Transcript Renal Failure Acute and Chronic

The Urinary System Assessment &
Disorders
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The kidneys, ureters, and bladder. (Source: Dorling Kindersley Media Library)
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An illustration of the internal structures of the kidney.
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The structure of the nephron and the processes of urine formation.
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Age-Related Changes
Nephrons lost with aging
Reduces kidney mass and GFR
Less urine concentration
Risk for dehydration
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Assessment
Use simple language
Assess for incontinence (esp. muliparous)
Family history
Chief concern
Location and character of pain
Previous UTI, stones, urinary problems
Pattern or urination
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Assessment
Color, clarity, amount of urine
Difficulty initiating urination or changes
in stream
Changes in urinary pattern
Dysuria, nocturia, hematuria, pyuria
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Assessment
History of urinary problems
Urinary or abdominal surgeries
Smoking, alcohol use
Chance of pregnancy
History of diabetes or other endocrine
disorders
Unexplained anemia
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Diagnostic Tests
Clean-catch urine
24-hour urine collection
Culture and sensitivity
BUN, creatinine and creatinine
clearance = {Vol. of urine (ML/hr) x
urine creatine}/serum creatinine
IVP, Retrograde Pyelography
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Diagnostic Tests
Cystography,
voiding cystogram
CT scan, MRI
Renal scan
Ultrasound
X-ray (KUB)
Cystoscopy
Renal Angiography
Kidney biopsy (by
needle or open
procedure)
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Glomerulonephritis
Inflammatory condition of glomerulus
Antigen–antibody complexes form in the
blood and become trapped in the
glomerular capillaries, inducing an
inflammatory response.
Damages capillary membrane
Blood cells and proteins escape into filtrate
Hematuria, proteinuria, azotemia (increase
BUN & Creatinin)
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Acute Glomerulonephritis Manifestations
Usually follows infection of group A
beta-hemolytic Streptococcus
Affect children > 2 years
Manifestations develop abruptly
Hematuria (? Microscopic, or frank, urine
is cola color), proteinuria, edema,
azotemia (High BUN and Creatineine)
hypertension, fatigue, hypoalbuminemia,
hyperlipidemia
? headache, malaise and flank pain
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Glomerulonephritis
Glomerulonephritis –
Diagnostic Tests
ASO titer (anti
streptolysine O)
BUN
Serum creatinine
Serum electrolytes
Urinalysis
KUB x-ray
Kidney scan or
biopsy
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Complications of acute
glomerulonephritis
Hypertensive encephalopathy,
Heart failure,
Pulmonary edema,
Without treatment, end-stage renal
disease (ESRD) develops in a matter of
weeks or months.
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Glomerulonephritis –
Treatment
Focus is on identifying and treating
underlying disease process and preserving
kidney function
If residual streptococcal infection is
suspected, penicillin.
Corticosteroids and immunosuppressant
medications may be prescribed for
patients with rapidly progressive acute
glomerulonephritis.
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Glomerulonephritis –
Treatment
Dietary protein is restricted when renal
insufficiency (elevated BUN) develop.
Sodium is restricted when the patient has
hypertension, edema, and heart failure.
Loop diuretic and antihypertensive
medications may be prescribed to control
hypertension.
Bed rest during acute phase.
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Glomerulonephritis –
Nursing Care
Decrease protein and increase CHO to
prevent protein breakdown.
Accurate I & O (consider insensible loss)
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Chronic Glomerulonephritis
Could be due to repeated episodes of acute
glomerulonephritis, hypertensive
nephrosclerosis, hyperlipidemia, glomerular
sclerosis
Other causes include SLE, DM
Kidney size reduce to 1/5th of original size
and many scar tissue formed leading to
ESRF.
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Chronic Glomerulonephritis/ S&S
Many are asymptomatic
? Discovered when patient diagnosed
with Hypertension.
? severe nosebleed, a stroke, or a
seizure, swollen feet at night.
Heneral symptoms, such as loss of
weight and strength, increasing
irritability, nocturia, Headaches,
dizziness, and digestive disturbances.
Finally, S&S of renal failure.
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Medical Management
Control BP: Na & water restriction,
antihypertensive drug
Monitor weight.
Diuretics.
Adequate CHO diet to spare protien
Treat UTI
? Dialysis.
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Nephrotic Syndrome
Is a cluster of clinical findings, including:
Marked increase in protein (particularly
albumin) in the urine (proteinuria)
2. Decrease in albumin in the blood
(hypoalbuminemia)
3. Edema (periorbital, ascites, and
dependent edema)
4. High serum cholesterol and low-density
lipoproteins (hyperlipidemia)
1.
