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1- Renal anatomy

2- Renal Physiology and functions

3- Renal failure
4- Types of renal failure :
a- acute renal failure
b- chronic renal failure
5- Dialysis and Types
6- Nursing Care plan

7- Medications used

1- Parenchyma: the solid part of the kidney, where the
process of waste excretion takes place.

2- Cortex: the outer layer of the parenchyma consisting

of connective tissue.

3- Glomeruli: convoluted tubules where filtration is


4- Medulla: area of the kidney where filtration and

concentration of wastes takes place, Henle·s loops,
pyramids of converging tubules.

5- Calyx (plural calyces):collecting area for urine within

kidney before it is passed through to renal pelvis.

6- Hilum: area of convergence of the renal collecting

system, ureter, renal artery and vein.
i- Ureteropelvic junction: point at which the renal
pelvis becomes the ureter.

8- Nephron: basic functional unit of kidney.

¢§he kidneys are a pair of brownish-red structures .

¢ §he kidneys lie in a retroperitoneal position, meaning

posterior to the parietal peritoneum, against the posterior
wall of the abdomen .

¢ §hey are located on either side of the vertebral column

and extend from the level of the last thoracic
vertebra(§12) to just above the third lumber vertebra(L3).

¢An adult kidney weigh 120 to 1i0 g and 12 cm long , 6 cm

wide, and 2.5 thick.

¢§he left kidney is often slightly larger then the right.

¢§he right kidney is lower the left kidney , because the

liver takes up some of the space above the right kidney.

¢ §he kidney are well protected by the ribs, muscles,

Gerota·s fascia, perirenal fat , and the renal capsule, which
surround each kidney
1. Urine formation

2. Excretion of waste products

3. Regulation of electrolytes, acid, and

water excretion

4. Auto regulation of blood pressure

5. Regulation of red blood cell production

6. Synthesis of vitamin D to active form

i. Secretion of prostaglandins
Urine is formed in the nephrone through
a complex three-step process:

Äël rul r filtr ti .

ÄTubul r r bs rpti .
ÄTubul r s cr ti .

§he various substances normally filtered

by the glomerulus, reabsorbed by the
tubules, and excreted in the urine
include sodium, chloride, bicarbonate,
potassium, glucose, urea, creatinine, and
uric acid.

Other are secreted from the blood into

filtrate as it travels down the tubule as
glucose , amino acids and protein ( are
completely reabsorbed)
§he major waste product of protein metabolism is urea, of which about 25
to 30 g is produced and excreted daily.

All of this urea must be excreted in the urine.

Other waste products of metabolism that must be excreted are creatinine,

phosphate, uric acid, and drug metabolites.

§he kidney is also responsible for the final conversion of

inactive vitamin D, to its active form, 1,25
dihydroxycholecalciferol, which are necessary for
maintaining normal calcium balance in the body.

ðhen the kidneys sense a decrease in the oxygen tension in
renal blood flow, they release Erythropoitin, which simulate the
bone marrow to produce red blood cells, thereby increasing the
amount of hemoglobin available to carry oxygen .

§he kidneys also produce prostaglandin E (PGE) and

prostacyclin (PGI) , which have a vasodilatory effect
and are important in maintaining renal blood flow.

Specialized vessels of the kidney called the vasa recta
constantly monitor blood pressure as blood begins its
passage into the kidney.

ðhen vasa recta detect a decrease in blood pressure

specialized juxtaglomerular cells near the afferent
arteriole, distal tubule, and efferent arteriole secrete
the hormone renin.

Renin converts angiotensinogen to angiotensin I then

converted to angiotensin II, the most powerful
vasoconstrictor known. §he vasoconstriction cause the
blood pressure to increase.

ðhen the vasa recta recognize the increase in blood

pressure, renin secretion stops.

1. ðhen the kidney are functioning normally the volume of
electrolyte excreted per day is equal to the amount
ingested .

