Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Do Case Studies from Critical Thinking Book Before Class! 1st CS on pg:327 Acute Renal Failure 2nd CS on pg:307 ESRD 3rd CS on pg:331 UTI Unit 8 Renal Conditions Part 1 Gordons Functional Health Pattern Elimination Pattern

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Fluid and Electrolyte Disturbances in Renal Disorders Fluid volume loss or excess Protein deficit Electrolyte abnormalities including Na +, K +, Ca ++, Mg ++, bicarbonate, and phosphorus See Table 44-1

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The most accurate indicator of fluid loss or gain in an acutely ill patient is which of the following? a.Abdominal girth b.Weight c.Skin turgor d.Level of consciousness

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Glomerular Diseases An inflammation of the glomerular capillaries Acute glomerulonephritis Chronic glomerulonephritis Nephrotic syndrome

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Glomerulonephritis Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis Manifestations include hematuria, edema, azotemia, proteinuria, and hypertension May be mild or may progress to acute renal failure Medical management includes supportive care and dietary modifications; treat cause, if appropriate, using antibiotics, corticosteroids, and immunosuppressants

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Sequence of Events in Acute Glomerulonephritis

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Management—Acute Glomerulonephritis Patient assessment Maintain fluid balance Fluid and dietary restrictions Patient education Follow-up care

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chronic Glomerulonephritis Causes include repeated episodes of acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage Some patients are asymptomatic for years; as glomerular damage increases, signs and symptoms of renal insufficiency and renal failure develop Abnormal laboratory test results include urine with fixed specific gravity, casts, and proteinuria; electrolyte imbalances; and hypoalbuminemia Medical management is determined by symptoms

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Management of Chronic Glomerulonephritis Assessment Potential fluid and electrolyte imbalances Cardiac status Neurologic status Emotional support Teaching self-care

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nephrotic Syndrome Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins Results in hypoalbuminemia and edema Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, amyloidosis, lupus erythematosus, multiple myeloma, and renal vein thrombosis Medical management includes drug and dietary therapy

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Sequence of Events in Nephrotic Syndrome

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Renal Failure Results when the kidneys cannot remove wastes or perform regulatory functions A systemic disorder that results from many different causes Acute renal failure is a reversible syndrome that results in decreased glomerular filtration rate ( GFR) and oliguria Chronic renal failure (ESRD) is progressive; irreversible deterioration of renal function results in azotemia

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Acute Renal Failure Hypovolemia Hypotension Reduced cardiac output and heart failure Obstruction of the kidney or lower urinary tract Obstruction of renal arteries or veins

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Causes of Chronic Renal Failure Diabetes mellitus Hypertension Chronic glomerulonephritis Pyelonephritis or other infections Obstruction of urinary tract Hereditary lesions Vascular disorders Medications or toxic agents

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question 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.

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Options for Renal Failure Hemodialysis Peritoneal dialysis Continuous renal replacement therapies (CCRT)

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Hemodialysis System

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Hemodialysis Catheter

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Internal Arteriovenous Fistula and Graft

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Continuous Venovenous Hemofiltration With Dialysis

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Peritoneal Dialysis

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Peritoneal Dialysis (cont.)

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The movement of solute (waste products) from an area of higher concentration to an area of lower concentration is which of the following? a.Anuria b.Diffusion c.Osmosis d.Ultrafiltration

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Management of the Hospitalized Patient on Dialysis Protect vascular access; assess site for patency and signs of potential infection, and do not use it for blood pressure or blood draws Monitor fluid balance indicators and monitor 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 blood pressure; antihypertensive agents must be held on dialysis days to avoid hypotension

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Management of the Hospitalized Patient on Dialysis (cont.) Monitor all medications and medication dosages carefully; avoid medications containing potassium and magnesium 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

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process—Assessment of the Patient With Renal Failure Fluid status Nutritional status Patient knowledge Activity tolerance Self-esteem Potential complications

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process—Diagnosis of the Patient With Renal Failure Excess fluid volume Imbalanced nutrition Deficient knowledge Risk for situational low self-esteem

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Collaborative Problems/Potential Complications Hyperkalemia Pericarditis Pericardial effusion Pericardial tamponade Hypertension Anemia Bone disease and metastatic calcifications

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process—Planning the Care of the Patient With Renal Failure Goals include maintaining IBW without excess fluid, maintenance of adequate nutritional intake, increased knowledge, participation in activities within tolerance, improved self-esteem, and absence of complications

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question As renal failure progresses and the GFR falls below 50 mL/min, which change occurs? a.Metabolic acidosis b.Hypokalemia c.Hypercalcemia d.Hypophosphatemia

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Excess Fluid Volume Assess for signs and symptoms of fluid volume excess; keep accurate I&O and daily weight records Limit fluid to prescribed amounts Identify sources of fluid Explain to patient and family the rationale for the restriction Assist patient in coping with the fluid restriction Provide or encourage frequent oral hygiene

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Imbalanced Nutrition Assess nutritional status, weight changes, and lab data Assess patient nutritional patterns and history; note food preferences Provide food preferences within restrictions Encourage high-quality nutritional foods while maintaining nutritional restrictions Assess and modify intake related to factors that contribute to altered nutritional intake, ie, stomatitis or anorexia Adjust medication times related to meals

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk for Situational Low Self-Esteem Assess patient and family responses to illness and treatment Assess relationships and coping patterns Encourage open discussion about changes and concerns Explore alternate ways of sexual expression Discuss role of giving and receiving love, warmth, and affection

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Question 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

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Kidney Surgery Preoperative considerations Perioperative concerns Postoperative management –Potential hemorrhage and shock –Potential abdominal distention and paralytic ileus –Potential infection –Potential thromboembolism

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Positioning and Incisional Approaches

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Renal Transplantation

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Postoperative Nursing Management Assessment: include all body systems, pain, fluid, and electrolyte status; patency and adequacy of urinary drainage system Diagnoses: ineffective airway clearance, ineffective breathing pattern, acute pain, fear and anxiety, impaired urinary elimination, and risk for fluid imbalance Complications: bleeding, pneumonia, infection, and DVT See Chart 44-9

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 potency of urinary drainage systems Use strict asepsis with catheter and appropriate techniques in providing all care Monitor for signs and symptoms of bleeding Encourage leg exercises, early ambulation, and monitor for signs of DVT

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Teaching Instruct both patient and family Care of drainage system Strategies to prevent complications Signs and symptoms Follow-up care Fluid intake Health promotion and health screening

Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Renal Cancer Accounts for 3% of U.S. cancer deaths Risk factors include male sex, increased BMI, tobacco use Manifestations include hematuria, pain, and mass in flank Treatments –Surgery: radical nephrectomy, laparoscopic nephrectomy, and partial nephrectomy –Renal artery embolization –Palliative radiation therapy –Use of chemotherapy is limited –Developing therapies