Kidneys:

2 kidney locate in Retroperitoneal area

Structure: basic functional unit = nephron
Cortex
Medulla
1-3 million nephrons of each kidney
Receives 20% to 25% of cardiac output
Performs numerous functions

Glomerular filtration rate (GFR)

Result of pressure gradient
80 to 125 mL/min
Reabsorption
Secretion
Hormonal control
Aldosterone
Antidiuretic hormone

 Reabsorption

of filtered bicarbonate
Production of new bicarbonate
Excretion of small amounts of hydrogen
ions

Juxtaglomerular apparatus
Renin-angiotensin-aldosterone system

Sudden deterioration of renal function

Oliguria: low urine output
Azotemia: accumulation of nitrogenous
wastes
Acid-base disturbances

Prerenal
Renal: intrinsic; parenchymal
Postrenal

Diminished blood flow; hypoperfusion of the

kidney
Volume depletion
Vasodilation
Decreased cardiac output

Can progress to intrarenal damage

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Obstruction of flow:
+Kidney stones
+Tumor in side and out side ureters,
bladder, urethra
Increase intratubular pressure leading to
decreased GFR
Reverses when obstruction is removed

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 Renal

tissue damage directly:

Glomerulo nephritis, exp: Streptococcal bacterial infections

may damage the glomeruli
Vascular
Acute interstitial nephritis
-Medications such as antibiotics, AINS (aspirin, brufen)
-Infections and immune-related diseases such as lupus ,
leukemia, lymphoma, and sarcoidosis.
Tubules
Hematologic problem

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Acute tubular necrosis (ATN)

Ischemia: trauma, hemorrhage shock
Nephrotoxic agents
Antibiotics: aminoglycoside, vancomycin
Non-steroidal anti-inflammatory drugs (NSAIDs)

Contrast-induced:
Rhabdomyolysis: convulsion, intoxication,
hemolyse

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Prerenal: decreased blood supply

Renal: failure of nephrons
Postrenal: obstruction of outflow

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Acute tubular necrosis

IV. Course of ARF: 3

phases

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PHASES OF ARF
Initiating

phase
Oliguric phase
Diuretic phase and probably recovery phase

Initiation phase
Time from event to signs of decreased renal
perfusion
Few hours to 2 days

Potentially reversible

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Maintenance phase (oliguric/anuric)

BUN and creatinine increase daily
Oliguria is common: Urine output less than 400
mL/day
Urine output less than 200 mL/day: anuric
Fluid overload, electrolyte imbalances, and
acidosis
Renal replacement therapy required

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Recovery phase
Return of tubular function
4 to 6 months for BUN and creatinine to return to
normal
Residual impairment of GFR
Early dialysis may prevent the traditional
diuretic phase of ARF

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V. How to assess the renal

system
(Nursing diagnoses)
-Pt history
-Clinical presentations
-Physical examinations
-Labolatory tests: serum, urine
-Diagnostic studies
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Predisposing factors
Disease states

Hypertension
Diabetes
Immunologic disease
Hereditary disorders

Hypotensive episodes
Exposure to nephrotoxic agents

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Vital signs may be altered

Blood pressure changes depending on etiology
Hyperventilation to compensate for metabolic
acidosis
Body temperature may be altered

Assess for volume depletion and volume

overload

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Skin: edema, dry, petechiae

Body weight (W gain/loss), input, output
information
Signs of overload: neck vein distention, BP, HR, dry
or wet mucous/membranes, breath sounds
Signs of complications:
+HF, pulmonary edema
+Anemia,
+Neuromuscular: drowsiness, confusion, irritability,
coma, convulsions
+Gastrointestinal signs: anorexia, nausea, vomiting

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Serum creatinine
Serum BUN

Affected by catabolism, bleeding, and dehydration

Bun: creatinine ratio

Normal 10:1 to 20:1
More than 20:1, suspect nonrenal causes of
laboratory abnormalities

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Urine creatinine clearance

Normal 84 to 138 mL/min
Can calculate an estimated value with serum lab
values (Cockroft and Gault formula)

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Urine electrolytes
Urine specific gravity
Urine osmolality

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Non-invasive tests
X-ray of kidneys, ureter, and bladder (KUB)
Size, shape, and position of kidneys
Calculi, cysts, and tumors

Renal ultrasound
Size of kidneys
Obstruction

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Invasive tests: doctor demand

