1. Renal Failure

3. Structure and Function of the Kidney
Primary unit of the kidney is the nephron
1 million nephrons per kidney
Composed of a glomerulus and a tubule
Kidneys receive 20% of cardiac output
Renal Lecture Required Picture #1

5. Key points The kidneys “ RF may be acute /chronic
Regulate fluid,
Regulate acid-base,
Regulate electrolyte balance, and
Eliminating wastes from the body.
?????
RF may be acute /chronic
ARF: sudden interruption of renal function. (obstruction, poor circulation, or kidney disease.

7. Acute Renal Failure - Definitions
Reversible
70% Non-oliguric , 30% Oliguric
Non-oliguric associated with better prognosis and outcome
“Overall, the critical issue is maintenance of adequate urine output and prevention of further renal injury.”

8. ARF
ARF is comprised of three phases:
Oliguria – begins with the renal insult and continues for 3 weeks.
Diuresis – begins when the kidneys begin to recover and continues for 7 to 14 days.
Recovery – continues until renal function is fully restored and requires 3 to 12 months.
Prerenal failure from hemorrhage or prolonged hypotension is the most common cause of acute renal deterioration and is usually reversible with prompt intervention.

9. Chronic Renal Failure (CRF)
a progressive, irreversible kidney disease.
End-stage renal failure exists when 90% of the functioning nephrons have been destroyed and are no longer able to maintain fluid, electrolyte, or acid-base
homeostasis.

10. Key Factors Risk factors for ARF may be classified as:
Prerenal, (hypovolemia, decreased cardiac output, Decreased peripheral vascular resistance, renal vascular obstruction)
Intrarenal, (Nephrotoxic injury, Acute glomerulonephritis) or
Postrenal. bilateral obstruction of urine outflow (???)

11. Key Factors Risk factors of CRF: ARF. DM HTN
Chronic glomerulonephritis.
Nephrotoxic medications (????) or chemicals.
Pyelonephrosis
Autoimmune disorders (SLE).
Polycystic kidney.
Renal artery stenosis recurrent UTI

12. Renal Failure - Diagnosis
Urinalysis
Hematuria, proteinuria, and alterations in specific gravity
Serum creatinine: gradual increase of 1 to 2 mg/dL per every 24 to 48 hr for ARF
Gradual increase over months to years for CRF
Blood urea nitrogen (BUN)

13. Renal Failure - Diagnosis
Serum electrolytes
Dilutional hyponatremia & hypocalcemia
Increased potassium, phosphorus, and magnesium
CBC; ????
Ultrasound
KUB CT

15. Renal Failure - Diagnosis
Aortorenal angiography
Cystoscopy
Retrograde pyelography
Renal biopsy
Nuclear medicine scans

16. Assessment S&Sx occur suddenly with ARF.
Client with CRF may be asymptomatic except during periods of stress (infection, surgery, and trauma).
In most cases, symptoms are related to fluid volume overload and include:
Renal – polyuria, nocturia (early), oliguria, anuria (late), proteinuria, hematuria, and dilute urine color when present.

17. Assessment
Cardiovascular – HTN, peripheral edema, pericardial effusion, CHF, cardiomyopathy, and orthostatic hypotension.
Respiratory – dyspnea, tachypnea, uremic pneumonitis, lung crackles, Kussmaul respirations, and pulmonary edema.
Hematologic – anemia, bruising, and bleeding.

18. Assessment
Neurologic – lethargy, insomnia, confusion, encephalopathy, seizures, .
GI – A, N, V, metallic taste, stomatitis,
diarrhea, uremic halitosis.
Skin – decreased skin turgor, yellow cast to skin, dry, pruritus, and bruising
osteomalacia, muscle weakness, pathologic fractures, and muscle cramps.
Reproductive – erectile dysfunction.

19. Assessment
Report:
Urinary elimination patterns (amount, color, odor, and consistency).
Vital signs (especially blood pressure).
Weight – 1 kg (2.2 lb) daily weight increase is approximately 1 L of fluid retained.
Assess/monitor vascular access or peritoneal dialysis insertion site.