2. §he main electrolyte excretion includes sodium and


1. §he kidney are responsible for excreting more

then 90% of daily potassium intake.

2. Aldosteron causes the kidney to excrete


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1. Acid production results from the catabolism or
breakdown of protein.

2. Unlike carbon dioxide(CO2), phosphoric and sulfuric

acids can't be eliminated by the lung, so it accumulated
in the blood which lower its pH and inhabit cell
functions, so they must be excreted in the urine.

3. Normal kidney excrete about i0 mEq of acid per day

1. ðith high fluid intake, a large volume of dilute urine
is excreted, and with low fluid intake a small volume
of concentrated urine is excreted.

2. Person normally ingests about 1 to 2 L of water per

day and normally about 400 to 500 ml of this fluid is
excreted in the urine.

It is the number of particles (electrolyte and other

molecules) dissolved per kilogram of urine.

ðhen person is dehydrated or retaining fluid, less

water excreted so more particles are present in urine
so they become concentrated with high osmolality.

ðhen the person excretes a large volume of water,

the particles are diluted so the osmolality is low.
1. ADH( also known as vasopressin) , regulate water
excretion and urine concentration in the tubule by
varying the amount of water that is reabsorbed.

2. Secreted by posterior part of the pituitary gland in

response to change in osmolality of the blood.

3. ðith the decrease in water intake , blood osmolality

increase, so stimulate ADH hormone release, in order
to increase reabsorbption of water , to return
osmolality of blood to normal.

4. ðhen excess water intake the secretion of ADH

suppressed, therefore less water reabsorbed.

Renal failure results when the kidneys cannot
remove the body's metabolic wastes or perform
their regulatory functions.

§he substances normally eliminated in the urine

accumulate in the body fluids as a result of
impaired renal excretion, leading to a disruption
in endocrine and metabolic functions as well as
fluid, electrolytes, and acid base disturbance.

Renal failure is a systemic disease and is a final

common pathway of many different kidney and
urinary tract disease.
1. Acute Renal Failure

2. Chronic Renal Failure

mcut l
F ilur

Pr r l l F ilur P st r l

Pr r l (c us s i th bl d suppl ):
[hypovolemia(decreased blood volume), usually from
shock or dehydration and fluid loss or excessive
diuretics use.

[hepatorenal syndrome in which renal perfusion is

compromised in liver failure

[vascular problems, such as atheroembolic disease

and renal vein thrombosis (which can occur as a
complication of the nephrotic syndrome)

[infection usually sepsis, systemic inflammation due

to infection

Renal (damage to the kidney itself):

[toxins or medication (e.g. some NSAIDs, aminoglycoside

antibiotics, iodinated contrast, lithium, phosphate
nephropathy due to bowel preparation for colonoscopy
with sodium phosphates)

[rhabdomyolysis the resultant release of myoglobin in

the blood affects the kidney; it can be caused by injury
(especially crush injury and extensive blunt trauma),

[Hemolysis - the hemoglobin damages the tubules; it may

be caused by various conditions such as sickle-cell
disease, and lupus erythematosus

[multiple myeloma, either due to hypercalcemia or "cast


[acute glomerulonephritis

Post-renal (obstructive causes in
the urinary tract) due to:
[medication interfering with normal bladder
emptying (e.g. anticholinergics).

[benign prostatic hypertrophy or prostate


[kidney stones.

[Abdominal malignancy (e.g. ovarian cancer,

colorectal cancer).

[obstructed urinary catheter.

