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RENAL FAILURE

Renal Failure = present when the


excretion of water, electrolytes and
metabolic waste products is insufficient
because of kidney damage that prevents
the kidneys from maintaining the normal
internal environment of the body.

Renal Failure
Causes:
Pre-Renal = due to
decreased renal
perfusion without
ischemic injury.
Hypovolemia
Hemorrhage
Dehydration
Excessive GI fluid
losses
Excessive fluid losses
due to burn injury
Decreased vascular
filling

Anaphylactic shock
Septic shock
Heart failure and
cardiogenic shock
Decreased renal perfusion
Vasoactive mediators
Drugs (ACE inhibitors)
Diagnostic agents
(radioactive agents)

Intrarenal / Intrinsic = due to ischemic, toxic or


obstructive tubular injury.
Acute tubular necrosis
Prolonged renal ischemia
Exposure to nephrotoxic drugs, heavy metals,
organic solvents
Intratubular obstruction resulting from
hemoglobinuria or myolobinuria
Acute renal diseases like AGN and
Pyelonephritis

Postrenal = due to obstruction of urinary


tract flow from the kidney
Bilateral ureteral obstruction
Bladder outlet obstruction

Renal Failure
Acute Renal Failure a sudden severe loss of renal
function; potentially reversible if factors causing the
condition are corrected or resolved.
Stages of ARF:
Onset short time from precipitating event to onset of
oliguria / anuria
Oliguric Phase period during which output less than
four hundred ml in twenty four hours; if longer prognosis
is poor; 1-3 weeks
Manifestations:

Subjective

Lethargy and drowsiness may progress from stupor to coma


Irritability, headache and weakness due to anemia
Tingling of extremities due to hypocalcemia
Anorexia

Acute Renal Failure


Objective
Sudden dramatic drop in urinary output appearing a
few hour after the causative event
Oliguria urinary output less than four hundred ml
but more than 100ml in twenty four hours; Anuria
urinary output less than 100ml/twenty four hours
Restlessness, twitching, convulsions
Nausea and vomiting may lead to fluid/electrolyte
imbalance
Skin pallor, anemia and increased bleeding time
may lead to epistaxis and internal hemorrhage

Ammonia/urine to breath and perspiration may


progress to uremic frost
Generalized edema, HPN, hypervolemia due to sdium
and water retention
Kussmauls respiration (deep and rapid respiration)
respiratory compensation to metabolic acidosis
Blood chemistry: Elevated BUN and creatinine
Serum electrolytes: Hyperkalemia, Hyperphosphatemia,
Hypocalcemia
Diuretic Phase lasts 1 week
Convalescent/Recovery Phase - from time
BUN/Creatinine, urine volume become normal; patient
returns to normal activity and nephrotoxic drugs should
be avoided.

Acute Renal Failure


Diagnostic Tests Result:
CBC, Electrolytes, BUN, CREA,
Creatinine clearance
ECG dysrhythmias due to potassium
imbalances
Renal Ultrasound may indicate
abnormally shaped kidneys
Renal Biopsy reveals extent of renal
damage

Acute Renal Failure


Nursing Care
Monitor I&O at frequent intervals
Monitor daily weight
Observe for signs of fluid retention and
overhydration such as edema,
crackles, distended neck vein, elevated
BP
Monitor serum electrolytes esp Potassium,
Phosphorus, Sodium, Calcium
Limit fluids as ordered

Encourage activity but avoid fatigue. Provide


periods of undisturbed rest to conserve energy
and oxygen
Protect client from injury caused by decreasing
LOC, possibility of convulsions, and clouded
sensorium
Protect client from injury caused by bleeding
tendencies and hemorrhage
Protect client from cross infection through
isolation, meticulous hand washing and use of
mask
Observe early signs and symptoms of
complications

Acute Renal Failure


Nursing Care
Provide special skin care relieve pruritus by avoiding
use of soap but instead emollient baths, keeping the skin
moist and control environmental temperature,
Antipruritics: Cyproheptadine (Periastin), Trineprazine
(Tenaril)
Monitor V/S and physical status at frequent intervals;
record and report any deviations immediately
Direct treatment toward correcting the underlying cause
of renal failure
Diet therapy: Low to moderate CHON, moderate high
fat, high CHO and calorie for energy, controlled sodium
and potassium intake (based on serum levels), calcium
supplements depending on varying phosphate levels

Pharmacological management:
Potassium lowering agents:
Eg: Dextrose 50% with insulin-facilitates Potassium
transport back into cells. Calcium gluconate
Kayexelate given via enema; retain for 30-60 mins;
promotes potassium excretion from the lower GI tract
Sodium Bicarbonate
May undergo peritoneal/hemodialysis depending on
MDs recommendation
Provide calm, supportive atmosphere
Assist in coping life-style and self-concept
Promote HOPE and opportunity for client to express
feelings about self

