Renal Failure

Kidney anatomyKidney anatomy

The kidneys are responsible for removing wastes from the body,

regulating electrolyte balance and blood pressure,

and stimulating red blood cell production.

RENAL DISEASESRENAL DISEASES

Terms:Terms:

*aldosterone*aldosterone *hematuria *hematuria*antidiuretic hormone *nocturia*antidiuretic hormone *nocturia*anuria*anuria *oliguria *oliguria*bacteriuria*bacteriuria *proteinuria *proteinuria*clearance*clearance *pyuria *pyuria*dysuria*dysuria *Valsalva Leak Maneuver Point *Valsalva Leak Maneuver Point *frequency*frequency *vesicoureteral reflux *vesicoureteral reflux *GFR*GFR

Test of Urine Specific Gravity:Test of Urine Specific Gravity:

1. Osmolality1. Osmolality 2. Specific gravity2. Specific gravity

IllustrationIllustration

IllustrationIllustration

KidneysKidneys

--retroperitoneal organsretroperitoneal organs

-120 – 170g-120 – 170g

-12cm long, 6cm wide and 2.5cm thick-12cm long, 6cm wide and 2.5cm thick

-with 8 – 18 pyramids-with 8 – 18 pyramids

-with 4 -13 minor calyces-with 4 -13 minor calyces

-with 2 – 3 major calyces-with 2 – 3 major calyces

-with protective structures:-with protective structures:

a. Pararenal fata. Pararenal fat

b. Gerota’s fasciab. Gerota’s fascia

c. Perirenal fatc. Perirenal fat

d. Renal capsuled. Renal capsule

NephronNephron

--basic structural and functional unit of the kidneybasic structural and functional unit of the kidney

3 Processes of Urine Formation3 Processes of Urine Formation1. Glomerular Filtration1. Glomerular Filtration2. Tubular Reabsorption2. Tubular Reabsorption3. Tubular Secretion3. Tubular Secretion

Renal function begins to decrease Renal function begins to decrease at a rate of 1% each year at 30.at a rate of 1% each year at 30.

A.A. Acute PyelonephritisAcute Pyelonephritis

-bacterial infection of the renal pelvis, tubules and -bacterial infection of the renal pelvis, tubules and interstitial tissueinterstitial tissue-an ascending infection-an ascending infection-predisposing factors:-predisposing factors: a. vesico-ureteral refluxa. vesico-ureteral reflux b. urinary tract obstructionb. urinary tract obstruction

-enlarged kidney-enlarged kidney-with abscess on the renal capsule and at the cortico--with abscess on the renal capsule and at the cortico-medullary junctionmedullary junction

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:

fever and chillsfever and chills costo-vertebral anglecosto-vertebral angle

leucocytosisleucocytosis tendernesstenderness

bacteriuria and pyuriabacteriuria and pyuria dysuriadysuria

flank painflank pain increase urinary frequencyincrease urinary frequency

DIAGNOSIS:DIAGNOSIS:

UTZUTZ Nuclear scanNuclear scan

CT scanCT scan Urine Culture and Sensitivity Urine Culture and Sensitivity

IVPIVP TestTest

MEDICAL MANAGEMENTMEDICAL MANAGEMENT::

a. uncomplicateda. uncomplicated-no dehydration, no nausea and vomiting, no sepsis-no dehydration, no nausea and vomiting, no sepsis

>2 weeks of oral antibiotics>2 weeks of oral antibioticsTrimethoprim-SulfamethoxazoleTrimethoprim-SulfamethoxazoleCiprofloxacinCiprofloxacinGentamicin with or without AmpicillinGentamicin with or without AmpicillinThird Generation CephalosporinsThird Generation Cephalosporins

>6 weeks of oral antibiotics if with relapse>6 weeks of oral antibiotics if with relapse*urine culture 2 weeks after antibiotic therapy*urine culture 2 weeks after antibiotic therapyb. complicatedb. complicated-pregnant patients-pregnant patients

>hospitalization (antibiotics from IV to oral)>hospitalization (antibiotics from IV to oral)