C s sus crit ri ( IFLE) f r th di g sis f m F
r :

[Risk: serum creatinine increased 1.5 times OR urine

production of <0.5 ml/kg body weight for 6 hours

[Injury: creatinine 2.0 times OR urine production <0.5 ml/kg

for 12 h

[Failure: creatinine 3.0 times OR creatinine >355 Ămol/l

(with a rise of >44) or urine output below 0.3 ml/kg for 24 h

[Loss: persistent ARF or complete loss of kidney function

for more than four weeks

[End-stage Renal Disease: complete loss of kidney function

for more than three months

[Kidney biopsy may be performed in the setting of acute

renal failure, to provide a definitive diagnosis and sometimes
an idea of the prognosis, unless the cause is clear and
appropriate screening investigations are reassuringly


ÄExcessive urination at night

ÄAnkle, feet, and leg swelling

ÄGeneralized swelling, fluid retention

ÄDecreased sensation, especially in the hands or feet

ÄDecreased appetite

ÄMetallic taste in mouth

ÄPersistent hiccups
ÄChanges in mental status or mood

[ Agitation , Mood changes

[ Drowsiness , Delirium or confusion
[ Lethargy , Coma , Hallucinations
[ §rouble paying attention

ÄSlow, sluggish, movements

ÄHand tremor (shaking)
ÄNausea or vomiting, may last for days
ÄBruising easily
ÄProlonged bleeding
ÄBloody stools
ÄFlank pain (between the ribs and hips)
ÄBreath odor
ÄHigh blood pressure

ÄUrinalysis may be abnormal.

ÄSerum creatinine, BUN, creatinine clearance, and

serum potassium levels may increase.

ÄArterial blood gas and blood chemistries may

show metabolic acidosis.

ÄKidney or abdominal ultrasound

- abdominal x-ray,
- abdominal C§ scan, or abdominal MRI ,can tell if
there is a blockage in the urinary tract.

Äðater and sodium restriction

ÄProtein restriction

ÄPotassium and phosphate restriction

ÄAdjust medication dosages

ÄAvoidance of further insults

BP support

Ä Nephrotoxins

Chronic renal failure is divided into five
stages of increasing severity. Stage 5
chronic kidney failure is also referred to as
end-stage renal disease, where in there is
total or near-total loss of kidney function
and patients need dialysis or transplantation
to stay alive.

ë  ë 

Slight kidney damage with normal or increased More than 90

I filtration

Mild decrease in kidney function 60-89

Moderate decrease in kidney
III 30- 59

Severe decrease in kidney function


Kidney failure requiring dialysis or

Less than 15
V transplantation
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[Fatigue and weakness (from anemia or accumulation of
waste products in the body)

[Loss of appetite, nausea and vomiting

[Need to urinate frequently, especially at night

[Swelling of the legs and puffiness around the eyes

(fluid retention)

[Itching, easy bruising, and pale skin (from anemia)

[Headache, numbness in the feet or hands (peripheral
neuropathy), disturbed sleep, altered mental status
(encephalopathy from the accumulation of waste products
or uremic poisons), and restless legs syndrome

[High blood pressure, chest pain due to pericarditis

(inflammation around the heart)

[Shortness of breath from fluid in lungs

[Bleeding (poor blood clotting)

[Bone pain and fractures

[Decreased sexual interest and erectile dysfunction

ÄUrine analysis for albumin and creatinin, BUN

ÄGlomerular Filtration Rate

ÄSerum creatinine, BUN, creatinine clearance, and serum

potassium levels may increase.

ÄArterial blood gas and blood chemistries may

show metabolic acidosis.

ÄKidney or abdominal ultrasound

- abdominal x-ray,
- abdominal C§ scan, or abdominal MRI ,can tell if there is
a blockage in the urinary tract.

Pr t i r stricti : Decreasing protein intake may slow the
progression of chronic kidney disease. A dietitian can help you
determine the appropriate amount of protein for you.

S lt r stricti : Limit to 4-6 grams a day to avoid fluid

retention and help control high blood pressure.

Fluid i t k : Excessive water intake does not help prevent

kidney disease. In fact, your doctor may recommend restriction
of water intake.

P t ssiu r stricti : §his is necessary in advanced kidney

disease because the kidneys are unable to remove potassium. High
levels of potassium can cause abnormal heart rhythms. Examples
of foods high in potassium include bananas, oranges, nuts, and

Ph sph rus r stricti : Decreasing phosphorus intake is

recommended to protect bones. Eggs, beans, cola drinks, and
dairy products are examples
m  of foods high in phosphorus.

