Transcript Document

Nursing Diagnosis of
Chronic Renal Failure
7/18/2015
Mary Roche, RN
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Nursing Diagnoses
Renal Failure
• Fluid Volume Deficit/Fluid Volume Excess
• Altered Nutrition: Less Than Body
Requirements
• Risk Of Impaired Skin Integrity Related to
Poor Nutrition/Edema And Pruritus
• Anxiety Related to Unknown Outcome of
Disease
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Chronic Renal Failure
• Progressive Reduction of Functioning Renal
Tissue
– Remaining Kidney Can No Longer Maintain Internal Environment
• Insidiously or Acutely Post Renal Failure
• Hypertension and Diabetes the Most
Common Causes
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Nursing Management of Electrolyte
Imbalances in ARF
• Check potassium after dialysis
• Check magnesium levels
• Add water soluble vitamins
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Dietary Restrictions
• Fluid
• Protein
• Potassium
– 60-70 Meq Per Day
• Sodium
• Phosphorus
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Medications for
Chronic Renal Failure
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Diuretics
Vitamins and Minerals
Sodium Bicarbonate
Erythropoietin
Calcium Preparations and Phosphorus Binders
Antihypertensives
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Goals for Dialysis
• Removal of Blood Urea and Creatinine
• Maintenance of Safe Concentration of
Serum Electrolytes
• Correction of Acidosis, Replenishment of
Bicarbonate Buffer System
• Removal of Excess Fluid from Blood
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Key Concepts of Dialysis
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Diffusion
Filtration and Ultrafiltration
Concentration Gradient
Osmosis
– See Page 283 Of Handout
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Medical Goals of
Chronic Renal Failure
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Preservation of Renal Function
Delay of Need for Dialysis or Transplant
Improvement of Body Chemistry
Alleviation of Extrarenal Effects
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Electrolyte Imbalances
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Potassium Increases
Phosphate Increases
Sodium - Normal or Decreased
Magnesium Increases
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Vascular Access For Hemodialysis
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Subclavian/Internal Jugular Double Lumen
Udall (Subclavian or Femoral)
Mahurkar and Permacath (Subclavian)
Av Fistula/Av Graft
– Refer To Iggy Page 1923, Figure 75.9
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Nursing Care of
Arteriovenus Fistula
• Initally Assess Hemorrhage, Infection,
Edema. Elevate Arm
• No B/P, Venipunctures, IV in Access Arm
• Assess Function Of Fistula
– Bruit And Thrill
• Assess Distal Pulse Circulation
• Allen’s Test
• No Carrying Heavy Objects
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Dialysis - Nursing Care
• Prior to Dialysis
• During Dialysis
– See Pages 283 To 292 in Handout
• Post Dialysis
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Nursing Management of Peritoneal
Dialysis
• Installations and Dwell Periods
• Dialysate
• Outflow Times
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Nursing Management of Peritoneal
Dialysis
• Installations
– 1 to 2 liters over 30 minutes
• Dwell Periods
• Dialysate
• Outflow Times
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Nursing Care Highlights
• Patients with Peritoneal Dialysis Catheter
– sterile procedure
• A mask should be worn by the patient also
– aseptic techniques
• follow procedure as defined
– catheter site
• must be free of signs and symptoms of infection
(redness, pus, odor)
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Chronic Renal Failure
Continuous Renal
Replacement Therapies
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Four Primary Types of CRRT
(CAVH)
Continuous Arteriovenous Hemofiltration.
Blood flows through a semipermeable filter and
an extracorporeal circuit.
CAVH is not a controlled procedure for fluid
removal. It is used primarily when a machine
with more advanced CRRT systems isn’t
available.
Its ability to remove and replace fluid is effective
and a relatively simple technology.
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Four Primary Types of CRRT
(CAVHD)
Continuous Arteriovenous Hemodiafiltration.
Blood flows through a semipermeable filter and
an extracorporeal circuit compartment.
CAVHD is used when CAVH does not provide
adequate waste removal.
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Four Primary Types of CRRT
(CVVH)
Continuous Venovenous Hemofiltration.
Blood flows through a semipermeable fiber
filter and an extracorporeal circuit. It requires
use of a pump to propel blood through the
circuit.
