Justine Willman Med, MSN, RN 2014 Renal System Justine Willman Med, MSN, RN 2014

Kidney Anatomy Protected by ribs but vulnerable if you receive a direct blow to the back Encased in 3 tissue layers Inner is the -renal capsule- thin membrane that helps seal the kidneys and prevent infections from spreading into renal tissue Adipose capsule- this tissue cushions and holds the kidneys in place Renal fascia - outer membrane also surrounds adrenal glands

Kidney Kidneys filter 45 gallons of blood a day Nephrons are the functioning unit where filtering occurs Glomerulus – capillary clusters that are the filtering unit of the nephron, covered by Bowman’s capsule Tubule – collecting channel in nephron that converts fluid to urine as it goes to the pelvis of the kidney

Renal Failure Partial or complete impairment of kidney function Acute & chronic Partial or complete impairment of kidney function Inability to excrete metabolic waste products, and water as well as functional disturbances of all body functions.

Acute Renal Failure (ARF) Rapid onset- rapid symptoms Rapid loss of renal function with progressive increase of BUN and Creatinine Potentially reversible Medical care: find and treat the cause to promote kidney health Clients will be defined as being in either oliguric or non oliguric ARF Oliguria is defined as urine output < 400 ml/day, therefore, if output does not drop this low, the client is classified as having non oliguric ARF

Prerenal: Any reduction in blood flow to the kidney Prerenal: Any reduction in blood flow to the kidney. This reduction takes place prior to the blood flow of the kidney. i.e. MI, shock, sepsis, code arrest, etc. 50- 65% Intrarenal: Direct damage such as a renal toxic antibiotic, IV contrast dye, renal infection, renal inflammation causing low blood flow within the kidney. 30-45% Postrenal: Least common and is the result of injury below the kidney; tumor, etc., usually enlarged prostate, Less than 5% There are 3 ways in which acute renal failure can occur. See the above visual for locations/causes 1, 2 & 3

Close to 50% of acute renal failure clients do not experience oliguria Almost half of those in acute renal failure (ARF) will go into the Oliguric Phase and will follow an expected sequence to recovery. 1. Oliguric Phase 2. Diuretic Phase 3. Recovery Phase Those in acute renal failure who do NOT have a drop in urine output <400 mL in 24 hour (oliguria) will not go through the above phases and have a better chance at full recovery. 1. Oliguria Urine output <400 ml/day Occurs 1-7 days after event Usually last 10-14 days, but can also last for months The longer it lasts the poorer the prognosis Close to 50% of acute renal failure clients do not experience oliguria

Oliguria Presentation As the nurse consider your immediate concerns during this phase. Priorities, actions, delegation, etc. Oliguria presentation includes Decrease urinary output < 400mL/24h Fluid volume excess and electrolyte imbalances ( K+ Na+ Phos, BUN, Creatinine & bicarbonate) As a result of these imbalances Metabolic acidosis can set in Anemia may occur Neurological changes: seizure, stupor, coma Possible nausea leading to vomiting Respiratory complications (pulmonary edema)

Interventions – Oliguric Phase As the nurse, think of where the fluid is going in ARF. Interventions are focusing on the complications as the result of low urine output. Monitor blood pressure (BP) Restrict fluid intake Limit IV fluids when giving the required IV medications Monitor for fluid overload – lungs & cardiac focus Daily weight Daily, or as ordered, electrolyte monitoring and replacement Dialysis as ordered

2. Diuretic Phase – follows the Oliguric phase As the nurse, predict the possible complications as a result of this phase. Since the client starts to diurese at this time, interventions will focus on: Prompt IV fluid replacement to avoid hypotension K+ replacement due to new onset diuresis Monitoring of BP, neuro, cardiac status & electrolytes Daily weights Dialysis as ordered During the diuretic phase, the kidneys recover the ability to excrete wastes but not to concentrate urine Watch for hypovolemia, hypotension, low Na+, low K+, and dehydration Urine output increases to 1-3 liters/day & can last from 1-3 weeks before progressing to the Recovery Phase