§here is no cure for chronic kidney disease.

§he four goals of therapy are as follows:

r§o slow the progression of disease

r§o treat underlying causes and contributing factors

r§o treat complications of disease

r§o replace lost kidney function

Dialysis(from Greek, "dia", meaning
through, and "lusis", meaning loosening)
A process by which waste products are
removed from the body by diffusion
from one fluid compartment to another
across a semi permeable membrane.

1- High level of serum potassium.

2- Fluid overload.

3- Impending pulmonary edema.

4- Increasing acidosis.

5- Pericarditis.

6- Severe confusion.

It may also be used to remove certain

medication or other toxins from the blood.
1- Chronic renal failure known as ESRF.

2- Hyperkalemia.

3- Fluid overload not responsive to

diuretics and fluid restriction.

Like healthy kidneys, dialysis keeps the body
in balance. Dialysis does the following:

1) Removes waste, salt and extra water to

prevent them from building up in the body

2) keeps a safe level of certain chemicals in

the blood, such as potassium, sodium and

3) Helps to control blood pressure.

1- Hemodialysis.

2- Peritoneal Dialysis

In hemodialysis, an artificial kidney
(hemodialyzer) is used to remove waste and
extra chemicals and fluid from the blood. §o get
blood into the artificial kidney, the doctor needs
to make an access (entrance) into blood vessels.
§his is done by minor surgery .

1) Fistula: an access is made by joining an artery

to a vein to make a bigger blood vessel called a
§he fistula takes 4-6 weeks to be mature
before it can be ready for use.

2) Graft: An anterior venous graft that connect
artery to vein by artificial substance places usually
in the forearm, upper arm or upper side.

3) A.V shunt: Connection of artery to vein


4) Subclavien, Internal jugular and femoral


§he time needed for the dialysis depends on:
-how well the kidneys work(if Mcut renal failure)
-how much fluid weight the clients gain between
-How much waste the clients have in his body.
-How big he is(§he type of artificial kidney used).
-Usually, each hemodialysis treatment lasts about
four hours and is done three times per week.

Ä §ypes of Peritoneal Dialysis:

1- Continuous Ambulatory Peritoneal Dialysis

(CAPD) most common type of peritoneal dialysis.

2- Continuous Cyclical Peritoneal Dialysis (CCPD) is

done by machine at night while the patient is

3- Intermittent Peritoneal Dialysis ² (IPD) ² uses

the same type of machine as CCPD. §his requires
assistance and is usually done at the hospital or

. In this type of dialysis, the blood is cleaned
inside the body. §he doctor will do surgery to place
a plastic tube called a catheter into the abdomen
(belly) to make an access. During the treatment
the peritoneal cavity is slowly filled with dialysate
through the catheter.

. §he blood stays in the arteries and veins that line

the peritoneal cavity. Extra fluid and waste
products are drawn out of the blood and into the

1. principles involved
2. access
3. location of dialyzing membrane
4. equipment
5. length of time involved
6. indications for use
i. advantages / disadvantages
8. complications
9. general nursing care(HD and PD)

 diMl sis P rit Ml DiMl sis

.An artificial way to remove

.An artificial way to
waste products and extra
remove waste products
fluid from the kidneys can no
and extra fluid from the
longer do so on their own.
blood when the kidneys
can no longer do so on
.Diffusion + smosis
their own.