B. Chronic PyelonephritisB. Chronic Pyelonephritis-repeated acute pyelonephritis >> chronic -repeated acute pyelonephritis >> chronic pyelonephritispyelonephritis

-no s/sx unless there’s an acute exacerbation-no s/sx unless there’s an acute exacerbation

-kidneys scarred, contracted and non functional-kidneys scarred, contracted and non functional

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:

fatiguefatigue polyuriapolyuria

headacheheadache excessive thirstexcessive thirst

anorexiaanorexia weight lossweight loss

DIAGNOSIS:DIAGNOSIS:

creatinine and BUN clearancecreatinine and BUN clearance

creatinine levelscreatinine levels

intravenous pyelographyintravenous pyelography

COMLICATIONS:COMLICATIONS:

a. ESRDa. ESRD

b. hypertensionb. hypertension

c. formation of renal stonesc. formation of renal stones

-may be due to the presence of urea -may be due to the presence of urea splitting microorganisms splitting microorganisms

MEDICAL MANAGEMENTMEDICAL MANAGEMENT::a. urine culture and sensitivity guided antibiotic therapya. urine culture and sensitivity guided antibiotic therapy

NitrofurantoinNitrofurantoin

TMP-SMZTMP-SMZ

NURSING MANAGEMENT:NURSING MANAGEMENT:

a. monitoringa. monitoring

-I&O-I&O

b. oral fluids b. oral fluids (3-4L/day)(3-4L/day)

c. symptomaticc. symptomatic

-antipyretics-antipyreticsd. educationd. education

-advise bed rest-advise bed rest-prevention of UTI-prevention of UTI

C. Acute GlomerulonephritisC. Acute Glomerulonephritis-primarily a disease of children older than 2 years old-primarily a disease of children older than 2 years old-may affect any age-may affect any age-causes:-causes:

>autoimmune>autoimmuneSLESLE

>streptococcal>streptococcalAcute Post Streptococcal Acute Post Streptococcal

GlomerulonephritisGlomerulonephritis

Acute Post Streptococcal GlomerulonephritisAcute Post Streptococcal Glomerulonephritis

-2 to 3 weeks after-2 to 3 weeks after

>impetigo>impetigo

>sorethroat>sorethroat

SINGS AND SYMPTOMS:SINGS AND SYMPTOMS:

hematuriahematuria hypertensionhypertension

tea colored urinetea colored urine headache, malaise, flank headache, malaise, flank painpain

proteinuriaproteinuria (+) kidney punch(+) kidney punch

inc serum BUN and creainc serum BUN and crea congestioncongestion

anemiaanemia confusion, somnolenceconfusion, somnolence

edemaedema and seizuresand seizures

Group A Beta-Hemolytic Streptococcal InfectionGroup A Beta-Hemolytic Streptococcal Infection

Antigen-Antibody ReactionAntigen-Antibody Reaction

Deposition in the GlomerulusDeposition in the Glomerulus

Increased Production of Epithelial Cells in the Increased Production of Epithelial Cells in the

GlomerulusGlomerulus

WBC InfiltrationWBC Infiltration

ThickeningThickening

ScarringScarring

Decreased GFRDecreased GFR

DIAGNOSIS:DIAGNOSIS:a. kidney biopsya. kidney biopsyb. electron microscopyb. electron microscopyc. immunoflourescence analysisc. immunoflourescence analysis

d. Anti-Streptolysin O Titerd. Anti-Streptolysin O Titer Anti-DNAse B TiterAnti-DNAse B Titer e. Serum Complement Determinatione. Serum Complement Determination

-decreased-decreased-will normalize in 2 – 8 weeks-will normalize in 2 – 8 weeks

IgA NephropathyIgA Nephropathy-most common type of primary -most common type of primary

glomerulonephritisglomerulonephritis-Inc IgA; with normal serum complement-Inc IgA; with normal serum complement-complications:-complications:

a. Hypertensive Encephalopathya. Hypertensive Encephalopathyb. Heart Failureb. Heart Failurec. Pulmonary Edemac. Pulmonary Edema

