Acute and Chronic Renal Failure

Tina Bayer-Hummel RN ANP Assistant Professor Of Nursing Queensborough Community College

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Assessment: Identify physical assessment changes in the client in renal failure. Communication: Utilize SBAR format and information technology to support and communicate plan of care for in acute renal failure. Caring Interventions:. Identify social, cultural, economic factors that impact care. Clinical decision Making: Identify and discuss nursing interventions appropriate for the client in acute/chronic renal failure. Teaching/Learning: Explain dialysis to families, significant others.

Objectives Based on the QCC Framework

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Collaboration: Describe collaborative management of the client in acute/chronic renal failure. Managing Care: Identify the nursing management of the client in acute/chronic renal failure.

Objectives Based on the QCC Framework

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1. 2. 3. 4. 5. 6. 7. 8. 9.

Eliminate water-soluble nitrgoenous endproducts of protein metabolism; Excretion of waste products. Maintain electrolyte balance in body fluids Get rid of the excess electrolytes. Discharge excess water in the urine. Maintain acid-base balance in body fluids and tissue. Control of blood pressure. Regulation of red blood cell production. Synthesis of vitamin D to active form. Regulates calcium and phosphorus balance.

Kidney System Functions

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BUN - Blood urea nitrogen. measure of the kidneys' ability to excrete urea, the chief waste product of protein breakdown Elevated in renal failure and dehydration 7 - 20 mg/dl

Creatinine: A waste product from protein in the diet and from the muscles of the body. removed from the body by the kidneys Increased in kidney disease 0.5 to 1.0 mg/dL

Important Lab Values

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Creatinine Clearance Test

compares the level of creatinine in urine with the creatinine level in the blood 24-hour urine sample Male: 97 to 137 ml/min. Female: 88 to 128 ml/min. estimate the glomerular filtration rate (GFR) -the standard by which kidney function is assessed range 90 - 120 mL/min

Important Test
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GFR-Levels below 60 mL/min for 3 or more months are a sign of chronic kidney disease. Those with GFR results below 15 mL/min are a sign of kidney failure.

GFR
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Parenchyma - The key elements of an organ essential to its functioning Uremia retention in the bloodstream of waste products normally excreted in the urine, urea, creatinine and other nitrogen containing waste products of proteins . Also called Azotemia. resulting from kidney disease Anuria - total urine output less than 50 mL in 24 h

Oliguria - total urine output less than 400 mL in 24 h

Definitions
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Increased age Preexisting renal disease Administration of several nephrotoxic agents simultaneously

Risk Factor for ARF

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Severe impairment or total lack of kidney function Inability to excrete metabolic waste products and water Classified as acute or chronic May manifest as oliguria, anuria, or normal urine volume

Renal Failure
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Rapid decline in renal function Potentially reversible but does have high mortality rate Nephrotoxins, Ischemia, Obstructions, Most Common Causes

Acute Renal Failure

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Progressive Azotemia- accumulation off nitrogenous wastes (BUN) Increased serum Creatinine Oliguria K

Acute Renal Failure

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Mechanisms: Pre-renal -- volume depletion, poor cardiac efficiency, vasodilation Intra-renal -- prolonged ischemia, myoglobinuria, infections, nephrotoxins, glomerulonephritis Post-renal -- obstruction from stone, tumor

Acute Renal Failure

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Mechanisms: Pre-renal -- volume depletion, poor cardiac efficiency, vasodilation

Intra-renal -- prolonged ischemia, myoglobinuria, infections, nephrotoxins, glomerulonephritis, trauma Post-renal -- obstruction from stone, tumor MECHANICAL OBSTRUCTION from the tubules to urethra. BPHmost common

Acute Renal Failure

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Prerenal -- Systemic Cause Hypo perfusion- in blood pressure Hypovolemia R/T-hemorrhage Cardiogenic Shock Sepsis

Types of Renal Failure

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Intrarenal Causes: Direct Damage to the Kidneys Ischemia from MI Myoglobinuria cause of Rhabdomylysis Hemoglobinuria Nephrotoxic Agents Acute plyleonephrirtis

Types of Renal Failure

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Post Renal Causes : Obstruction of Urine Flow

Tumors STONES Clots Strictures

Types of Renal Failure

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Four clinical phases: Initiation: Initial insult to oliguria 400ML/24hrs Oliguria: Bun/Creatinine, Rise in serum concentration of substances excreted by kidney K+, Magnesium, U/O Diuresis: Gradually increasing U/O lab values stabilize Recovery: Improvement of renal function 3-12 months Permanent 1-3% reduction in GFR