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Treatment
Diuretics (be careful not to cause sever
hypovolemia as it may lead to ARF)
Loop diuretics + ACE inhibitors lead to
decreasing protienuria.
Immunosuppresive agents (i.e. cytoxan).
Coriticosteroids.
Restrict protein and sodium.
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Nephrotic Syndrome
Acute Renal Failure (ARF)
Is a reversible clinical syndrome where there
is a sudden and almost complete loss of
kidney function (decreased GFR) over a
period of hours to days with failure to excrete
nitrogenous waste products and to maintain
fluid and electrolyte homeostasis
May progress to end stage renal disease,
uremic syndrome, and death without
treatment
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Acute Renal Failure
Persons at Risks
Major surgery
Major trauma
Receiving nephrotoxic medications
Elderly
ARF mostly occur within hospital
settings
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Causes of ARF
1. Prerenal Failure
2. Intrarenal Failure
3. Postrenal Failure
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Prerenal Failure
Volume depletion resulting from:
Hemorrhage
Renal losses (diuretics, osmotic diuresis)
Gastrointestinal losses (vomiting, diarrhea,
nasogastric suction)
Impaired cardiac efficiency resulting from:
Myocardial infarction
Heart failure
Dysrhythmias
Cardiogenic shock
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Prerenal Failure
Vasodilation resulting from:
Sepsis
Anaphylaxis
Antihypertensive medications or other
medications that cause vasodilation
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Intrarenal Failure
Prolonged renal ischemia resulting from:
Pigment nephropathy (associated with the
break-down of blood cells containing pigments
that in turn occlude kidney structures)
Myoglobinuria (trauma, crush injuries, burns)
Hemoglobinuria (transfusion reaction, hemolytic
anemia)
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Intrarenal Failure
Nephrotoxic agents such as:
Aminoglycoside antibiotics (gentamicin,
tobramycin, amicacin)
Radiopaque contrast agents
Heavy metals (lead, mercury)
Solvents and chemicals (ethylene glycol,
carbon tetrachloride, arsenic)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Angiotensin-converting enzyme inhibitors (ACE
inhibitors)
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Intrarenal Failure
Infectious processes such as:
Acute pyelonephritis
Acute glomerulonephritis
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Postrenal failure
Urinary tract obstruction, including:
Calculi (stones)
Tumors
Benign prostatic hyperplasia
Strictures
Blood clots
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Phases of Acute Renal Failure
Initiation period: begins with the initial insult
and ends when oliguria develops.
Oliguria period: UOP < 400 ml/day, increase in
urea, creatinine, uric acid, K & magnesium.
Some people have normal urine output (2 L/d)
Diuretic – UOP ^ to as much as 4000 mL/d but
BUN & Cretinine still high, at end of this stage
may begin to see improvement
Recovery – things go back to normal. It may
take up to 3-12 months
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Acute Renal Failure S & S
The patient may appear critically ill and
lethargic.
The skin and mucous membranes are dry
from dehydration.
Central nervous system signs and
symptoms include drowsiness, headache,
muscle twitching, and seizures.
Urine output varies (scanty to normal
volume), ? hematuria & urine has a low
specific gravity
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Acute Renal Failure
Diagnostic tests
BUN, creatinine, potassium increase.
pH
Hgb and Hct
Urine studies
US of kidneys
High phosphorus and low calcium.
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Prevention of ARF
Provide adequate hydration
Prevent and treat shock promptly
Hourly urine output for critical patients
Continuosally assess renal function
Prevent and treat infections promptly
Monitor for effects of toxic drugs
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Medical treatment of ARF
Objectives of treatment are to restore
normal chemical balance and prevent
complications until repair of renal tissue
and restoration of renal function can occur.
Management includes
maintaining fluid balance,
avoiding fluid excesses, or
possibly performing dialysis.
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Acute Renal Failure
Medical treatment
Treat the cause
Fluid and replacement or restrictions
Monitor for fluid overload
Diuretics
Maintain E-lytes
May need dialysis (especially with high K)
May need to stimulate production of urine
with IV fluids, Dopomine, diuretics, etc.
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Acute Renal Failure
Medical treatment
Hemodialysis
Subclavian approach
Femoral approach
Peritoneal dialysis
Nutritional Therapy
? Decrease Protein (according to BUN level)
Increase CHO
Decrease potassium and phosphrous
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Acute Renal Failure
Nursing Diagnosisimbalanced fluid volume= excess
Altered electrolyte balance
Impaired tissue perfusion: renal
Anxiety
Imbalanced nutrition
Risk for infection
Fatigue
Knowledge deficit
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Acute Renal Failure
PlanPromote recovery of optimal kidney
function.