Rapidly Progressive GlomerulonephritisRapidly Progressive Glomerulonephritis

-patient deteriorates in weeks to months-patient deteriorates in weeks to months

-course is more severe and more rapid-course is more severe and more rapid

Management To GlomerulonephritisManagement To Glomerulonephritis

Goals:Goals:

1. Treat symptoms1. Treat symptoms

2. Preserve renal function2. Preserve renal function

3. Treat complications3. Treat complications

a. antibioticsa. antibiotics d. protein restrictiond. protein restriction

b. steroidsb. steroids e. sodium restrictione. sodium restriction

c. cytotoxic agentsc. cytotoxic agents f. diureticsf. diuretics

g. dialysisg. dialysis

D. Chronic GlomerulonephritisD. Chronic Glomerulonephritis-components:-components:

repeated acute glomerulonephritisrepeated acute glomerulonephritis

hypertensive nephrosclerosishypertensive nephrosclerosis

hyperlipidemiahyperlipidemia

chronic tubulo-interstitial injurychronic tubulo-interstitial injury

hemodynamically mediated glomerular hemodynamically mediated glomerular sclerosissclerosis

-contraction of the kidneys to 1/5 of its original size-contraction of the kidneys to 1/5 of its original size

-deformed kidneys-deformed kidneys

-may result to ESRD-may result to ESRD

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:

may be asymptomaticmay be asymptomatic hypertensionhypertension

inc BUN and Creainc BUN and Crea bipedal edemabipedal edema

retinal hemorrhagesretinal hemorrhagesophthalmoscopyophthalmoscopy

papilledemapapilledemaweight lossweight lossweakness and irritabilityweakness and irritabilitynocturianocturiaGIT disturbancesGIT disturbancesanemiaanemiaheart failureheart failureperipheral neuropathy, decreased DTRperipheral neuropathy, decreased DTRpulsus paradosuspulsus paradosus

DIAGNOSIS:DIAGNOSIS:

1. Urinalysis- fixed sp. Gravity at 1.0101. Urinalysis- fixed sp. Gravity at 1.010 proteinuria; urinary castsproteinuria; urinary casts

2. serum chemistry2. serum chemistry

-hyperkalemia-hyperkalemia

- hypoalbuminemia - hypoalbuminemia

-hyperphosphatemia-hyperphosphatemia

-hypocalcemia-hypocalcemia

-hypermagnesemia-hypermagnesemia

3. CBC3. CBC

-anemia-anemia

4. Chest X-Ray4. Chest X-Ray

-cardiomegaly-cardiomegaly

-pulmonary edema-pulmonary edema

5. ECG5. ECG

-left ventricular hypertrophy-left ventricular hypertrophy

MANAGEMENT:MANAGEMENT:

1. treatment of hypertension1. treatment of hypertension

2. weight monitoring2. weight monitoring

3. give proteins of high biologic value3. give proteins of high biologic value

4. adequate calories4. adequate calories

5. dialysis5. dialysis

NURSING MANAGEMENT:NURSING MANAGEMENT:

1. monitoring1. monitoring

E. Nephrotic SyndromeE. Nephrotic Syndrome

-components:-components:

proteinuriaproteinuria hyperlipidemiahyperlipidemia

hypoalbuminemiahypoalbuminemia

CAUSES:CAUSES:

a. chronic glomerulonephritisa. chronic glomerulonephritis

b. diabetes mellitusb. diabetes mellitus

c. amyloidosisc. amyloidosis

d. SLEd. SLE

e. multiple myelomae. multiple myeloma

f. renal vein thrombosisf. renal vein thrombosis

SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:

edema edema (soft and pitting)(soft and pitting)

-eyes, dependent area and abdomen-eyes, dependent area and abdomen

malaisemalaise irritabilityirritability

headacheheadache fatiguefatigue

DIAGNOSIS:DIAGNOSIS:1. Urinalysis1. Urinalysis

-proteinuria (3-3.5g/day)-proteinuria (3-3.5g/day)