20. NANDA Nursing Diagnoses
Imbalanced nutrition
Risk for infection
Impaired gas exchange
Activity intolerance
Impaired skin integrity
Disturbed thought processes
Deficient knowledge

21. ARF - Management Nutrition management Initially very catabolic Goals:
Adequate calories
Low protein
Low K and Phos
Decreased fluid intake

22. Nursing Interventions
Provide high carbohydrate and moderate fat content in the client’s diet.
Restrict the client’s intake of fluids (based on urinary output).
Balance the client’s activity and rest.
Prepare the client for hemodialysis.

23. Nursing Interventions
Provide skin care to prevent breakdown.
Protect the client from injury.
Provide emotional support to the client and family.
Encourage the client to ask questions
Encourage the client to diet, exercise, and take medication to control hyperlipidemia.

24. Nursing Interventions
Administer medications as prescribed.
Antihypertensives –
Iron supplements and folic acid as needed
Erythropoietin
Vitamin D supplements and calcium supplements
Stool softeners
Diuretics (except in ESRD)

26. For clients with ARF, the nurse should:
Identify and assist with correcting the underlying cause.
Prevent prolonged episodes of hypotension and hypovolemia.
Prepare for fluid challenge and diuretics Restrict fluid intake , Na, & K during oliguric phase.

27. For clients with CRF, the nurse should:
Obtain a detailed medication Hx to determine the client’s risk
Control protein intake
Restrict the client’s dietary Na, K, ph, and Mg
Refer the client to a community resource or support group.

28. Client with CRF Encourage the client to stop smoking .
Encourage diabetic client to adhere to strict blood glucose control ????
Teach the client how to measure BP & Wt at home.

29. Complications and Nursing Implications
Hyperkalemia – Administer Kayexalate or insulin as prescribed.
HTN – Administer antihypertensives and diuretics as prescribed.
Seizures – Implement seizure precautions.
Cardiac dysrhythmias – Provide life support interventions for lifethreatening
dysrhythmias. Monitor the client for and report non-lethal dysrhythmias.

30. Complications and Nursing Implications
Pulmonary edema – Prepare the client for hemodialysis.
Infection – Maintain the client’s surgical asepsis of invasive lines. Monitor the client for signs of localized and systemic infections and report.
Metabolic acidosis – Prepare the client for hemodialysis.
Uremia – Prepare client for hemodialysis.s

31. Renal Replacement Therapy
Peritoneal Dialysis
Acute Intermittent Hemodialysis
Continuous Hemofiltration

32. Function of Dialysis Rid the body of excess fluid & electrolytes.
Achieve acid-base balance.
Eliminate waste products.
Restore internal homeostasis
Dialysis can sustain life.
Dialysis does not replace the hormonal functions of the kidney.

33. Hemodialysis
Shunts the client’s blood from the body through a dialyzer and back into the
client’s circulation.
Requires internal or external access device.

34. Therapeutic Procedures and Nursing Interventions
Prior to hemodialysis, assess for patency of the access site (presence of bruit,
palpable thrill, distal pulses, and
circulation).
Before and after assess: Vital signs.
Laboratory values (BUN, serum creatinine, electrolytes, hematocrit).
Weight.

35. After hemodialysis assess:
For complications (hypotension, access clotting, headache, muscle cramps, hepatitis).
Access site for indications of bleeding, infection.
For nausea, vomiting, level of consciousness.. (hypovolemia)

36. Nursing Interventions
Discuss with Dr any medications to be
withheld until after dialysis.
Provide emotional support prior
Avoid taking BP, administering injections, performing venipunctures or inserting IV lines on an arm with an access site.
Avoid invasive procedures (4 - 6 hr) after d
Elevate the extremity following surgical development of AV fistula to avoid swelling.

37. Teach the client to Avoid lifting heavy objects with access-site arm.
Avoid carrying objects that compress the extremity.
Avoid sleeping with body weight on top of the extremity with the access device.
Perform hand exercises that promote fistula maturation.

38. Complications and Nursing Implications
Hemodialysis
Clotting/Infection of Access Site
Use sterile technique
Avoid compression of access site/extremity
Hypotension
Discontinue dialysis.
Place the client in the Trendelenburg position.
Anemia: Administer prescribed medication Infectious Diseases esp bloodborne diseasess .