.Ultrafiltration via pressure

.Diffusion, Hemofiltration
and Convection

.Ultrafiltration via
pressure gradient
 diMl sis P rit Ml DiMl sis

Ä §unneled Catheter into

ÄInternal Access the peritoneal cavity.
[ AV Fistula
[ AV Graft Ä Inserted via:
[ Laparascope.
[ Open Laparotomy
ÄExternal Access
[ subclavian cath
[ juguler or
femoral cath

 diMl sis P rit Ml DiMl sis

Uses an ´extracorporeal ðith peritoneal dialysis,

circuitµ the network of tiny blood
vessels in the peritoneal
‡ parchment, collodion, cavity is used to filter
cellophane inside the
´dialyzerµ ‡ ´Naturalµ occurring =
‡ Fixed Pore Size size may vary

‡ In general thought to be

 diMl sis P rit Ml DiMl sis
Dialysis machine
Indwelling catheter

‡ Dialysate
‡ Needles / §ubing to
access site ‡ Administration
§ransfer Set

‡ Dialysate
‡ Continuous cycler

 diMl sis P rit Ml DiMl sis

CAPD: 30-40µ 4-5 times

daily using 2 liters of
dialysate each time
[ 3-5 hours §Ið

‡ CCPD: 10-12 hours

during the night with 1
‡ Daily for 1-2 hours exchange during the day

‡ NIPD: 10-12 hours for

times a week
 diMl sis P rit Ml DiMl sis

‡ bide time until a possible [ bide time until a possible

kidney transplant. kidney transplant.

‡ Benefits outweigh risks ‡ Benefits outweigh risks

‡In ARF:
‡ Uncomplicated ARF
‡ Uncomplicated ARF
² Improve Organ
System Failure
² Replace renal function

 diMl sis P rit Ml DiMl sis
[less equipment.
[Patients do not need to
have an external access
‡ §reatments done at home
for greater independence
‡ Patients benefit from
regular contact with other
[§reatment times more
‡ §here is no need to have
[§here is less stress for
equipment at home.
some patients
[ Patient benefit from
continuous nursing care.
 diMl sis P rit Ml DiMl sis
During §reatment: [ Infections
² Hypotension and
arrhythmias [Slower
² Abdominal cramping
and nausea ‡ Cannot be used if
abdominal adhesions h/o
‡ Patients must travel to a peritonitis, hernias,
center three times a morbid obesity, severe
week. COPD, Pre-existing
Vertebral disease
‡ §here is a fixed schedule
‡ Cannot be used if patient
‡ Diet and fluid restriction not capable of performing

‡ Permanent access site ‡ ðeight gain

‡ Fatigue/weaknes
 diMl sis P rit Ml DiMl sis
ðeak immune system (ESRD) ðeak immune system (ESRD)
² Peritonitis
‡ Graft Malfunction
² Exit Site Infections
² Clotting / §hrombus ² SubQ§unnel Infections
‡ Outflow problems
‡ Rejection of AV Graft ‡ Catheter Malfunction
‡ Hypotension, Arrhythmias can ‡ Intraperitoneal Bleeding
occur during procedure ‡ Protein Loss
‡ May not work for all:
‡ Dialyzer Reactions can occur during procedure
‡ Air Embolus
‡ Dialyzer Reactions
‡ Hepatitis
‡ Muscle Cramps
² Inadequate removal of
‡ Disquilibrium Syndrome toxins
‡ Low back pain
‡ Pulmonary
‡ Anemia

‡ Renal Osteodystrophy


‡ Fluid overload

‡ Pericarditis

‡ Hyperkalemia

‡ Nerve damage

‡ Infection

‡ Heartm disease
Nursig DiMgsis Exp ct d Outc s Nursig It rv tis
§he patient will maintain adequate [Assess vital signs before and during
dialysis to establish base line
fluid balance. measurement and help detect changes
Outcome measurements criteria : in fluids status.

[ðeigh the patient before and after

[Balance fluid intake and output dialysis and documents result.