-inc WBC-inc WBC

2. Protein Electrophoresis2. Protein Electrophoresis

ImmunoelectrophoresisImmunoelectrophoresis

3. Biopsy3. Biopsy

4. AntiC1q antibodies (SLE)4. AntiC1q antibodies (SLE)

COMPLICATIONS:COMPLICATIONS:a. infectiona. infection d. acute RFd. acute RF

b. thromboembolismb. thromboembolism e. acceleratede. accelerated atherosclerosisatherosclerosis

c. pulmonary embolic. pulmonary emboli

MANAGEMENT:MANAGEMENT:

1. diuretics1. diuretics

2. ACE inhibitors2. ACE inhibitors

3. immunosuppressants3. immunosuppressants

4. steroids4. steroids

5. hypolipidemic agents5. hypolipidemic agents

6. sodium restriction6. sodium restriction

7. CHON intake of 0.8g/kg/day7. CHON intake of 0.8g/kg/day

low saturated fatslow saturated fats

UrolithiasisUrolithiasis-stones or calculi in the urinary tract-stones or calculi in the urinary tract-supersaturation of substances such as calcium -supersaturation of substances such as calcium oxalate, calcium phosphate and uric acidoxalate, calcium phosphate and uric acid

SIGNS AND SYMPTOMPSSIGNS AND SYMPTOMPS::>depends on >depends on

*the site of obstruction*the site of obstruction *edema*edema

*infection*infection ASSESSMENT AND DIAGNOSIS:ASSESSMENT AND DIAGNOSIS:

>IVP, Intravenous Urography>IVP, Intravenous Urography>Retrograde Pyelography>Retrograde Pyelography>UTZ>UTZ>serum chemistries and 24 urine tests>serum chemistries and 24 urine tests

deficiency of citrate, mgdeficiency of citrate, mg

nephrocalcin & uropontinnephrocalcin & uropontin

dehydrationdehydration

infectioninfection

UrolithiasisUrolithiasis

urinary stasisurinary stasis

periods of immobilityperiods of immobility

hypercalciuria and hypercalcemiahypercalciuria and hypercalcemia

Causes of hypercalcemia and hypercalciuria:Causes of hypercalcemia and hypercalciuria:

a. hyperparathyroidisma. hyperparathyroidism

b. renal tubular acidosisb. renal tubular acidosis

c. cancersc. cancers

d. granulomatous diseased. granulomatous disease

e. excessive intake of Vitamin De. excessive intake of Vitamin D

f. excessive intake of milk and alkalif. excessive intake of milk and alkali

g. myeloproliferative diseaseg. myeloproliferative disease

-substances other than calcium that may precipitate -substances other than calcium that may precipitate and form stonesand form stones

a. uric acida. uric acid

-5%-10% of renal stones-5%-10% of renal stones

-gout, myeloproliferative disorders-gout, myeloproliferative disorders

b. struviteb. struvite

-15% of renal stones-15% of renal stones

-in persistently alkaline and ammonia rich urine-in persistently alkaline and ammonia rich urine(caused by urease-splitting bacteria)(caused by urease-splitting bacteria)-in neurogenic bladder, foreign bodies and -in neurogenic bladder, foreign bodies and recurrent UTIrecurrent UTI

c. cystinec. cystine

-1%-2% of renal stones-1%-2% of renal stones

-hereditary defect in the renal absorption-hereditary defect in the renal absorption -medicines that increases the risk of urolithiasis-medicines that increases the risk of urolithiasis

a. acetazolamidea. acetazolamide d. laxativesd. laxativesb. Vitamin Db. Vitamin D e. high doses of aspirine. high doses of aspirinc. antacidsc. antacids

MANAGEMENT:MANAGEMENT:a. eradicate the stone a. eradicate the stone

b. determine the stone typeb. determine the stone type

c. prevent nephron destructionc. prevent nephron destruction

d. control infectiond. control infection

e. relieve any obstructione. relieve any obstruction

>Opioid Analgesics>Opioid Analgesics

NSAIDsNSAIDs

>Hot Baths and Moist Heat to the flank >Hot Baths and Moist Heat to the flank areaarea

