Transcript End Stage Renal

Chronic Renal Failure (End Stage Renal
Disease “ESRD”)
Dr. Belal Hijji, RN, PhD
April 18 & 23, 2012
Learning Outcomes
At the end of this lecture, students will be able to:
• Recognise what ESRD means and its causes.
• Discuss the pathophysiological changes associated with
ESRD.
• Describe the clinical manifestations of ESRD, and related
assessment and diagnostic findings.
• Describe the medical management of a patient with ESRD.
• Discuss the nursing management of a patient with ESRD.
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Introduction
• Chronic renal failure, or ESRD, is a progressive and
irreversible deterioration in renal function in which the body’s
ability to maintain metabolic and fluid and electrolyte balance
fails, resulting in retention of urea and other nitrogenous
wastes in the blood.
• Diabetes mellitus may cause ESRD. Other causes may be
hypertension, chronic glomerulonephritis, pyelonephritis,
obstruction of the urinary tract, heredity, as in polycystic
kidney disease, vascular disorders, infections, medications, or
toxic agents.
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Pathophysiology of ESRD
• As renal function declines, the end products of protein
metabolism accumulate in the blood. Uremia develops and
adversely affects every system in the body. The greater the
buildup of waste products, the more severe the symptoms.
• ESRD occurs when there is less than 10% nephron function
remaining. All of the normal regulatory, excretory, and
hormonal functions of the kidney are severely impaired.
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Pathophysiology of ESRD (Continued….)
• The rate of decline in renal function and progression of
chronic renal failure is related to the underlying disorder, the
urinary excretion of protein, and the presence of hypertension.
The disease tends to progress more rapidly in patients who
excrete significant amounts of protein or have elevated blood
pressure than in those without these conditions.
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Clinical Manifestations of ESRD
• Because virtually every body system is affected by the uremia
of chronic renal failure, patients exhibit a number of signs and
symptoms. The severity of these signs and symptoms depends
in part on the degree of renal impairment, other underlying
conditions, and the patient’s age. The clinical manifestations
accompanying certain disorders associated with ESRD are
presented next.
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Clinical Manifestations of ESRD
• Cardiovascular: These are hypertension (due to sodium and
water retention), heart failure and pulmonary edema (due to
fluid overload), and pericarditis (due to irritation of the
pericardial lining by uremic toxins).
• Dermatologic symptoms: Severe itching (pruritus) is common.
• Other systemic manifestations: GI signs and symptoms
(anorexia, nausea, vomiting, and hiccups) are common.
Neurologic changes (altered levels of consciousness, inability
to concentrate, muscle twitching, and seizures) were reported.
It is generally thought that the accumulation of uremic waste
products is the probable cause.
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Assessment and Diagnostic Findings
• Glomerular filtration rate: GFR (see next slide) is decreased
resulting in a decrease in creatinine clearance, whereas the
serum creatinine and BUN levels increase. Serum creatinine is
the more sensitive indicator of renal function because of its
constant production in the body.
• Sodium and water retention: In ESRD, some patients retain
sodium and water, increasing the risk for edema, heart failure,
and hypertension. Other patients may lose salt and run the risk
of developing hypotension and hypovolemia.
Nephron
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Assessment and Diagnostic Findings (Continued…)
• Metabolic acidosis: This condition develops as the kidney
cannot excrete increased loads of acid. Decreased acid
secretion primarily results from inability of the kidney tubules
to excrete ammonia
(NH3) and to reabsorb sodium
bicarbonate (CHNaO3).
• Anemia: Anemia results from inadequate erythropoietin
(stimulates bone marrow to produce RBCs) production by
kidneys, the shortened life span of RBCs, nutritional
deficiencies, and blood loss during hemodialysis.
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Medical Management
• Pharmacologic therapy:
– Antacids: Hyperphosphatemia and hypocalcemia are treated
with aluminum-based antacids that bind dietary phosphorus in
the GI tract. To avoid the potential long-term-toxicity of
aluminum and its association with neurologic symptoms,
calcium carbonate is prescribed.
