. Dietary. Medical.

 b. EDECRIN. intrarenal. Diuretic therapy-LASIX. Identify and treat precipitating cause of acute renal failure (management varies according to prerenal.Medical  a. or postrenal disorder). 3/20/2012 161 . MANNITOL.

3/20/2012 162 .  (1) Administration of glucose and insulin. Decrease serum potassium.correct metabolic acidosis and causes electrolyte shift.  (2) IV administration of soda bicarbonate. c.promotes potassium to move into the cells.

 3) IV administration of calcium gluconate-antagonizes the adverse cardiac effects of hyperkalemia.  (4) Administration of a cation exchange resin (KAYEXALATE) by mouth or retention enema. 3/20/2012 163 .

potassium.  c. protein of high biologic value.Dietary  a. intake may be carefully calculated with output. Increased carbohydrate intake. 3/20/2012 164 . Fluid restriction.  b. and sodium intake is regulated according to serum plasma levels. Protein.

NURSING CARE • Monitor fluid and electrolyte balance. • Monitor alteration in fluid volume. & reduce/relieve anxiety 3/20/2012 165 . • Promote optimal nutritional status • Prevent complications from impaired mobility • Prevent fever and infection • Support client/S.O.

3/20/2012 166 .Chronic Renal Failure  CRF is a progressive. Progressive irreversible destruction of the kidneys causing severe renal dysfunction. irreversible reduction in renal function such that the kidneys are no longer able to maintain the body environment.  The GFR gradually decreases as the nephrons are destroyed.  Gradual.

3/20/2012 167 . resulting in hypertrophy and inability to concentrate urine. The result is azotemia to UREMIA  The nephrons left intact are subjected to an increased work load.

is irreversible. It occurs in stages. and results in uremia or end-stage renal disease CRF affects all of the major body systems and requires dialysis or kidney transplant to maintain life 3/20/2012 168 .

or hypovolemia can occur owing to the inability of the kidneys to conserve sodium and water 3/20/2012 169 . Hypervolemia can occur owing to the inability of the kidneys to excrete sodium and water.

Chronic Renal Failure Predisposing factors:  DM= worldwide leading cause  Recurrent infections  Exacerbations of nephritis  urinary tract obstruction  hypertension 3/20/2012 170 .

Diabetic nephropathy. May follow ARF  b.  c. 3/20/2012 171 .  d. Chronic glomerulonephritis and pyelonephritis. Chronic hypertension.Causes  a.

Chronic urinary obstruction  h. Nephrosclerosis and renal artery disease.  f. e. Recurrent infections 3/20/2012 172 . Renal artery occlusion  g.

    i. Metabolic disorders k. Hypertension j. Diabetes mellitus l. Autoimmune disorders 3/20/2012 173 .

 n. Lupus erythematosus. m. Polycystic kidney disease. 3/20/2012 174 . Renal disease secondary to nephrotoxic drugs or chemicals.  o.

filtration of macromolecules Inc. uremic Syndrome. excretion of Solute per nephron Systemic Hormonal Changes in blood Tubular cell damage & interstitial fibrosis 3/20/2012 Extrarenal organ Damage.Loss of Neprhons Glomerular hypertrophy and inc. SNGFR Glomerulosclerosis Accumulation of solute Tubular hyperthrophy High intraglomerular Pressure and inc.toxic Effects on renal cells Maintenance of internal Environment up to limits of Nephron adaptation And hyperthrophy Pathophysiology of CRF 175 .

Chronic Renal Failure PATHOPHYSIOLOGY As renal functions decline Retention of end-products of metabolism 3/20/2012 176 .

7590% loss of nephron function STAGE 3= end-stage renal disease. DIALYSIS IS THE TREATMENT! 3/20/2012 177 .Chronic Renal Failure PATHOPHYSIOLOGY STAGE 1= reduced renal reserve. more than 90% loss. 40-75% loss of nephron function STAGE 2= renal insufficiency.

Stages of Chronic Renal Failure  STAGE I: DIMINISHED RENAL RESERVE  STAGE II: RENAL INSUFFICIENCY  STAGE III: END STAGE 3/20/2012 178 .

CLINICAL FINDINGS STAGE 1 Diminished Renal Reserve STAGE 2 Renal Insufficiency STAGE 3 End Stage 3/20/2012 179 .

Nocturia and polyuria occur as a result of decreased ability to concentrate urine     3/20/2012 180 .Diminished renal reserve a. b. Absence of symptoms. Normal BUN and serum creatinine. c. Renal function is reduced d. No accumulation of metabolic wastes  e. The healthier kidney compensates  f.