>Advise to increase oral fluid intake>Advise to increase oral fluid intake

(urine output of >2L/day is (urine output of >2L/day is advisable)advisable)

SPECIFIC MANAGEMENT:SPECIFIC MANAGEMENT:

1. Calcium stones1. Calcium stones

-restrict proteins and sodium in the diet-restrict proteins and sodium in the diet

-acidify the urine using Ammonium -acidify the urine using Ammonium chloride chloride

or Acetohydroxamic Acidor Acetohydroxamic Acid

-Cellulose sodium phosphate-Cellulose sodium phosphate

(binds calcium from food)(binds calcium from food)

-thiazide diuretics -thiazide diuretics (if caused by inc PTH)(if caused by inc PTH)

2. Uric Acid Stones2. Uric Acid Stones

-low purine diet -low purine diet (shellfish, mushrooms, (shellfish, mushrooms, asparagus, organ meats) asparagus, organ meats)

-Allopurinol-Allopurinol

-alkalinize the urine-alkalinize the urine

3. Cystine 3. Cystine

-low protein diet-low protein diet

-penicillamine -penicillamine (to decrease excretion (to decrease excretion through the urine) through the urine)

4. Oxalate4. Oxalate -dilute the urine-dilute the urine

-limit oxalate containing foods-limit oxalate containing foods

(spinach, strawberries, rhubarb, tea, (spinach, strawberries, rhubarb, tea, bran) bran)

SURGICAL MANAGEMENTSURGICAL MANAGEMENT::a. Ureteroscopya. Ureteroscopy

b. Extracorporeal Shock Wave Lithotripsyb. Extracorporeal Shock Wave Lithotripsy

c. Percutaneous Nephrostomy or c. Percutaneous Nephrostomy or NephrolithotomyNephrolithotomy

ACUTE RENAL FAILUREACUTE RENAL FAILURE

Acute Kidney Failure

Acute kidney failure occurs when the kidneys suddenly stop working. This may occur after surgery or due to an injury. It can also occur due to the use of certain drugs. People with acute renal failure may regain their kidney function depending on the cause of the damage.

Acute Kidney Failure

Acute Renal FailureAcute Renal Failure

-sudden and almost complete loss of renal function-sudden and almost complete loss of renal function

-s/sx:-s/sx:

*oliguria*oliguria *normal urine output*normal urine output

*anuria*anuria *rising serum creatinine and *rising serum creatinine and

BUN BUN

1.1. PrerenalPrerenal

-shock-shock

2. Intrarenal2. Intrarenal

-the result of actual parenchymal damage-the result of actual parenchymal damage

-use of nephrotoxic drugs (NSAIDs and ACE inh)-use of nephrotoxic drugs (NSAIDs and ACE inh)

3. Postrenal3. Postrenal

-the result of an obstruction in the distal urinary tract-the result of an obstruction in the distal urinary tract

Acute Renal FailureAcute Renal Failure

ACUTE RENAL FAILURE

PRE-RENAL INTRA-RENAL POST-RENAL

Four Clinical Phases of ARFFour Clinical Phases of ARF1. Initiation1. Initiation

-begins with the initial insult and ends when oliguria develops-begins with the initial insult and ends when oliguria develops

2. Oliguria2. Oliguria

-rise in the serum of waste products of metabolism-rise in the serum of waste products of metabolism

-rise in serum potassium and magnesium-rise in serum potassium and magnesium

33. Diuresis. Diuresis

-with gradually increasing urine output-with gradually increasing urine output

-renal function may still be markedly abnormal-renal function may still be markedly abnormal

