2. ACUTE RENAL FAILURE CHRONIC RENAL FAILURE

3. 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

4. NORMAL KIDNEY FUNCTION
What does the kidney do in terms of?
wastes and water balance?
Acid base balance?
Controlling BP?
Controlling anemia?

5. RENAL FAILURE DEFINED Kidneys no longer function properly
Kidneys unable to excrete waste
kidneys cannot concentrate urine
Kidneys cannot conserve electrolytes

6. HORMONES WHICH INFLUENCE THE KIDNEY
ALDOSTERONE
Produced:
Action:
RENIN/ANGIOTENSIN

7. HORMONES WHICH INFLUENCE THE KIDNEY
ANTIDIURETIC HORMONE
Produced:
Action:
ERYTHROPOIETIN (EPO)

8. 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, H ions, urea
GLORMERULAR SECRETION: hydrogen and potassium, remove acids (hydrogen) to maintain appropriate acid base balance, potassium, urea

9. ASSESSMENTS OF RENAL FUNCTION
u/a: negative for glucose, protein, blood, leukocytes, nitrites, ketones
Specific gravity: measures concentration of the urine; normal values:
Urine osmolality: normal mOsm/ kg/24
Serum creatinine: mg/dl
BUN: 7-18mg/dl
BUN to creatinine ratio: about 10:1

10. 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 ml/min

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

12. 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)

13. CAUSES OF RENAL FAILURE CONTINUED
Multiple problems may exist at same time
AGING

14. RENAL FAILURE DEFINED
To define renal failure ask yourself: How is the kidney functioning with regard to?
Excreting nitrogenous wastes
Concentrating urine
Conserving electrolytes

15. PROBLEMS FOR PATIENT Retention of metabolic wastes
Imbalance of fluid and electrolytes
Alterations of sensorium

16. 3 phases of acute renal failure
Oliguria
Diuresis
Recovery

17. OLIGURIC PHASE (lasts 10-14 days)
Urinary changes
Fluid volume excess
Metabolic acidosis
Sodium balance
Potassium excretion

18. OLIGURIC PHASE (lasts 10-14 days)continued
Hematologic disorders
Calcium deficit and phosphate excess
Waste product accumulation
Neurologic disorders

19. DIURETIC PHASE (lasts 1-3 wks)
Gradual increase of urine output as a result of osmotic diuresis
Why does this happen?
What is the state of nephron?
Can the kidney excrete wastes?
Can the kidney concentrate urine?
What would we see in the patient during this stage?

20. RECOVERY PHASE
When does this begin?
Do all patients recover?

21. GOALS OF TREATMENT Restore renal function Identify cause
Eliminate cause

22. MAINTAINING FLUID AND ELECTROLYTE BALANCE
How do we assess fluid excess?
How can we control fluid intake?
What physical assessments would be done?
What would you expect to see?
What laboratory tests would be used to assess client status?

23. NURSING CARE FOR: Elevated serum phosphate: Hypocalcemia:
Hypermagnesemia:
Hypovolemia:
Fluid retention: diuretics:
Hypertension:
Metabolic acidosis:

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

25. DIET FOR ACUTE RENAL FAILURE
dietary protein
calories
K and phosphorus Na Fe
Limit dietary protein to 1 Gm per kg of body weight: minimize protein breakdown and to prevent accumulation of byproducts of protein metabolism
High calorie diet to promote good nutrition
Restrict foods and fluids high in K and phosphorus:
K intake is resricted to mEq/day; such as bananas, citrus fruits and juices, coffee
Foods high in phosphorus include milk and milk products, whole grains, dried beans and peas, nuts and seeds, organ meats, meat and fish, colas, chocolate and some types of baking powder.
Restrict Na to 2 Gm a day
Fe supplements for anemia. This occurs as a result of decrease in erythropoietin production

26. 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

27. TERMS ASSOCIATED WITH CHRONIC RENAL FAILURE
Azotemia: collection of nitrogenous wastes in blood
Uremia: azotemia
Uremic syndrome: systemic clinical and laboratory manifestations of ESRD

28. Alterations: Chronic Renal Failure
Metabolic Disturbances:
elevated BUN,
creatinine,
hyponatremia,
hyperkalemia,
metabolic acidosis,
hypocalcemia,
hyperphosphatemia
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

29. ALTERATIONS OF CHRONIC RENAL FAILURE CONTINUED
Gastrointestinal Disturbances: Anorexia, N&V, metallic taste in mouth, breath smells like ammonia, stomatitis, ulcers/GI bleeding, constipation
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

30. 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

31. NURSING CARE FOR PT WITH CHRONIC RENAL FAILURE
FOR ANEMIA:
FOR HYPOCALCEMIA
FOR FLUID RETENTION AND HYPERTENSION
FOR SKIN ITCHING

32. DIETARY RESTRICTIONS FOR CHRONIC RENAL FAILURE
calorie
protein Na K
calcium
Phosphorus
Magnesium

33. DIALYSIS: peritoneal and hemodialysis

36. PERITONEAL DIALYSIS
Diffusion of solute molecules through a semi-permeable 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

37. 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

38. NURSING CARE OF PT ON PERITONEAL DIALYSIS
Baseline VS and wgt
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

39. Nursing care during PD
Drainage bag is lower than the client’s 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

40. 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

41. COMPLICATION OF PD: Fibrin Clot formation
Milking the tubing
Xray

42. COMPLICATION OF PD: LEAKAGE
Dialysate leakage
See with obese, diabetic, older clients, those on long term steroids

43. HEMODIALYSIS
Process by which the uremic toxins and accumulated waste products are removed from the blood

44. HEMODIALYSIS CONTINUED
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

45. Access to pt’s circulation via:
AV shunt (less common): external silastic 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

46. COMPLICATIONS Hemodialysis vascular access
BLEEDING
INFECTION
CLOTTING

47. 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

48. Nursing care pre dialysis
Vasoactive drugs which cause hypotension are held until after treatment
CHECK WITH MD ABOUT WHICH DRUGS TO BE HELD
Know pt’s BP predialysis

49. Post dialysis nursing care
BP and wgt
Hypotension
Temperature may also be elevated:
If client has a fever
Bleeding risk:

50. 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

51. POSTOPERATIVE CONCERNS AFTER TRANSPLANT
major concern is rejection
Drugs given to suppress immunologic reactions: Imuran, prednisone, cyclosporin (Cyclosporin A)
Next concern is infection

52. 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 wgt gain
Assess for rise in serum creatinine and BUN values