Fatigue and weakness. 3/20/2012 181 . mild anemia.  c. BUN and serum creatinine increased (azotemia).  b. GFR is 25 percent of normal.Renal insufficiency  a.

nocturia. and polyuria. d.  e. Headaches. Metabolic wastes begin to accumulate  f. Oliguria and edema occur as a result of decreased responsiveness to diuretics 3/20/2012 182 .

End-stage renal failure (uremia)  Excessive accumulation of metabolic wastes  Kidneys are unable to maintain homeostasis  Dialysis or other renal replacement therapy is required 3/20/2012 183 .

GFR is less than 10 percent of normal.  (3) Metabolic acidosis.  (1) Severe azotemia. (4) Decreased urine output 3/20/2012 184 .  (2) Hyperkalemia.Assessment  a. hypernatremia and hyperphosphatemia.

amenorrhea. hematuria. oliguria eventually leads to anuria.  c. sexual dysfunction (impotence). decreased libido 3/20/2012 185 . pyuria. b. Endocrine system-hypothyrodism hyperparathyroidism. casts. infertility. Urinary system-specific gravity of urine fixed at 1. proteinuria.010.

3/20/2012 186 . ASHD. hypertension. pericarditis.Fluid overload and signs of heart failure. pericardial effusion. Cardiovascular system. CHF.  e. Hematologic system-anemia and bleeding. d.

 f. 3/20/2012 187 . and peptic ulcer disease. gastrointestinal bleeding. vomiting.  g. hyperlipidemia. Gastrointestinal system-anorexia. gout. diarrhea. ammonia (uremic fetor) odor to the breath. hypoproteinemia. nausea. Metabolic system-hyperglycemia.

general central nervous system depression and peripheral neuropathy 3/20/2012 188 . Neurologicsystem-headache. followed by convulsions and coma. confusion and lethargy. h.

weakness and fatigue. renal osteodystrophy. tissue calcification.Muscle twitching and numbness of the extremities. 3/20/2012 189 . Musculoskeletal system. i.

axilla. eyebrows. and groin in clients with advanced uremic syndrome 3/20/2012 190 .Kussmaul respirations  k. j. Respiratory system . Integumentary system -Uremic frost: a layer of urea crystals from evaporated perspiration that appears on the face.

uremic frost seizures.Chronic Renal Failure Dermatologic CNS CVS Pulmo Hema dry skin. fatigue Acute MI. osteodystrophy Musculoskeletal 3/20/2012 191 . edema. altered LOC. foot drop. hypertension. pericarditis Uremic lungs Anemia loss of strength. pruritus. anorexia.

CLINICAL FINDINGS Nausea and vomiting Uremic frost Decreased urinary output Azotemia Hypertension (later) Convulsions Pericardial friction rub 3/20/2012 Dyspnea Hypotension (early) Lethargy Memory impairment CHF 192 .

 e. Increased BUN and serum creatinine level. Increased scrum potassium.  d.  b. Anemia (decreased hemoglobin and hematocrit). Elevated blood sugar and triglycerides. 3/20/2012 193 .  c.Diagnostics  a. Decreased urinary creatinine clearance.

3/20/2012 194 . Dietary. 3. 4. Dialysis. Medical. 2.kidney transplant.Treatment     1. Surgical-.

INDERAL. (LASIX). Measures to reduce scrum potassium (see discussion under acute renal failure). APRESOLINE. the loop diuretics. 3/20/2012 195 .Medical  a. CATAPRES).  c. Administer antihypertensives (ALDOMET.  b. are used later. Diuretics-Thiazide diuretics may be used early.

Important Drugs Aluminum hydroxide (Amphogel) Kayexalate Binds with PHOSPHATE to decrease phosphorus Binds with POTASSIUM to manage hyperkalemia Diuretics To decrease edema Erythropoietin (Epogen) To increase RBC Anti-Hypertensives 3/20/2012 To manage Hypertension 196 .

3/20/2012 197 . both adipose tissue and muscle mass. Restricted protein intake. may vary from just a decrease in protein intake.  b. Problems with the client losing body weight. to a specific 20 to 40 gm per day.Dietary  a.

Protein should be of a high biologic value.  d. Water restriction-adjusted according to urinary output-if no urine output 100 cc/day. c. 3/20/2012 198 . and forms less nitrogen waste products. this enhances the utilization of the amino acids.

Keto acid supplements-help maintain a positive nitrogen balance (Shohl's solution). e. 3/20/2012 199 . Sodium and potassium restrictionbased upon laboratory values.  f.

and prevent injury. 3/20/2012 200 . • Monitor/prevent alteration in F/E. • Monitor for bleeding complications. • Promote optimal GI function.NURSING CARE: • Prevent neurologic complications. • Promote maintenance of skin integrity.