4. Recovery Period4. Recovery Period

-improvement of renal function-improvement of renal function

-may take 3-12 months-may take 3-12 months

-with normal laboratory values-with normal laboratory values

-with permanent 1-3% reduction in GFR-with permanent 1-3% reduction in GFR

CharacteristicsCharacteristics PrerenalPrerenal IntrarenalIntrarenal PostrenalPostrenalEtiologyEtiology hypoperfusionhypoperfusion parenchymal parenchymal

damagedamageobstructionobstruction

BUN valueBUN value increasedincreased increasedincreased IncreasedIncreased

Creatinine Creatinine valuevalue

increasedincreased increasedincreased IncreasedIncreased

Urine outputUrine output decreaseddecreased varies, often varies, often decreaseddecreased

varies, may be varies, may be decreased or decreased or anuriaanuria

Urine sodiumUrine sodium Decreased, Decreased, <20mEq/L<20mEq/L

Increased, Increased, >40mEq/L>40mEq/L

Varies, often Varies, often <20mEq/L<20mEq/L

Urinary Urinary SedimentSediment

Normal, few Normal, few hyaline castshyaline casts

Abnormal castsAbnormal casts Usually normalUsually normal

CharacteristicsCharacteristics PrerenalPrerenal IntrarenalIntrarenal PostrenalPostrenal

Urine Urine osmolalityosmolality

Increased to Increased to 500mOms500mOms

Abnormal casts Abnormal casts and debrisand debris

Usually normalUsually normal

Urine specific Urine specific gravity gravity

IncreasedIncreased Low normal, Low normal, 1.0101.010

VariesVaries

ASSOCIATED PROBLEMS:ASSOCIATED PROBLEMS:

*metabolic acidosis*metabolic acidosis*hyperphophatemia and hypocalcemia*hyperphophatemia and hypocalcemia*anemia*anemia

PREVENTION:PREVENTION:*prevention of exposure to nephrotoxic drugs*prevention of exposure to nephrotoxic drugs

-aminoglycosides, cyclosporine, amphotericin B-aminoglycosides, cyclosporine, amphotericin B*serum BUN and creatinine monitoring*serum BUN and creatinine monitoring

MANAGEMENT:MANAGEMENT:a. restore chemical balance and prevent complicationsa. restore chemical balance and prevent complicationsb. identification and treatment of the underlying causeb. identification and treatment of the underlying causec. maintain fluid balancec. maintain fluid balance

-BP, CVP, serum and urine elect., fluid loses-BP, CVP, serum and urine elect., fluid loses

d. monitoring for over hydrationd. monitoring for over hydration

-dyspnea, crackles, distended neck veins-dyspnea, crackles, distended neck veins

-Furosemide, Ethacrynic Acid-Furosemide, Ethacrynic Acid

e. dialysise. dialysis

-to prevent serious complications-to prevent serious complications

*hyperkalemia*hyperkalemia

*severe metabolic acidosis*severe metabolic acidosis

*pericarditis*pericarditis

*pulmonary edema *pulmonary edema

f. pharmacologicf. pharmacologic

-cation exchange resin-cation exchange resin

(sodium polystyrene sulfonate-kayexalate)(sodium polystyrene sulfonate-kayexalate)

-retention enema-retention enema

-diuretic therapy-diuretic therapy

-low dopamine dose (1-3g/kg)-low dopamine dose (1-3g/kg)

-phosphate binding agents (AlOH)-phosphate binding agents (AlOH)

g. nutritional therapyg. nutritional therapy

-give additional proteins (1g/kg/day during the -give additional proteins (1g/kg/day during the oliguric phase)oliguric phase)

-high potassium and phosphate foods are -high potassium and phosphate foods are restricted (banana, citrus and coffee)restricted (banana, citrus and coffee)