Clinical Manifestations
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Every system of the body is affected CNS-Lethargy, Confusion, Headache ,Seizures CV-Congestive Heart Failure ,HTN Lungs- SOB Skin/Hair/Nails-Dry thin scaly GI- Diarhea ,Nausea, Vomiting, Uremic GI lesions Gu-Oliguria Anuria Blood in urine

Clinical Manifestations
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BUN, Creatinine-Azotemia As a result of catabolism( breakdown of protein) and impaired renal perfusion Creatinine Glomerular damage

Abnormal lab values

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Hyperkalemia as result of the in GFR Patients can not excrete K+ normally Protein catabolism K+ = in body fluid Can cause dysrhythmias and cardiac arrest Source of K+ is GI blood loss, dietary, extracellular shift related to metabolic acidosis

Abnormal lab values

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RBC ,Hemoglobin/HCT R/T abnormally low production of red blood cells by the bone marrow R/T inability of the failing kidneys to secrete the hormone erythropoietin Uremic GI lesions Blood loss Reduced RBC life span

Anemia
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Related to oliguria unable to eliminate acids Normal renal buffering system fails Fall in CO2 combining power Progressive Can cause cardiac arrhythmias

Metabolic Acidosis
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Increase in serum phosphate Decrease in calcium levels Decreased CA++ absorption from GI tract At risk for stress fractures

Changes in Calcium and Phosphorus

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Summary of ARF Categories

Characteristics Etiology BUN PreRenal Intrarenal Postrenal Obstruction Increased Hypo-perfusion Parenchymal damage Increased Increased (out of normal 20:1 proportion to creatinine) Increased Increased

Creatinine

Increased

Urine output

Decreased

Varies, often decreased

Increased to >40 mEq/L Abnormal casts & debris

Varies, may be decreased, or sudden anuria

Varies, often decreased to 20 mEq/L or less Usually normal

Urine sodium Urinary sediment

Decreased to <20 mEq/L Normal, few hyaline casts

Urine osmolality
Urine specific gravity

Increased to 500 mOsm

Increased

About 350 mOsm similar to serum

Low normal

Varies, increased or equal to serum

Varies Spring 2013
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Restore normal electrolyte balance Prevent complications Prevent anuria if possible Allow kidneys time to regenerate until normal kidney function resumes

Medical Management
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Pre-Renal
Increase renal perfusion Blood loss Blood transfusion

Intra-Renal
Supportive Restrict meds that are excreted by kidneys Remove causative agent

Post-Renal
Remove obstruction Avoid Complications

Hypovolemia -Infuse Albumin ,Normal Saline

Aggressive Management of prerenal and post renal causes

concentrations, losses, B/P Measure all output

Treatment Fluid balance based on daily body weight, CVP, serum and urine
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Supportive Management

Increase renal perfusion Blood loss Blood transfusion Hypovolemia -Infuse Albumin ,Normal Saline

Prerenal treatment
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Supportive Restrict meds that are excreted by kidneys Remove causative agent Aggressive Management of prerenal and post renal causes

Intra Renal Treatment

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Remove obstruction Avoid Complications

Post Renal Treatment

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Fluid balance based on daily body weight, CVP, serum and urine concentrations, losses, B/P Measure all output

Management
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Limit protein to 1g/kg during oliguric phase to minimize protein breakdown and avoid accumulation of toxic end products High carbohydrate protein sparing diet provides energy and lets protein be used for tissue healing

Dietary Modifications
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Foods with K+ are restricted including bananas, citrus juices, coffee K+ intake restricted to 40-60 mEq/day Na restricted to 2 g/day Oliguric phase may go for 20 days Protein may be increased after the diuretic phase is over

Diet Modifications
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Hyperkalemia

(Sodium Polystyrene Sulfonate) exchange Na for K+ in the intestinal tract orally/ Retention Enema High Phosphate - Use aluminum base antacid

- Give Kayexalate

Medical Management
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Monitor fluid and electrolyte balance strict I/O Monitor V/S Reduce metabolic rate- catabolism releases K+ and accumulates urea and creatinine Bed rest, treat fever promptly Promote pulmonary function- cough and deep breathe Prevent skin infection, skin care

Nursing Management
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Dialysis support Full Assessment listen to lungs check for rales check for edema at periorbital, sacral, pedal areas Monitor for infection prevent where possible Monitor CVP Swan Ganz readings if available