CVVH uses a process called convective
transport to effect solute removal.
Replacement solution can be added and fluid
removal can occur if desired.
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Four Primary Types of CRRT
(CVVHDF) Continuous Venovenous
Hemodiafiltration.
Blood flows through a semipermeable filter
and dialysate is delivered through the
extracorporeal compartment of the filter.
It increases solute removal (via diffusion) more
effectively than convective transport of CVVH
does.
Fluid removal can occur as well, if desired.
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Advantages
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Less risk of overload.
TPN is enhanced.
Optimizes hemodynamic status.
Decreases extravascular lung water.
Corrects lactic acid levels.
Corrects clear chemical mediators such as
leukotrienes.
• Associated with lower rates of morbidity and
mortality.
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Advantages
• Associated with higher rates of complete renal
recovery.
• Gentle continuous hemofiltration avoids
complicates associated with hemodialysis
(cardiac stress, rapid fluid shifts, etc.).
• High ultrafiltration rate permits large-volume
fluid administration as in TPN and drug dosing.
• CVVH and CVVHDF do not require arterial
access making management safer.
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Disadvantages
Need for arterial access in CAVH and CAVHD.
– These two methods use the patient’s own BP and clotting may
occur.
• Clearance of nephrotoxic substances is limited in patients
who are catabolic.
• Bleed is a risk.
– If line is disconnected, exsanguination would be rapid.
• No air detectors,
– Possibility of air embolism exists.
• Limited patient mobility.
• Slower solute and fluid removal.
• Anticoagulation often needed to maintain patency.
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Indications for Use
Indications include:
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Hemodynamic instability, and.
Multiple organ dysfunction syndrome.
When accompanied by:
1. Renal failure,
2. Fluid volume overload, and.
3. Metabolic and acid-base disturbances.
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Conditions or Situations
Necessitate Strict Fluid Regulation
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The period after MI
The period after open heart surgery
Resistance to diuretic therapy
Total parenteral nutrition
End-stage renal disease in patients too unstable to
tolerate hemodialysis or peritoneal dialysis
Adult respiratory distress syndrome
Crush injuries
Lactic acidosis
Heart failure
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Contraindications
• include the following:
– Coagulopathy
– Liver disease
– Active bleeding
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Contraindications
• Anticoagulant therapy
– an integral part of CRRT,
– administration may be contraindicated in some patients
with bleeding or clotting disorders or liver disease.
• Heparin
– need not always be used,
– nurses should be aware of the increased risk of filter
clotting.
– Alternatives to heparin, such as sodium citrate, may be
used. Because of possible metabolic derangements with
sodium citrate, it should be used only with CAVHD or
CVVHDF.
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Contraindications
• Hyperkalemia
– Because of slow solute removal, CAVH and
CVVH are not recommended in patients with
life-threatening hyperkalemia.
• Diffusion
– the movement of solutes from an area of higher
concentration, passing across a semipermeable
membrane, to an area of lower concentration,
until equilibrium is reached.
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How CRRT Works
• Convection
– involves the transfer of solutes and solvents
simultaneously across a semipermeable membrane.
• When water moves across a semipermeable membrane, the
pressure gradient causes friction. Some molecules are then
dragged across with the water, creating a sort of vacuum.
• This solute movement is convective transport.
• Both the CAVH and CVVH processes use convection to
remove some solutes.
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How CRRT Works
In CAVHD and CVVHDF, both diffusion and
convective transport take place, resulting in a
greater clearance of solute than in CAVH and
CAVVH, which involve only convective transport.
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Extracorporeal Systems
• All four methods of CRRT have relatively simple
extracorporeal systems.
• Each uses a semipermeable membrane of hollow
fibers, a collection bag, and two blood lines.
• The access line (arterial or venous) is where blood
travels from the patient to the filter.
• The return line (venous) is where the blood returns
from the filter to the patient.
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Extracorporeal Systems
• The hollow fiber filter comprises a cylindrical support case
that surrounds the semipermeable membrane (the hollow
fibers).
• The space between the support case and the outside of the
membrane is the extracapillary side.
• The inside of the membrane is the blood or capillary side.
• There are two ports on the filter casing, one leading to a
collection bag for filtrate and another that delivers the
dialysate to the filter.
