RENAL FAILURE

ACUTE RENAL FAILURE CHRONIC RENAL FAILURE

OBJECTIVES
Identify normal functioning of the kidney and laboratory tests that assess kidney function Define renal failure Discuss the causes of acute renal failure and compare those with chronic renal failure Compare prerenal, intrarenal and postrenal conditions Identify the alterations seen in patients, explaining why they exist Identify nursing measures appropriate to the

alterations

RENAL FAILURE DEFINED

Kidneys no longer function properly Kidneys unable to excrete waste kidneys cannot concentrate urine Kidneys cannot conserve electrolytes

IDENTIFYING THE THREE PRIMARY RENAL FUNCTIONS

GLOMERULAR FILTRATION:glucose, amino acids, creatinine, urea, phosphates, uric acid GLOMERULAR REABSORPTION:bicarbonate, phosphates, sulfates, 65% of Na and water, glucose, K, amino acids, urea GLORMERULAR SECRETION: hydrogen and potassium, remove acids (hydrogen) to maintain appropriate acid base balance, potassium, urea

ASSESSMENTS OF RENAL FUNCTION

u/a: negative for glucose, protein, blood, leukocytes, nitrites, ketones Specific gravity: measures concentration of the urine; normal values: 1.010-1.025 Urine osmolality: normal 300-900 mOsm/ kg/24 Serum creatinine: 0.6-1.2mg/dl BUN: 7-18mg/dl BUN to creatinine ratio: about 10:1

DIAGNOSTIC ASSESSMENTS CONTINUED

STANDARD FOR RENAL FUNCTION: assess glomerular filtration rate (GFR) Norm for this assessment is the creatinine clearance test done over 24 hours: normal rate is 80-125ml/min

DEFINITIONS
OLIGURIA: urine output is less than 30 ml/hr ANURIA: no urinary output NORMAL URINARY OUTPUT: 15001800ml/day

CAUSES OF ACUTE RENAL FAILURE

PRERENAL or factors external to the kidney which interferes with renal perfusion (55% cases of ARF) INTRARENAL: conditions that cause direct damage to renal tissue (35-40% cases of ARF) POSTRENAL: mechanical obstruction in the urinary tract (5% cases of ARF)

CAUSES OF RENAL FAILURE CONTINUED

Multiple problems may exist at same time AGING

3 phases of acute renal failure

Oliguria Diuresis Recovery

OLIGURIC PHASE (lasts 10-14 days)

U.O = 400 mls. Or < per day Increases BUN, Crea Edema, HPN Hyperkalemia Hyponatremia Hyperphospatemia Metabolic acidosis

DIURETIC PHASE (lasts 1-3 wks)

Gradual increase of urine output as a result of osmotic diuresis:
U.O =3 5 L/day Initially BUN, Creatinine elevated BP elevated Metabolic acidosis Later Normalize Hypokalemia

RECOVERY PHASE
Takes 3 to 12 months Avoid nephrotoxic drugs

ARF Signs and Symptoms

Weight gain Peripheral edema Hypertension Hyperkalemia Nausea/Vomiting Pulmonary edema Ascites Asterixis Encephalopathy

Lab findings
Rising creatinine and urea Rising potassium Decreasing Hb Acidosis Hyponatraemia Hypocalcaemia

GOALS OF TREATMENT
Restore renal function Identify cause Eliminate cause

MAINTAINING FLUID AND ELECTROLYTE BALANCE

Monitor for fluid & electrolyte balance: Assess I & O every 8 hrs Weigh patient every day Assess presence and extent of edema Auscultate breath sounds Monitor cardiac rhythm & BP every 8 hrs. Encourage patient to remain within prescribed fluid restriction

MAINTAINING FLUID AND ELECTROLYTE BALANCE

Provide small quantities of fluid spaced over the day to stay within fluid restrictions Encourage a diet high in CHO & w/in the prescribed sodium, potassium, phosphorus & CHON limits

PREVENT INFECTION & INJURY

Promote meticulous skin care Encourage activity w/in prescribed limits but avoid fatigue Protect confused person from injury Protect person from exposure to infectious agents Maintain good medical/surgical asepsis during treatment & procedures

PROMOTE COMFORT
Medicate patient PRN for pain Encourage use of damp cloth to keep lips moist; give oral hygiene Encourage rest for fatigue; encourage self care as tolerated Provide calm, supportive atmosphere

ASSIST WITH COPING IN LIFESTYLE-CONCEPT

Promote hope Provide opportunity for patient to express feeling about self Identify available community resourses

TREATING HYPERKALEMIA
Regular insulin IV Sodium bicarbonate Calcium gluconate IV Dialysis Dietary restriction

DIET FOR ACUTE RENAL FAILURE

Dietary protein Limit CHON to 1gm/kg of body wt. Calories High calorie diet to promote good nutrition K and phosphorus restrict foods & fluids high in K (banana, citrus fruits, juices & coffee) & phosphorus (milk, whole grains, dried beans & peas, nuts & seeds, organ meat, meat & fish, cola, chocolate) Na Restrict Na to 2 gm a day Fe for anemia w/c occurs as a result of dec. in erythropoietin production

CHRONIC RENAL FAILURE DEFINED

Progressive deterioration in renal function resulting in fatal uremia (excess of urea and other nitrogenous wastes in the blood) Irreversible destruction of nephrons Called ESRD (end stage renal disease) Dialysis or transplant