-potassium restricted to 20-40mEq/day-potassium restricted to 20-40mEq/day

-sodium restricted to 2g/day-sodium restricted to 2g/day

-may require parenteral nutrition-may require parenteral nutrition

NURSING MANAGEMENT:NURSING MANAGEMENT:

a. monitoring fluid and electrolyte balancea. monitoring fluid and electrolyte balance

b. reducing metabolic rateb. reducing metabolic rate

-bed rest, prevention of fever and infection-bed rest, prevention of fever and infection

c. promoting pulmonary functionc. promoting pulmonary function

-assistance in changing positions-assistance in changing positions

-advise to cough and deep breath-advise to cough and deep breath

d. preventing infectiond. preventing infection

-asepsis-asepsis

-avoid inserting an indwelling urinary catheter-avoid inserting an indwelling urinary catheter

e. providing skin caree. providing skin care

f. providing supportf. providing support

CHRONIC RENAL FAILURECHRONIC RENAL FAILURE

Patients with kidney dysfunction (i.e. Renal Failure) are typically identified by the increased blood levels of Cr and BUN on routine blood lab testing. By definition we separate kidney failure into ACUTE vs. CHRONIC.

Chronic Renal FailureChronic Renal Failure-is a progressive irreversible deterioration in renal -is a progressive irreversible deterioration in renal functionfunction-with uremia or azotemia (severity of build up will be -with uremia or azotemia (severity of build up will be proportional to the severity of s/sx)proportional to the severity of s/sx)-prognosis will be determined by the presence or -prognosis will be determined by the presence or absence of absence of hypertensionhypertension and and proteinuriaproteinuria

CAUSES:CAUSES:*diabetes mellitus- most common*diabetes mellitus- most common*hypertension*hypertension*chronic glomerulonephritis*chronic glomerulonephritis*obstruction of the urinary tract*obstruction of the urinary tract*polycystic kidney disease*polycystic kidney disease*infections*infections*nephrotoxic medications*nephrotoxic medications

STAGES:STAGES:Stage 1Stage 1

--Reduced Renal ReserveReduced Renal Reserve-40%-75% loss of nephron function-40%-75% loss of nephron function-usually asymptomatic-usually asymptomatic

Stage 2Stage 2--Renal InsufficiencyRenal Insufficiency-75%-90% loss of nephron function-75%-90% loss of nephron function-increase in serum BUN and creatinine-increase in serum BUN and creatinine-inability to concentrate urine-inability to concentrate urine-anemia may develop-anemia may develop-with polyuria and nocturia-with polyuria and nocturia

Stage 3Stage 3--End Stage Renal DiseaseEnd Stage Renal Disease-<10% of nephron function remaining-<10% of nephron function remaining-regulatory, excretory and hormonal functions -regulatory, excretory and hormonal functions

are lost are lost-requires dialysis-requires dialysis

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

cardiovascularcardiovascular

*hypertension*hypertension *pulmonary edema*pulmonary edema*heart failure*heart failure *pericarditis*pericarditis

dermatologicdermatologic

*pruritus*pruritus*uremic frost (deposit of urea crystals)*uremic frost (deposit of urea crystals)

GI and Neurologic s&sxGI and Neurologic s&sx

ASSESSMENT AND DIAGNOSIS:ASSESSMENT AND DIAGNOSIS:

a. glomerular filtration ratea. glomerular filtration rate

creatinine clearancecreatinine clearance

b. serum electrolytesb. serum electrolytes

c. ABGc. ABG

d. CBCd. CBC

COMPLICATIONS:COMPLICATIONS:

a. Hyperkalemiaa. Hyperkalemia

b. Pericarditis, Pleural Effusion and Cardiac b. Pericarditis, Pleural Effusion and Cardiac TamponadeTamponade

c. Hypertensionc. Hypertension

d. Anemiad. Anemia

e. Bone Diseasee. Bone Disease

MEDICAL MANAGEMENT:MEDICAL MANAGEMENT:a. maintain kidney function and homeostasisa. maintain kidney function and homeostasisb. treat the underlying cause and contributory b. treat the underlying cause and contributory

factorsfactors>medications>medications >dialysis>dialysis>diet therapy>diet therapy

1. Pharmacologic Therapy1. Pharmacologic Therapya. antihypertensivesa. antihypertensives

> includes intravascular volume control> includes intravascular volume control*fluid restriction*fluid restriction*sodium restriction*sodium restriction

b. sodium bicarbonateb. sodium bicarbonatec. erythropoietinc. erythropoietin

>will achieve a Hct of 33%-38%>will achieve a Hct of 33%-38%

>IV or SC 3x a week>IV or SC 3x a week>takes 2-6 weeks to increase Hct>takes 2-6 weeks to increase Hct>A/R:>A/R:

