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Renal Failure

Renal Failure. 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. Key points. The kidneys “ Regulate fluid ,

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Renal Failure

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  1. Renal Failure

  2. 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

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

  4. 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.”

  5. 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.

  6. 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.

  7. 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 (???)

  8. 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

  9. 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)

  10. Renal Failure - Diagnosis • Serum electrolytes • Dilutionalhyponatremia & hypocalcemia • Increased potassium, phosphorus, and magnesium • CBC; ???? • Ultrasound • KUB • CT

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

  12. 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.

  13. 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.

  14. 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.

  15. 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.

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

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

  18. 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.

  19. 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.

  20. 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)

  21. 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.

  22. For clients with CRF, the nurse should: • Obtain a detailed medication Hxto 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.

  23. 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.

  24. 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.

  25. 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

  26. Renal Replacement Therapy • Peritoneal Dialysis • Acute Intermittent Hemodialysis • Continuous Hemofiltration

  27. 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.

  28. 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.

  29. 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.

  30. 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)

  31. Nursing Interventions • Discuss with Dr any medications to be withheld until after dialysis. Provide emotional support prior • Avoid taking BP, administering injections, performing venipuncturesor 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.

  32. 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.

  33. 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 espbloodbornediseasess • .

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