Maintain normal fluid and electrolyte
balance.
Decrease anxiety.
Increase knowledge.
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Nursing interventions
Monitoring Fluid and Electrolyte Balance
Reducing Metabolic Rate
Promoting Pulmonary Function
Preventing Infection
Providing Skin Care
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Chronic Renal Failure
Chronic renal failure, or ESRD, is a
progressive, irreversible deterioration in renal
function in which the body's ability to
maintain metabolic and fluid and electrolyte
balance fails, resulting in uremia or azotemia.
Results from gradual, progressive loss of
renal function
Occasionally results from rapid progression of
acute renal failure
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Chronic Renal Failure
Conditions that cause ESRD include
systemic diseases, such as diabetes
mellitus (leading cause); hypertension;
chronic glomerulonephritis;
pyelonephritis; obstruction of the
urinary tract; hereditary lesions, as in
polycystic kidney disease; vascular
disorders; infections; medications; or
toxic agents.
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Chronic Renal Failure
Symptoms occur when 75% of function
is lost but considered chronic if 90-95%
loss of function
Dialysis is necessary D/T accumulation
of uremic toxins, which produce
changes in major organs
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Chronic renal failure/ S&S
Cardiovascular: the most common
cause of death
Hypertension
Pitting edema (feet,
hands, sacrum)
Periorbital edema
Pericardial friction rub
Acidosis (kidney can’t
excrete amonia,
reabsorb bicarb, high
phosphate)
Engorged neck veins
Pericarditis
Pericardial effusion
Pericardial
tamponade
Hyperkalemia
Hyperlipidemia
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Chronic renal failure/ S&S
Neurologic
Weakness and
fatigue
Confusion
Inability to
concentrate
Disorientation
Tremors
Seizures
Asterixis
Restlessness of legs
Burning of soles of
feet
Behavior changes
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Chronic renal failure/ S&S
Pulmonary
Integumentary
Crackles
Thick, tenacious sputum
Depressed cough reflex
Pleuritic pain
Shortness of breath
Tachypnea
Kussmaul-type
respirations
Uremic pneumonitis
Gray-bronze skin color
ّ ‫ ) ُمق‬skin
Dry, flaky (‫شر‬
Pruritus
Ecchymosis
Purpura
Thin, brittle nails
Coarse, thinning hair
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Chronic renal failure/ S&S
Gastrointestinal
Hematologic
Ammonia odor to breath
Anemia
(“uremic fetor”)
Thrombocytopenia
Metallic taste
Mouth ulcerations and
bleeding
Anorexia, nausea, vomiting
Hiccups
Constipation or diarrhea
Bleeding from GI tract
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Chronic renal failure/ S&S
Reproductive
Musculoskeletal
Amenorrhea
Testicular atrophy
Infertility
Decreased libido
Muscle cramps
Loss of muscle
strength
Renal
osteodystrophy
Bone pain
Bone fractures
Foot drop
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Chronic Renal Failure
Lab findings
BUN – indicator of glomerular filtration rate
and is affected by the breakdown of
protein.
Serum creatinine – waste product of
skeletal muscle breakdown and is a better
indicator of kidney function.
Creatinine clearance is best determent of
kidney function (GFR). Must be a 24 hour
urine collection.
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Chronic Renal Failure
K+
The kidneys are means which K+ is excreted.
Normal is 3.5-5.0 ,mEq/L. maintains muscle
contraction and is essential for cardiac function.
Both elevated and decreased can cause problems
with cardiac rhythm
Hyperkalemia is treated with IV glucose and Na
Bicarb which pushes K+ back into the cell
Kayexalate (Sodium polystyrene sulfonate ) is also
used to promote the exchange of sodium and
potassium in the body.
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Chronic Renal Failure
Ca
With disease in the kidney, the enzyme for
utilization of Vit D is absent
Ca absorption depends upon Vit D
Also, phosphate level increase leading to
decreasing level of Ca
Parathyroid hormone level increase in attempt to
increase calcium, but because of the high
phosphorus level, there is limited response.
Body moves Ca out of the bone to compensate.
Renal osteodystrophy is the end result
Hypocalcemia = tetany
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Chronic Renal Failure
Other abnormal findings
Metabolic acidosis
Fluid imbalance
Insulin resistance
Anemia
Immunoligical problems
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Complications
Hyperkalemia
Pericarditis, pericardial effusion, and
pericardial tamponade
Hypertension
Anemia
Bone disease and metastatic and
vascular calcifications
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Medical management
Calcium carbonate, or calcium acetate:
bind to phosphours and decrease its
level.