• The dialysate ultimately drains into the same collection
bag as the filtrate.
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Nursing Management
• CRRT is performed in the ICU to minimize
complications.
– It is essential to continually assess the hemodynamic
status as well as BP, heart rate and rhythm while blood
is pumped onto extracorporeal circulation.
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Nursing Management
• Assessment of fluid status, including central
venous pressure, pulmonary artery pressure, and
pulmonary artery occlusive pressure, provides
clinical data.
– Nurses should watch for changes in mental status,
breath sounds, and skin turgor and for the presence of
arrhythmias, edema and signs and symptoms of
bleeding or infection.
• Calculation of fluid balance is based on hourly and
cumulative measurement of fluid intake and
output.
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Nursing Management
• Aggressive management of hypotension related to
hypovolemia is required to avoid alterations in
tissue perfusion.
– Monitoring for signs of hemorrhage as there is high risk
caused by accidental disconnection of the lines from the
body.
• Monitoring heat loss as a significant amount of
heat is lost as the blood makes its way through the
extracorporeal part of the circuit.
– Assessing for infection at catheter sites and monitoring
white blood count as well as monitoring for fever.
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Managing The CRRT System
• The nursing role
– Nurses have a pivotal role in assessing patient’s
tolerance to therapy and in managing equipment and the
patency of the circuit
• Electrolyte and acid-base imbalances
– Patients receiving CRRT are at risk for electrolyte and
acid-base imbalance either as a result of the underlying
condition or through loss in the ultrafiltrate
– The nurse must manage and monitor the acid-base
balance and administer supplements as necessary
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Managing The CRRT System
• Filter clotting and anticoagulation
– Heparin is often administered to maintain the patency
of the circuit and prevent filter clotting
– Monitoring both patients and filters is essential to
preventing complications of heparin therapy
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Managing The CRRT System
• Air and blood leakage detectors
– During CAVH, ultrafiltrate should be tested for the
presence of occult blood every four to six hours
– An air detector to prevent the development of an air
embolus is part of the CVVH circuit
– Another part of the CVVH system is a blood leakage
detector which helps identify ruptured hollow fibers
within the filter. If blood is detected an alarm will
sound
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Peritoneal Dialysis
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Osmosis
Diffusion
Dialysate concentrations
Dwell times
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Post Dialysis Nursing Management
• Observe for:
– Disequilibrium syndrome
– Orthostatic Hypotension
• Monitor for:
– Bleeding
– Hematoma
– Patency
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Post Dialysis Nursing Management
• Obtain vital signs and weight
• Perform frequent Neuro assessment
• See pages 287 to 291 in handout
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Complications of
Peritoneal Dialysis
• Peritonitis
– Use meticulous aseptic technique
– Check for
• Fever, rebound tenderness, nausea, malaise
– Monitor WBC count
• Hyperglycemic and Hyperosmolar states
• (Especially with high glucose dialysate)
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Nursing Diagnoses For
Chronic Renal Failure Patient
• Fluid volume deficit or excess
• Altered nutrition
– Less than body requirements
– Related to anorexia, nausea
• Fatigue
– Related to anemia and altered metabolic state
• Impaired skin integrity
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Nursing Diagnoses For
Chronic Renal Failure Patient
Continued:
• Knowledge deficit
– Related to disease process and treatment
• Ineffective management of therapeutic regime
• Ineffective family coping
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Kidney Transplants
• Intervention for irreversible kidney failure
• Implantation of a human kidney to one patient
from another
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Living Related Donor
• Requirements
– Two properly functioning kidneys
– Excellent health
– Compatible
• ABO
– Blood type
• Tissue type
• HLA
– Human leukocyte antigen
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Cadaver Donor
• Requirements
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Must meet criteria for brain death
Under 60 years of age
Normal renal function
Normal BP
Negative hepatitis antigen
Negative HIV antibody
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Post Operative Management
• Rejection
– Hyperacute
• Within 48 hr after surgery
– Acute
• 1 wk to 2 yr post operatively
– Chronic
• Occurs gradually during a period of months to year
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Immunosuppressant Drugs
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Cyclosporine (Sandimmune)
Muromonab-cd3
Tacrolimus (Prograf, FK-506)
Mycophenolate (Cellcept)
Prednisone
Azathioprine (Imuran)
Sirolimus (Rapamune)
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The End
Mary Roche, MSN, RN, CS
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Public Version
• This presentation was developed for Mary Roche
by peter martin dba Stacy house designs
• A public version is available under the web
developments section of www.stacyhouse.com
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Using The Umbilicus For
Catheterization
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The Mitrofanoff Procedure
• Creates a catheterizable channel between a stoma
on the skin of the abdomen (usually the umbilicus)
and the bladder.