IV pyelogram
Computed tomography
Structures, accumulation of fluid

Renal angiography
Abnormalities in blood flow; infarction, masses

Renal scan
Renal uptake of isotopes

Renal biopsy
Histologic changes

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Each nursing care plan includes:

1. Nursing diagnosis
2. Interventions
3. Rationales

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Hyperkalemia
Low excretion

Hyperphosphatemi
a

Hyponatremia

Low excretion

Fluid retention

Hypocalcemia

Hypermagnesium
Low excretion

Low excretion of
phosphorus
Decreased level of
vitamin D

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Due to decreased GFR

Reduced content

Kayexalate
Diuretics

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Shift intracellularly
Glucose and insulin
Alkali (sodium bicarbonate)

Antagonize cellular membrane effect

Calcium gluconate

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R/t fluid overload

Salt wasting can occur as nephrons
damaged
Treated with fluid restriction

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Metabolic acidosis
Treatment based on severity of imbalance
May need IV bicarbonate
Monitor ionized calcium as hypocalcemia can
occur as pH is corrected

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Early recognition
Fluid or volume replacement
Caution in patients with underlying cardiac
disease

May require inotropes, antidysrhythmic agents,

preload/afterload reducers, intraaortic balloon
pump
May require hemodynamic monitoring to guide
treatment

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Medications
Dietary control

Protein and electrolyte restrictions

Management of fluid/electrolyte
imbalances
Dialysis or CRRT

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Reduce obstruction: remove, operate the

calculous, hyperprostate
May need stent: ureter

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Convert oliguria to nonoliguric state

Hypovolemia corrected first
Loop (furosemide); Osmotic (mannitol)
Acetylcysteine: prevent contrast-induced ARF
Epoetin alfa: treat anemia
Must adjust dosages and timing of medication
if patient on dialysis

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Higher than normal basal requirement

Provide adequate energy, protein, and
micronutrients
25 to 35 kcal/kg of ideal body wt per day
Restricted

Protein
Sodium
Potassium
Fluid intake (output + 600-1000 mL)

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Save the pts by RRT

Classification

Hemodialysis
Continuous renal replacement therapy (CRRT)
Peritoneal dialysis

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Indication: doctors
Plan for access: temporary centre catheter, AVF..
Care the incision
When use the AVF
Plan for IHD: 2-3/week
Other care
- BP
-Body weight
-Nutrition
-Hematology
-Underly diseases

Mecanism by two physical principles

Diffusion
Ultrafiltration

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Fluid overload: big edema, cerebral

edema, pulmonary edema..
Electrolyte imbalances: hyper K, Hypo Na
Acid-base disturbances: acidose
metabolism

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Percutaneous catheters
Arteriovenous (AV) fistulas
Grafts
External shunts

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What are important nursing interventions

for the patient with a percutaneous dialysis
catheter?
Can the dialysis catheter be used to draw
blood samples or give medications?
What are appropriate interventions if the
patient has a graft or shunt?

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Usually done at the bedside in the ICU

Pre- and post-dialysis labs and weight
Monitor for complications

Volume depletion
Dysrhythmias
Hypoxemia
Disequilibrium syndrome
Infection vascular access

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Which medications should be given before

dialysis?
Which should be withheld until after
dialysis?
How can you determine whether to give
medications before dialysis?

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Used with patients too unstable for

hemodialysis
Advantages

More gradual solute removal

Flexible fluid administration
Minimal heparin
Can be done by staff nurses at the bedside

Disadvantages
Bed rest
One-to-one nursing care

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CAVHcontinuous arteriovenous
hemofiltration
CVAcontinuous venovenous hemofiltration
CAVHDcontinuous arteriovenous
hemodialysis
CVVHDcontinuous venovenous
hemodialysis

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Removal of solutes and fluids using the

peritoneal membrane as a filter
Rarely used in the critical care setting
because it is less efficient
High risk of peritonitis
Describe the procedure

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-Fever, tachycardia, breath sounds, chest X-ray

-Cultures: body fluids, blood, wounds
-WBC

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-Signs and manifestations

-Monitor, explain, calm, sedative medications
-Early recognition of signs and symptoms,
inform doctors
-Transfer to calm, restful, relaxed environment

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Assess the Pts

Provide specific and factual information
about the disease process, include the
family

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Normal decline owing to aging

Comorbidities

Diabetes
Hypertension

Prescribed medications

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