1) High risk for [Blood pressure with normal range [Contact the physician to clarify
fluid volume deficit withholding of drugs that may
contribute to hypovolemia , such as
r/t fluid removal [Stable heart and respiratory rate analgesics.
during dialysis and
possible blood loss [Observes for signs and symptoms of
[Absence of tachycardia, dizziness, hypovolemia such as dizziness
from access device. restlessness, nausea and vomiting. restlessness anxiety, nausea ,
vomiting and postural hypotension.
[Clotting time within normal range. [Assess patency of fistula or graft
used for dialysis by palpating or
[Acceptable weight loss without auscultating for bruit. Check patency
of external shunt by observing for
hypotension continuous blood flow through shunt.

[Absence of blood loss from access [Apply pressure dressing to fistula

site, and monitor frequently for
device. bleeding or oozing.

Nursig DiMgsis Exp ct d Outc s Nursig It rv tis
§he patient will remain free of [Measure oral temperature
infection. and other vital signs Q 1 hr
Outcome measurements criteria : or as needed.
[Observe for diaphoresis
[Oral temperature at or below 3i.2 C. and chills
[Monitor ðBC count, and
High risk for [ðBC counts within normal range. report abnormalities to the
infection r/t physician.
invasive nature of [Vital signs within normal range [Use sterile technique when
hemodaialysis . inserting and removing
[Absence of diaphoresis and chills. access needle.
[Check graft, shunt, or
[Absence of warmth, redness, fistula site for S&S of
tenderness, and swelling at graft, infection: redness, swelling,
shunt or fistula site. warmth, and tenderness.
[Maintain universal
precautions all times to
protect the patient and
nurse from spread of

Nursig DiMgsis Exp ct d Outc s Nursig It rv tis
§he patient will remain free of [Measure vital signs.
S&S of disequilibrium syndrome. frequently to detect
Outcome measurements criteria changes.
[Monitor for confusion,
headache, nausea, vomiting
and restlessness.
[Vital signs within normal ranges. [Observe the patient
3) Altered closely toward end of
thought process [Orientation to person, place, dialysis session and
r/t disequilibrium and time. afterward, when
syndrome disequilibrium syndrome is
secondary to [Absence off headache, most likely to occur.
[Implement seizure
hemodialysis . restlessness, nausea and
precautions if necessary.
vomiting. Report seizure to physician
[Absence of seizures. Keep bed in low position
with side rails up to
[Absence of S&S of injury. prevent injury.
Administer mild analgesics,
as prescribed if the patient
complains off headache.
Provide quiet, restful
Nursig DiMgsis Exp ct d Outc s Nursig It rv tis
§he patient will express an Explain need for dialysis and its
effect on kidney function,
understanding of dialysis and blood chemistry result, and
follow up care. dietary restrictions.

Verbalization of understanding Describe sequence of activities

that occur during dialysis.
of dialysis.
Discuss common complication of
Adherence to dietary hemodialysis such as
hypotension cramps, nausea,
restrictions. and vomiting. Explain how these
) Knowledge problems are treated.
deficit regarding Demonstration of correct
dialysis and follow technique for shunt, graft, and Discuss names, purposes,
dosage, and common adverse
up care. fistula care. effects of prescribed
medications. If ordered
Identifications of conditions to instruct the patient to withhold
certain drugs before dialysis
repport to physician. session.

Verbalization of importance of Demonstrate how to care for

follow up care vascular access device. (
caution the patient to avoid
injections, and blood pressure
  measurement in arm with
vascular access device).
ame of §herapeutical Side Effect
Medication/ Action ursing Role
route of
Hemax Stimulator of - Arterial -Monitoring of blood
r-Hu-Erythropoietin Erythropoiesis hypertension pressure and serum
S/c or IV push. - Vascular electrolyte.
§hrombosis - when blood pressure
- Bone pain raises antihypertensive
- Chills after treatment should be
Injection applied.
-Skin reaction -Monitoring of Hb
- Eyelid every month (as per
edema hospital internal policy)
and when needed.
- change the S/c
injection site to prevent
Name of medication §herapeutical uses Side Effects

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Name of §herapeutical uses Side Effect Nursing Role

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Name of medication §herapeutical uses Side Effects

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