• Allows patients to intermittently empty their
bladder by inserting a disposable catheter into the
channel.
– Also called an appendicovesicostomy because
the appendix is used to create the channel.
• First described in 1980, has become the most
widely used alternative to urethral selfcatheterization in the world.
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The Mitrofanoff Procedure
• It is highly successful with continence achieved in
more than 90% of patients.
• Is used for patients who have:
– A neurogenic bladder or other conditions that
interfere with continence and.
– Who are unable to easily self-catheterize
through the urethra.
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The Mitrofanoff Procedure
• Typically, this procedure is performed in pediatric
specialty institutions or major medical centers.
• Understanding this procedure is important if you
work in med-surg, long-term care, school, or rehab
setting.
• For most patients, the primary reason to undergo
the Mitrofanoff procedure is physiological – to
maintain a healthy urinary tract and establish
urinary continence through intermittent
catheterization via an easily accessible stoma.
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The Mitrofanoff Procedure
• For patients with spinal cord injuries, the
procedure can help stem the continued potential
for deterioration of renal function.
• For others, there is improved quality of life.
• It is essential to make sure that the patient has the
physical ability, mental capacity, self-discipline,
and psychological readiness to perform the selfcatheterizations.
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Screening Candidates
• The majority of patients who undergo a
Mitrofanoff procedure will require a rigid
schedule of self-catheterization – typically once
every four hours while awake – to achieve dryness
and prevent the complications of continued
incontinence.
• There is extensive bowel prep, antibiotic therapy
and laboratory work preop.
– Cystourethrogram and renal ultrasound are needed to
assess the patient for any structural abnormalities of the
urinary tract.
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Using The Appendix
to Create a Channel
• During the procedure, a channel from the bladder
to the abdomen is created to achieve entrance to
the bladder.
• Because the appendix has a constant, reliable
blood supply, supple muscular wall, and adequate
lumen, it has proven to be the ideal tissue with
which to create the channel.
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Using The Appendix
to Create a Channel
• After the mucosa to mucosa anastomy a flap valve
is created to prevent reflux and leakage of urine.
• The stoma is then created and concealed in the
umbilicus.
• Postoperatively, patients generally have a 12F cath
placed through their appendicovesicostomy.
• While undergoing surgery some patients may
undergo bladder augmentation with segment of
stomach or intestine.
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Using The Appendix
to Create a Channel
• The catheter remains in place about three weeks
and the patient goes home with them.
• After then, the stoma is healed and functional.
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Post Op And Followup
• Patients are sent home with the
appendicovesicostomy and urethral catheters in
place, though the appendicovesicostomy catheter
is clamped.
• Approximately three weeks postop, the patient
returns to the hospital.
– Both catheters are removed and the patient is taught
how to perform self-cath through the
appendicovesicostomy.
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Post Op And Followup
• Patient must be explained that since the catheter is
entering the bladder from above, emptying is like
siphoning liquid from a gas tank.
– The container must be lower than the bladder, and when
urine begins to flow, the catheter should be pushed in
another one to one-and-one-half inches to insure
adequate bladder drainage.
• Patients should be taught to use sterile technique
and report any signs of infection.
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Post Op And Follow-up
• Patients must use the conduit regularly to ensure
patency.
– To date, minimal complications have been reported.
– Stomal stenosis must be watched for and 7% to 24% of
patients experience this.
– Stomal stenosis can occur if the appencovesicostomy is
not dilated frequently enough.
– Repeated self dilation by intermittent selfcatheterization can usually remedy this problem.
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Post Op And Follow-up
• Stone formation in the bladder or kidney can be a
long-term complication.
• The longer a channel is in place, the greater the
chance for stone formation.
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