TERMS ASSOCIATED WITH CHRONIC RENAL FAILURE

Azotemia: collection of nitrogenous wastes in blood Uremia: azotemia Uremic syndrome: systemic clinical and laboratory manifestations of ESRD

Alterations: Chronic Renal Failure

Metabolic Disturbances:
elevated BUN eleveted creatinine hyponatremia hyperkalemia metabolic acidosis hypocalcemia hyperphosphatemia

Alterations: Chronic Renal Failure

Reproductive Disturbances:
For woman: menstrual irregularities, amenorrhea, infertility, decreased libido For men: impotence, reduced sperm motility

Integumentary Disturbances:

pruritus,dry,hair brittle, nails thin, UREMIC FROST: white/yellow crystals of urate on skin

ALTERATIONS OF CHRONIC RENAL FAILURE CONTINUED

Gastrointestinal Disturbances: Anorexia N&V metallic taste in mouth breath smells like ammonia Stomatitis ulcers/GI bleeding constipation

ALTERATIONS OF CHRONIC RENAL FAILURE CONTINUED

Neurological Distrubances: uremic encephalopathy progresses to seizures & coma CHF: from increased workload on heart from anemia, hypertension and fluid overload Uremic pericarditis: pericardium becomes inflammed from toxins

ALTERATIONS OF CHRONIC RENAL FAILURE CONTINUED

Respiratory: breath smells like urine: uremic fetor or uremic halitosis Metabolic acidosis: see tachypnea (increased rate) and hyperpnea (increased depth) indicates worsening metabolic acidosis
See Kussmaul respirations extreme hyperventilation

DIETARY RESTRICTIONS FOR CHRONIC RENAL FAILURE

calorie protein Na K calcium Phosphorus Magnesium

DIALYSIS: Peritoneal Dialysis Hemodialysis

PERITONEAL DIALYSIS
Diffusion of solute molecules through a semipermeable membrane passing from the side of higher concentration to that of lower concentration Fluids passing through the semi-permeable membrane via osmosis Renal Failure pt has dialysis to remove waste products and to maintain life until kidney function can be restored Dialysis indicated for high levels of K and fluid overload

PERITONEAL DIALYSIS
Sterile dialyzing fluid is introduced into the peritoneal cavity Peritoneum is an inert semipermeable membrane The dialyzing solution promotes osmosis leading to diuresis Urea and creatinine are removed

NURSING CARE OF PT ON PERITONEAL DIALYSIS

Baseline VS and wt. Assess for fluid overload Maintain highly accurate inflow and outflow records When PD starts the outflow may be bloody or blood tinged This clears within a week/two Effluent should be clear and light yellow

Nursing care during PD

Drainage bag is lower than the clients abdomen to enhance gravity drainage Avoid kinking or twisting, ensure clamps are open Reposition client to stimulate inflow or outflow Sitting/standing/coughing: increases intraabdominal pressure

COMPLICATIONS OF PERITONEAL DIALYSIS

Respiratory difficulties Hypotension Infection:
peritonitis: see cloudy or opaque dialysate outflow (effluent), fever, abdominal tenderness, pain, malaise, N&V

Hypo-albuminemia Bowel perforation Bladder perforation Catheter may get clogged

COMPLICATION OF PD: Fibrin Clot formation

Milking the tubing X-ray

COMPLICATION OF PD: LEAKAGE

Dialysate leakage See with obese, diabetic, older clients, those on long term steroids

HEMODIALYSIS
Process by which the uremic toxins and accumulated waste products are removed from the blood A synthetic semi-permeable membrane replaces the renal glomeruli and tubules and acts as a filter for the impaired kidneys Must have 3 times/week for 4 hours per treatment for rest of life

Access to pts circulation via:

AV shunt (less common): external elastic tubing placed in an adjacent artery and vein AV Fistula: internal access using pts own vessels (artery and vein) AV Graft: internal access using a foreign material

COMPLICATIONS Hemodialysis vascular access

BLEEDING INFECTION CLOTTING

Assessment during Hemodialysis

Assess for disequilibrium reaction CAUSE:
due to rapid decrease in fluid volume and BUN levels Change in urea levels can cause cerebral edema and increased intracranial pressure Neurologic complications: HA, N&V, restlessness, decreased LOC, seizures, coma, death PREVENTION: starting HD for short periods with low blood flows

Nursing care pre dialysis

Vasoactive drugs which cause hypotension are held until after treatment CHECK WITH MD ABOUT WHICH DRUGS TO BE HELD Know pts BP, Wt. predialysis

Post dialysis nursing care

BP and wt - Hypotension Temperature may also be elevated: - If client has a fever Bleeding risk: - Site

KIDNEY TRANSPLANT
Involves transplanting a kidney from a living donor or human cadaver to a recipient who has end-stage renal disease and requires dialysis to live

POSTOPERATIVE CONCERNS AFTER TRANSPLANT

Major concern is rejection Drugs given to suppress immunologic reactions: Imuran, prednisone, cyclosporin (Cyclosporin A) Next concern is infection

NRSG CARE POST KIDNEY TRANSPLANT

TO DETECT REJECTION: Assess for increased temp, pain or tenderness over grafted kidney Assess for decrease in urine output, edema, sudden wt gain Assess for rise in serum creatinine and BUN values