Nursing Management
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Prevalence (2010): More than 10 percent of people, or more than 20 million, ages 20 years and older in the United States have CKD End-stage Renal Disease (ESRD) Prevalence (2008): 547,982 U.S. residents were under treatment as of the end of the calendar year.

http://kidney.niddk.nih.gov/kudiseases/pubs/k ustats/ Statistics ESRD

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Diabetes mellitus Hypertension Chronic glomerulonephritis Pyelonephritis or other infections Obstruction of urinary tract Hereditary lesions Vascular disorders Medications or toxic agents

Causes of Chronic Renal Failure

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Rate of decline, progression of CRF related to underlying disorder, hypertension, rate of protein excretion Manifestations: CV problems manifested in ESRD-Hypertension, CHF, pulmonary edema, pericarditis, pericardial friction rub, hyperkalemia,hyperlipidemia

Chronic Renal Failure

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Progressive irreversible deterioration in renal function Results in impaired fluid and electrolyte imbalance Azotemia retention of nitrogenous wastes in the blood

Chronic Renal Failure

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Periorbital edema GU - progressively less to no urine output CV- CHF HTN edema Pulmonary rales, SOB, depressed cough reflex, respirations, GI- Nausea, Vomiting, metallic taste, mouth ulcerations, and bleeding, constipation, diarrhea Skin- Puritits, grey bronze color, ecchymosis, thinning hair Hematologic Anemia,Thrombocytopenia Musculoskeletal- muscle cramps Bone fractures

Manifestations
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Calcium and Phosphorus imbalance happens R/T decreased filtration rate there is a increase in serum phosphate level and decrease in serum calcium level Increased parathyrohormone abnormal response with Calcium leaving bone causes bone disease uremic bone disease renal osteodystophy

Manifestations
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Hyperkalemia due to catabolism, excessive intake of medications Pericarditis- pericardial effusion, tamponade Hypertension- malfunction of reninangiotensin aldosterone system Anemia- decreased RBC production and life span at risk for GI bleeding

Complications
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Reverse obstructions Epogen Iron Phosphate binding agents Calcium supplements Dialysis Antacids aluminum based bind to phosphorus calcium carbonate with food avoid magnesium-based antacids

Management
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Internal AV Fistula and Graft

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Used to remove fluid and uremic waste products when the kidneys can not do so Used to treat edema (severe) hyperkalemia, hypercalcemia, Hypertension, hepatic coma and uremia -Types-Hemodialysis, Peritoneal, (CRRT) Contiuous Renal Replacement Therapy

Dialysis
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Hemodialysis most common 3-4 times a week for 3-4 hrs Wastes removed by diffusion excess fluid by osmosis Access achieved via double lumen catheter Into Femoral, Subclavian, Internal Jugular, Veins

Dialysis
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Internal Arteriovenous Fistula and Graft

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Permanent access via surgically created synthetic graft between artery and vein Or a Fistula by joining an artery to a vein -Needles inserted into vessel -Arterial segment used for arterial flow -Venous for reinfusion of dialyzed blood - 4-6 weeks for Fistula to mature

Hemodialysis
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No Blood pressure on affected arm Monitor for infection Feel for thrill as part of daily assessment Listen for Bruit with stethoscope as part of daily assessment Whooshing Sound

Care of Fistulas/Grafts
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 CV-CHF,CAD,

Dysrthymias Pulmonary- SOB, Rales GU- Infections GI-Gastric Ulcers, Nausea/Vomiting Hematological- Anemia,Tryglycerides, Thrombocytopenia

Complications of Hemodialysis
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Disconnect from tubing pt can bleed out Malnourishment Painful muscle cramping Pruritis Fluid overload Hypotension

Complications of Hemodialysis
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Protect vascular access

assess for patency and signs of infection do not use it for BP or blood draws

Bruit, or thrill, at least every 8 hours Monitor fluid balance indicators & IV therapy carefully; keep accurate I&O and IV administration pump records Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data Monitor cardiac and respiratory status carefully Monitor BP; antihypertensive agents must be held on dialysis days to avoid hypotension

Nursing Management
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Reverse obstructions Epogen Iron Phosphate binding agents Calcium supplements Dialysis Antacids aluminum based bind to phosphorus calcium carbonate with food avoid magnesium-based antacids

Management
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Tell whether the following statement is true or false. Hypercalcemia is the most life-threatening of the fluid and electrolyte changes that occur in patients with renal disturbances

Question
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Peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane More gradual change Sterile dialysate fluid Medications added Warmed infused by gravity into the peritoneal cavity 5 to 10 minutes is usually required to infuse 2 to 3 L of fluid Prepare tubing to prevent air entering catheter Abdominal catheter Catheters for long-term use (Tenckhoff, Swan, Cruz) have three sections and two cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms.