– Antihypertensive and Cardiovascular Agents: Hypertension
is managed by intravascular volume control (via dietary salt
restriction) and a variety of antihypertensive agents. Heart failure
and pulmonary edema may also require treatment with fluid
restriction, low-sodium diets, diuretic agents, inotropic agents
such as digitalis or dobutamine, and dialysis.
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• Pharmacologic therapy (Continued……):
– Antiseizure Agents: Neurologic abnormalities such as
seizures are controlled via intravenous diazepam (Valium) or
phenytoin (Dilantin). The side rails of the bed should be padded
to protect the patient.
– Erythropoietin: Anemia associated with chronic renal failure
is treated with recombinant human erythropoietin (Epogen).
Anemic patients (hematocrit less than 30%) are treated with
Epogen to achieve a hematocrit of 33% to 38%, which generally
alleviates the symptoms of anemia. Epogen is administered
either intravenously or subcutaneously three times a week, and it
may take 2 to 6 weeks for the hematocrit to rise.
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• Nutritional therapy:
– Protein is restricted because urea, uric acid, and organic acids
accumulate rapidly in the blood. The allowed protein must be of
high biologic value (dairy products, eggs, meats). Usually, the
fluid allowance is 500 to 600 mL more than the previous day’s
24-hour urine output. Calories are supplied by carbohydrates and
fat to prevent wasting. Vitamin supplementation is necessary
because a protein-restricted diet does not provide the necessary
complement of vitamins. Additionally, the patient may lose
water-soluble vitamins from the blood during dialysis.
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• Hemodialysis:
– Hyperkalemia is usually prevented by ensuring adequate dialysis
treatments with potassium removal and careful monitoring of all
medications for their potassium content. The patient is placed on
a potassium-restricted diet. Dialysis is usually initiated when the
patient cannot maintain a reasonable lifestyle with conservative
treatment.
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Nursing Care Plan of a Patient With ESRD
• Nursing diagnosis: Excess fluid volume related to decreased
urine output, dietary excesses, and retention of sodium and water.
• Goal: Maintenance of ideal body weight without excess fluid.
• Interventions: The nurse should:
 Assess fluid status (Daily weight, intake and output balance,
skin turgor and presence of edema, distention of neck veins,
blood pressure, pulse rate, and rhythm, respiratory rate and
effort).
 Limit fluid intake to prescribed volume.
 Identify potential sources of fluid (medications and fluids used
to take medications; oral and intravenous, foods).
 Explain to patient and family rationale for restriction.
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Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Imbalanced nutrition; less than body
requirements related to anorexia, nausea, vomiting, and
dietary restrictions.
• Goal: Maintenance of adequate nutritional intake.
• Interventions: The nurse should:
 Assess nutritional status (weight changes, serum electrolyte, BUN,
creatinine, protein, transferrin, and iron levels).
 Assess patient’s nutritional dietary patterns (diet history, food
preferences, calorie counts).
 Assess for factors contributing to altered nutritional intake
(Anorexia, nausea, or vomiting, diet unpalatable to patient, depression,
lack of understanding of dietary restrictions, stomatitis).
 Provide patient’s food preferences within dietary restrictions.
 Promote intake of high biologic value protein foods
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Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Deficient knowledge regarding condition and
treatment.
• Goal: Increased knowledge about condition and related
treatment.
• Interventions: The nurse should:
 Assess understanding of cause of renal failure, its meaning and
consequences, and its treatment.
 Provide explanation of renal function and consequences of renal
failure at patient’s level of understanding and guided by patient’s
readiness to learn.
 Provide oral and written information as appropriate about renal
function and failure, fluid and dietary restrictions, medications,
reportable problems, signs, and symptoms, follow-up schedule,
community resources, and treatment options.
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Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Activity intolerance related to fatigue,
anemia, retention of waste products, and dialysis procedure.
• Goal: Participation in activity within tolerance.
• Interventions: The nurse should:
 Assess factors contributing to fatigue (anemia, fluid and electrolyte
imbalances, retention of waste products, depression)
 Promote independence in self-care activities as tolerated; assist if
fatigued.
 Encourage alternating activity with rest.
 Encourage patient to rest after dialysis treatments.
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