*hypertension*hypertension*increased clotting of vascular *increased clotting of vascular

access access sitessites

*seizures*seizures*depletion of body iron stores*depletion of body iron stores

d. iron supplementationd. iron supplementatione. antiseizure agentse. antiseizure agents

>Diazepam>Diazepam>Phenytoin>Phenytoin

f. antacidsf. antacids

>aluminum based antacids>aluminum based antacids

neurologic symptomsneurologic symptoms

osteomalaciaosteomalacia

>calcium carbonate>calcium carbonate

2. Nutritional Therapy2. Nutritional Therapy

-regulation of protein intake-regulation of protein intake

-regulation of fluid intake-regulation of fluid intake

((500-600ml500-600ml more than the previous day’s 24 more than the previous day’s 24 hour UO)hour UO)

-regulation of sodium intake-regulation of sodium intake

-regulation of potassium-regulation of potassium

-adequate calories and vitamins-adequate calories and vitamins

3. Dialysis3. Dialysis

-to prevent hyperkalemia-to prevent hyperkalemia

NURSING MANAGEMENT:NURSING MANAGEMENT:

a. avoid the complications of reduced renal a. avoid the complications of reduced renal functionfunction

b. assess fluid statusb. assess fluid status

c. identify potential sources of the imbalancec. identify potential sources of the imbalance

d. implement a dietary programd. implement a dietary program

e. encourage self care and independencee. encourage self care and independence

ADPIEADPIE

AssessmentAssessment Subjective: Subjective: Dysuria and Frequent Dysuria and Frequent

urinationurination Objective: Objective: Hyperthermia Urinary Hyperthermia Urinary

incontinence or retentionincontinence or retentionNursing DiagnosisNursing Diagnosis-Impaired urinary elimination r/t renal -Impaired urinary elimination r/t renal

problems as evidenced by urinary problems as evidenced by urinary incontinence.incontinence.

-Hyperthermia r/t kidney infections.-Hyperthermia r/t kidney infections.-Acute pain r/t damaged kidney.-Acute pain r/t damaged kidney.

ADPIEADPIEPlanningPlanning STG: After an hour of nursing intervention the patient’s body temperature STG: After an hour of nursing intervention the patient’s body temperature

will decreased and the pain will be verbalized as tolerable.will decreased and the pain will be verbalized as tolerable. LTG: Within hospital stay the patient will maintain normal body LTG: Within hospital stay the patient will maintain normal body

temperature, verbalizes pain not occurring and will maintain normal temperature, verbalizes pain not occurring and will maintain normal urinary elimination.urinary elimination.

Intervention Intervention --TSBTSB

-Provide teachings of safety measures-Provide teachings of safety measures -Explain patient’s condition-Explain patient’s condition -Monitor VS to know any alteration-Monitor VS to know any alteration -Assess patient’s pain tolerance-Assess patient’s pain tolerance -Administer medications as prescribed-Administer medications as prescribed -Monitor I and O-Monitor I and OEvaluationEvaluation STG: After an hour of nursing intervention the patient’s body temperature STG: After an hour of nursing intervention the patient’s body temperature

has reduced and the patient verbalizes pain as tolerable.has reduced and the patient verbalizes pain as tolerable. LTG: Within hospital stay the patient has maintain normal body LTG: Within hospital stay the patient has maintain normal body

temperature, verbalizes pain not occurring and has maintained normal temperature, verbalizes pain not occurring and has maintained normal urinary elimination.urinary elimination.

REFERENCESREFERENCES

Brunner and Suddarth’s Textbook of Brunner and Suddarth’s Textbook of Medical and Surgical NursingMedical and Surgical Nursing

10th Edition, Suzanne C. 10th Edition, Suzanne C. Smeltzer; Brenda BareSmeltzer; Brenda Bare

www.google.com

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GoD BlessGoD Bless