Antihypertensive and Cardiovascular
Agents
Antiseizure Agents
Erythropoietin
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Nutritional Therapy
Protein is restricted (allowed protein
should be of high biologic value)
Restrict fluid (500-600 ml/day more
than previous day’s urine output).
Restrict K, Na, Phosphorus
Increase CHO to meat caloric needs
Vitamin suplements
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Treatment
Dialysis
Transplantation
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Chronic Renal Failure
Nursing diagnosis
Excess fluid volume related to decreased
urine output, dietary excesses, and
retention of sodium and water
Imbalanced nutrition: less than body
requirements related to anorexia, nausea
and vomiting, dietary restrictions, and
altered oral mucous membranes
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Nursing diagnosis
Deficient knowledge regarding condition
and treatment regimen
Activity intolerance related to fatigue,
anemia, retention of waste products, and
dialysis procedure
Risk for situational low self-esteem related
to dependency, role changes, changes in
body image, and sexual dysfunction
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Chronic Renal Failure
Nursing care : see world document
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Dialysis
Dialysis is used to remove fluid and uremic
waste products from the body when the
kidneys are unable to do so.
Chronic: in ESRF when the kidney can’t
remove waste products.
Acute: high level of serum K+, fluid
overload, or impending pulmonary edema,
acidosis, to remove certain medications or
other toxins from the blood.
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Dialysis
½ of patients with CRF eventually
require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
Hemodialysis
Peritoneal dialysis
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Principles for dialysis
Diffusion: toxins and wastes in the
blood are removed
Osmosis: excess water is removed from
the blood
Ultrafiltration: helps water to move
faster under high pressure to an area of
lower pressure
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Hemodialysis
3-4 times a week
Takes 2-4 hours
Machine (dialyzer)
filters blood
and returns it to
body
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Chronic Renal Failure
Hemodialysis
Vascular access
Temporary – subclavian or
femoral
Permanent – shunt, in arm
Care post insertion
Can be done rapidly
Takes about 4 hours
Done 3 x a week
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Types of Access
Temporary site:
subclavian or
femoral
Permanent: shunt,
in arm
AV fistula
Surgeon constructs
by combining an
artery and a vein
3 to 6 months to
mature
AV graft
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What This Means For You
No BP on same arm as fistula
Protect arm from injury
Never inject anything into catheter
Control obvious hemorrhage
Bleeding will be arterial
Maintain direct pressure
No IV on same arm as fistula
A thrill will be felt – this is normal
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Complication of dialysis
Hypotension
Painful muscle cramping (due to rapid
alterations in electrolyte balance)
Dysrhythmias may result from
electrolyte and pH changes
Air embolism
Dialysis disequilibrium results from
cerebral fluid shifts.
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Peritoneal Dialysis
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Peritoneal Dialysis
Abdominal lining filters blood
3 types
Continuous ambulatory
Continuous cyclical
Intermittent
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Dialysis
Peritoneal dialysis
Semipermeable
membrane
Catheter inserted
through abdominal wall
into peritoneal cavity
Cost less
Fewer restrictions
Can be done at home
Risk of peritonitis
3 phases – inflow, dwell
and outflow
Automated peritoneal
dialysis
Done at home at night
Maybe 6-7 times /week
CAPD
Continous ambulatory
peritoneal dialysis
Done as outpatient
Usually 4 X/d
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Chronic Renal Failure
Transplant
Must find donor
Waiting period long
Good survival rate – 1 year 95-97%
Must take immunosuppressant’s for life
Rejection
Watch for fever, elevated B/P, and pain over
site of new kidney
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Chronic Renal Failure
Post op care
ICU
I/O
B/P
Weight changes
Electrolytes
May have fluid volume deficit
High risk for infection
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Transplant Meds
Patients have decreased resistance to
infection
Corticosteroids – anti-inflammarory
Deltosone
Medrol
Solu-Medrol
Cytotoxic – inhibit T and B lymphocytes
Imuran
Cytoxan
Cellcept
T-cell depressors - Cyclosporin
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Renal Trauma
? due to rib fractures or fractures
vertebrae.
80% to 90% of all renal injuries are
blunt injuries
S & S: Pain, hematouria, S & S of shock
Rx: Bed rest, antibiotics. In sever cases,
need surgical repair or ? Nephrectomy.
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