3. Recovery Phase – follows the Diuretic phase Glomerular filtration rate increases BUN and Creatinine decrease. This phase can last 1-2 weeks  12 months As the nurse, understand that reduction or stopping of IV fluids may be needed for stabilization of blood pressure. Continue to monitor K+ and for symptoms of imbalance Monitoring of BP, neuro, cardiac status & electrolytes Daily weights Overall outcome for this ARF depends on client overall health, severity of renal disease & the number and types of systematic complications. Outcome is best if the client never falls into the Oliguric phase to begin

REVIEW - Chronic Renal Failure Chronic RF is a progressive, irreversible destruction of the nephrons of both kidneys 43% diabetic neuropathy 23% HTN 12% glomerunephritis 3% cystic kidney disease 19% “other” Staged by level of function “glomerular filtration rate” through creatinine clearance Normal creatinine clearance 85-135 Stage 1: increase GFR 90 or above Stage 2: decreased GFR 60-89 Stage 3: decreased GFR 30-59 Stage 4: decreased GFR 15-29 Stage 5: GFR 45 and needs dialysis REVIEW - Chronic Renal Failure Partial or complete impairment of kidney function Inability to excrete metabolic waste products, and water as well as functional disturbances of all body functions.

Classic Presentation of CRF Every body system is affected due to decrease in body waste filtration – the retained substances, urea, creatinine, hormones, electrolytes, water UREMIA- is the term used for this build up of toxins Many client are tolerant to the toxins as it can develop slowly. In time is causes lethargy and fatigue Oliguria is common and at times may  anuria A 68 year old CRF client presents with the following results & assessment finding: Serum K+ of 6.2 mEq Serum Mg++ of 3.1 mEq/L 2 plus edema bilateral legs Arterial blood pH of 7.32 Serum BUN of 44 mg/dL Serum creatinine of 2.6 mg/dL Explain the lab results Which result would you address first? What signs and symptoms are associated with these values?

As a Result of CRF Progression HTN, CHF& pulmonary edema will set in: due to fluid retention Diarrhea/ constipation, N/V are possible Anemia is common, as the nurse, why do you think this is and what can be done to help? Increase for risk of infection Neurological changes such as seizures, lethargy, coma are common Yellow-gray skin may occur, as the nurse, what do you think is causing this? Pale, dry scaly skin may also begin due to anemia and decreased oils Pruritis – is also common due to dry skin As a Result of CRF Progression As with any chronic disease, emotional changes, withdrawal & depression may be expected

Treatment & Management of Acute & Chronic As the nurse, your focus is on the correction of extra cellular fluid overload or deficit in your client Nutritional therapy Dietician consult/change TPN Decreased protein, sodium, potassium, phosphate diet Dialysis Fluid restriction CA++ and phosphorous supplements Antihypertensive meds Decrease K+ Kaexelate as indicated & ordered Electrolyte imbalance assessments Treatment & Management of Acute & Chronic Renal US/ scan or CT BUN, Creatinine, 24 hour creatinine clearance UA, C&S

Hemodialysis Basics Dialysis is the movement of fluid and molecules across semi a permeable membrane, one compartment to another Begins when uremia can no longer be adequately managed conservatively (diet, etc.) With CRF, once dialysis is started, it rarely ends because CRF is progressive & irreversible With ARF, dialysis can be temporary

Hemodialysis & Vessel Access AV Fistula: Created by joining an artery to a vein Less complications 4-6 week healing AV Graft: A man-made tube that connects an artery to a vein More complications (infection & thrombus) 2-4 week healing No BPs, IVs, venipuncture in affected limb If a person “may” be a candidate for dialysis this rule also hold true. AV Graft What assessments will the nurse do to determine functionality of HD fistulas & grafts?

Temporary or Emergency Access for Dialysis Right or left Internal jugular, femoral or subclavian veins are used Inter jugular vein (IJ) is most common due to the lower incidence of thrombus Highest risk of infection with femoral and subclavian These are considered “central lines”. As the nurse, consider the precautions and responsibilities of managing a central line catheter.

Peritoneal Dialysis Complications include: Exit site infections, peritonitis, abdominal pain, outflow problems, hernias, lower back problems, bleeding, pulmonary complications

Complications of Hemodialysis Decrease or increased in BP due to volume changes Muscle cramps (rapid removal of Na+ and water) Hepatitis: Hepatitis C most common Sepsis Disequilibrium syndrome: rapid changes in extracellular fluids, urea, Na+ and solute. N/V confusion, h/a, twitching, jerking, seizures