AlternaGEL • Promote/maintain maximal cardiovascular function. 201 .NURSING CARE • Assess for hyperphosphatemia Paresthesias Muscle cramps Seizures Abnormal reflexes • Administer Aluminum hydroxide gels as ordered . 3/20/2012 • Provide care for client receiving dialysis.Amphogel.

have a life expectancy of at least two more years. 3/20/2012 202 . and have reasonable expectations that the transplant will improve the quality of life.Surgical-kidney transplant  a.  (1) Candidates are usually under 70 years old. Recipient criteria: candidates are evaluated on an individual basis as to how well they would benefit from the transplant.

COPD. 3/20/2012 203 . when they are not available. severe cardiac problems. then cadaver donors are considered. Donor criteria: live related donors (LRD) provide the best possible match. (2) Clients with uncontrolled malignancies.  b. severe systemic diseases are not good transplant candidates.

and have normal renal perfusion and function.  (2) The cadaver donor must meet the criteria for brain death. 3/20/2012 204 .  (3) The cadaver donor should be free from all systemic diseases. (1) Either type of donor must he evaluated for adequate tissue matching.

3/20/2012 205 .

Thank you!!! 3/20/2012 206 .

Accurate intake and output.Nursing Intervention (ARF)  Goal: To maintain client in normal homeostasis and preserve renal function while the kidneys are repairing.  2.3 kg/day during oliguric phase).  1. 3/20/2012 207 .2 to . Daily weight (may lose .

Identify and monitor high-risk clients.  4. cardiac dysrhythms. 3. 3/20/2012 208 . fluctuations of sodium and potassium levels. Assess for hypervolemia during the oliguric Phase.

 5.  6. Support the client in relation to symptoms occurring in other body systems. 3/20/2012 209 . Evaluate for postural hypotension.

3/20/2012 210 . To prevent infection.  2. Client at increased risk due to compromised immune system.  1. Assess for development of infectious processes. Avoid indwelling catheter if possible. Goal.

 3. Beds and protective devises to prevent pressure areas (decubitus ulcers).  1. Frequent turning and positioning. inspect the skin for problem areas. 3/20/2012 211 . Goal: to prevent skin breakdown.  2. Frequent range of motion and activities to increase circulation.

 3. 3/20/2012 212 . Goal: To provide emotional support. Provide honest information regarding progress of condition.  1. Always explain procedures. Encourage client to express fears and concerns regarding condition.  2.

3/20/2012 213 .

 1. Discuss with the client how to monitor the fluid intake and plan for the allocated amount to be distributed over the day.Nursing Intervention(CRF)  Goal: to assist the client to maintain homeostasis. Daily weight. Evaluate adequacy of fluid balance. Postural hypotension. 3/20/2012 214 . Level of fluid intake.  d.  c.  b.  a.

 a. Plan diet according to client preferences if possible. 3/20/2012 215 .  b. 2.  c. Encourage adequate nutritional intake within dietary guidelines. Relieve GI dysfunctions prior to serving meals. Advise client that most salt substitutes contain potassium and should not be used.

Prevent problem of constipation. Include bran in diet. a. Avoid use of sedatives and hypnotics. increased sensitivity to these medications due to decreased ability of kidney to metabolize them.    3. 4. 3/20/2012 216 . b. Stool softeners.

Monitor electrolyte balance. especially level of potassium. and increased work load on the heart from the chronic anemic state.  6. 3/20/2012 217 . Assess cardiovascular status to determine how effectively the client is compensating with the increased fluid load. 5.

3/20/2012 218 . and decreased platelet adhesiveness. Assess client for bleeding tendencies related initially to decrease in production of erythropoietin. Evaluate client for pruritus and assist with measures to decrease the skin irritation and itching.  8. 7.

 Goal: to provide emotional support and promote psychological/equilibrium.  1. Encourage client to express concerns. 3/20/2012 219 . Recognize that the long-term management of a chronic disease may lead to anxiety and depression.  2.

Encourage ventilation of feelings regarding life style changes.  4. 3. Make available to client and family members other renal clients who are undergoing the same treatment approaches. 3/20/2012 220 .

Maintain client's metabolic state as close to homeostasis as possiblecontinue with dialysis. Tissue typing and antibody screening is con. 3/20/2012 221 .  1.  2. Goal: to provide preoperative care for kidney transplant.ducted to determine histocompatibility of the donor and the recipient.

3/20/2012 222 . and cyclosporin. Conduct routine preoperative procedures. and prednisone.IMURAN.  4. Administer immunosuppressant drugs. 3.

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