Chronic Renal Failure


a slow, progressive, insidious, and irreversible impairment
of renal function; continued renal damage ends in fatal
Uremia or End Stage Renal Disease (ESRD).
Stages of CRF:
Renal Reserve/Impairment = GFR forty-50%
Renal Insufficiency = GFR twenty-forty %
Renal Failure = GFR 10-twenty %
Uremia/ESRD= GFR less than 10%
Normal GFR=one hundred twenty five ml per minute
Manifestations:
Subjective
Lethargy or drowsiness
Headache
Nausea
Pruritus
Fatigue

Chronic Renal Failure


Objective
Oliguria =urine output less than four
hundred ml but more than 100ml/twenty
four hrs
Vomiting
Decreasing LOC
Anemia
Signs of bleeding
Signs of infection
Decreased serum pH

Hypertension
Hypocalcemia and Hyperphosphatemia
RenalOsteodystrophy
Kussmauls respirations to compensate for
metabolic acidosis
Uremic fetor = uriniferous odor of breath from
ammonia
Uremic frost = powdery substance on the skin
from urate water, usually present in ESRD, late
sign
Peripheral neuropathy, numbness and
paresthesias = due to hypocalcemia

Chronic Renal Failure


Therapeutic Interventions:
Fluid and salt restrictions
Antihypertensive drugs
Maintain skin integrity
Maintain acceptable electrolyte
Controlled CHON, CHO, and Fat if client is
on hemodiaysis. Unrestricted diet with
high CHON intake to replace albumin loss
if on CAPD.

Correct Anemia:
Blood transfusion for immediate correction of Anemia
Recombinant Human Erythropoetin (Epogen) 50-100
U/kg 3x a week IV to manage anemia by stimulating
erythrocyte production; not for immediate correction
of anemia.
Expected effect = increased hematocrit in weeks
Nursing Responsibility:
May elevate BP
Do not shake vial because it will inactivate the
drug
Kidney transplantation from a compatible donor for
client with ESRD

Dialysis
= a process used to remove fluid and waste
products from the body when the kidneys
are unable to do so because of impaired
function or when toxins or poisons must be
removed immediately to prevent permanent
or life-threatening damage.
2 Forms of Dialysis
1. Hemodialysis refers to the flow of a
patients blood from a vascular access
through a catheter and tubing to an
artificial kidney.
2. Peritoneal Dialysis refers to the instillation
of dialysate into a patients peritoneal cavity.

Principle of Dialysis
Dialysate solution
used on the opposite
side of the membrane
of the blood that
controls the amount
and direction of
movement across the
semipermeable
membrane of wastes
and other substances.

Hemodialy
sate

Peritoneal
Dialysate

Sodium

130-135

1 4 0-1 4 1

Calcium

2.5 -3.5

3.5

Magnesi
um

0.5-1.0

0.5-1.5

Potassiu 0-2.0
m

0- 4

Chloride

100-119

96-102

Acetate

32 - 38

Lactate

35-40

Bicarbon 30-38
ate
Glucose

1-200mg/dl

Dextrose 1.5%
4. 25%

15g/dl
42.5g/L

WHO NEEDS DIALYSIS?


(Check the vowels)
A Acid-Base problems
E Electrolyte problems
I Intoxications
O Overload of fluids
U Uremic Symptoms

Hemodialysis
Hemodialysis = a process used for patients who
are acutely ill and require short-term dialysis
(days to weeks) or for patients with end-stage
renal disease (ESRD) who require long-term
therapy.
= uses dialyzer, a synthetic, semipermeable
membrane replaces the renal glomeruli and
tubules and acts as the filter for the impaired
kidneys.

Care of the Patient Undergoing


Hemodialysis
Nursing management predialysis: V/S, weight
its comparison with the postdialysis weight from
the last treatment to identify net fluid gain or
loss, fluid assessment, chest assessment,
vascular access, findings indicating electrolyte
imbalance, assistance in determining
anticoagulation needs, neurologic and
psychologic assessment, educational needs.

Care of the Patient Undergoing


Hemodialysis
Nursing management during: collect all
required blood samples at the time of
hookup but before dialysis has started,
monitors all equipment, continually
monitors the patient for possible
complications, observe for signs of
emotional distress.

Care of the Patient Undergoing


Hemodialysis
Nursing management postdialysis: assist
the patient in restful position, observe the
vascular access for hematoma formation
or obvious bleeding & patency, observe for
other sources of bleeding like epistaxis,
monitors V/S, review the patients dialysis
record.

Care of the Patient Undergoing Hemodialysis


through Femoral, Internal Jugular(IJ),Subclavian

Observe the site every shift to note signs


of infection, perform site care using
aseptic technique, monitor pulse, capillary
filling, presence or absence of edema in
distal extremity. If bleeding occurs or
catheter dislodged apply pressure and
notify physician immediately