Peritoneal Dialysis
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The patient must be alert and have good fine motor skills Pt must be independently able to perform dialysis at home Risk of peritonitis from introduction of bacteria into the peritoneal cavity The higher the dialysate the greater the osmotic gradient the more water is removed Solutions used 1.5% 2.5% 4.25%

Peritoneal Dialysis
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C Continuous Dialysis carries on all the time. A Ambulatory Unlike Haemodialysis you can move around as normal and carry out your daily activities. P Peritoneal An enclosed layer of tissue where Dialysis takes place. The Peritoneal surrounds your intestines. D Dialysis Dialysis removes waste products from your blood.

CAPD
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Usually takes 36 to 48 hrs to achieve what hemodialysis accomplishes in 6 to 8 hrs Diffusion and osmosis Ultrafiltration (water removal) occurs in peritoneal dialysis through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration. Signed consent Baseline vital signs, weight, and serum electrolyte levels The patient is encouraged to empty the bladder and bowel Aseptic technique

Peritoneal Dialysis
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# 1 Peritonitis: evidenced by cloudy drainage, ABD pain, fever, rebound tenderness

Leakage causing infections and skin ulceration Bleeding Complications Hernias of Peritoneal

Dialysis

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Monitor all medications and medication dosages carefully; avoid medications containing K & Mg Address pain and discomfort Implement stringent infection control measures Monitor dietary sodium, potassium, protein, and fluid; address individual nutritional needs Provide skin care: prevent pruritus; keep skin clean and well moisturized; trim nails and avoid scratching Provide CAPD catheter care

Nursing Management
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A patient receiving peritoneal dialysis is complaining of pain with rebound tenderness. The dialysate drainage is cloudy. This symptom is indicative of which acute complication? a. Hernia b. Bleeding c. Leakage d. Peritonitis

Question
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Teaching regarding disease process Teaching regarding diet Teaching regarding Meds Teaching regarding technique especially for Peritoneal Dialysis Evaluation of teaching via return demonstration

Nursing management
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Fluid volume overload Fluid volume deficit Alteration in elimination Alteration in skin integrity Alteration in respiration

Nursing Diagnosis
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Kidney Surgery

Preoperative considerations Perioperative concerns Postoperative management Potential hemorrhage and shock Potential abdominal distention and paralytic ileus Potential infection Potential thromboembolism
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Patient Positioning and Incisional Approaches

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Renal Transplantation

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Living Donor- Relative Cadaver Living Donor- Non Relative

Types of transplants
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Interventions

Pain relief measures and analgesic medications Promote airway clearance and effective breathing pattern by appropriate pain relief, deep-breathing coughing exercises, and incentive spirometry and positioning Monitor UO and maintain patency of urinary drainage systems Monitor for signs and symptoms of bleeding Encourage leg exercises, early ambulation, and monitor for signs of DVT
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MUST STAY ON FOR LIFE! Cyclosporine: Block T cell communication Corticosteroids Also blocks T cell communication Azathioprine: Slows production of T cells Newer antirejection drugs include: Sirolimus ,tacrolimus

Immunosuppressive Drugs Post Transplant

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A 52 year old male with PMH of HTN and DM presents for a diagnostic Cardiac Catherization S/P a positive stress test. The patient has a stent placed in his RCA. After the procedure his BUN and Creatnine begin to rise and his urine output begins to decline What type of renal failure is this patient experiencing? What lab values are most important to evaluate and why? What are the phases of renal failure? What physical assessment changes would be expected? What interventions might you expect? What are your nursing priorities/ diagnosis?

Case Study
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Although there has been a recent decrease in the number of cases, peritonitis is the most common and serious complication of peritoneal dialysis. Because of protein loss with continuous peritoneal dialysis, the patient is instructed to eat a high-protein well-balanced diet. Hypotension, a result of oversecretion of rennin, is common in renal failure

True/False
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The critical care nurse is caring for a patient with acute renal failure in the oliguric phase. The nurse will closely monitor the patient for which commonly experienced electrolyte imbalance? A) Hyperkalemia B) Hypercalcemia C) Hyperlipidemia D) Hyperbilirubinemia

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