1 Nursing Care and Interventions in Managing Chronic Renal
Failure Keith Rischer RN, MA, CEN Slide 2 2 Todays Objectives
Review the pathophysiology and causes of chronic renal failure
(CRF). Contrast lab findings and physiologic changes associated
with acute vs. chronic renal failure. Identify relevant nursing
diagnosis statements and prioritize nursing care for clients with
CRF including dietary modifications. Compare and contrast the
following treatment modalities: peritoneal dialysis, hemodialysis,
and continuous renal replacement therapies. Identify nursing care
priorities with hemodialysis and peritoneal dialysis. Prioritize
teaching needs of clients with CRF. Slide 3 3 Slide 4 4 Patho Slide
5 5 Patho:Chronic Renal Failure Progressive, irreversible kidney
injury Kidney function does not recover Azotemia Increase
nitrogenous wastes such as BUN Creatinine Uremia azotemia with
symptoms (chart 75-5 p.1739) Anorexia, N&V, fatigue, SOB Uremic
syndrome (urine in the blood) Altered fluid, lyte and acid-base
balance clinical and lab manifestations of renal failure More
severe weakness, lethargy, confusioncoma..death Slide 6 6
Patho:Stages of Chronic Renal Failure Diminished renal reserve GFR
normal Compensation w/healthy nephrons Renal insufficiency Nephrons
destroyedremaining adapt BUN, creatinine, uric acid elevate
Priorities: fluid volume, diet, control of HTN, End-stage renal
disease Severe fluid, acid-base imbalances Dialysis needed or will
die Slide 7 7 Patho:Physiologic Changes Kidney Decreased GFR Poor
H2O excretion Metabolic BUN and creatinine increased Electrolytes
Sodium- later stages sodium retention Potassium increased EKG
changes Kayexelate Acid-base balance: metabolic acidosis Calcium
decreased and phosphorus increased Slide 8 8 Patho:Physiologic
Changes Cardiac Hypertension Hyperlipidemia Congestive heart
failure Uremic pericarditis Hematologic anemia Gastrointestinal
Halitosis Stomatitis PUD Slide 9 9 Patho:Physiologic Changes
Neurologic lethargy Uremic encephalopathy Respiratory pulmonary
effusion SOB Urinary proteinuria, oliguria, dilute Skin dry,
pallor, pruritus, ecchymosis Slide 10 10 Drug Therapy chart 75-3
p.1737 Cardioglycides Digoxin/Lanoxin Calcium channel blockers
Diuretics Vitamins and minerals Folic Acid Ferrous Sulfate Biologic
response modifiers Erthropoetin (Epogen) Phosphate binders Aluminum
hydroxide Stool softeners and laxatives Slide 11 11 Patho of One
Dialysis/ESRD Client DM II Retinopathy ESRDhemodialysis 3x/week
Anemia CAD PTCA 1994 w/redo 2005 AMI 2005-stent to LAD, Cx CHF 25%
EF w/global hypokinesis and severe inferior hypokinesis AFib AAA
Neuropathy Obesity Rt Femoral Bypass Rt BKA Medications ASA Phoslo
Coumadin Digoxin Epoetin Lantus insulin Novolog per sliding scale
Lipitor Neurontin NTG subl prn Slide 12 12 ED Renal Case Study 69yr
female HPI: Hemodialysis earlier in day. Found to have HR in the
40s afterwards. Did not increase. Has no c/o lightheadedness. Has
no other physical c/o VS: T-97.8 P-42 (AFib) R-20 BP-122/76 sats
96% 3l per n/c Slide 13 13 Labs Slide 14 14 Excess Fluid Volume
Interventions: Monitor I&O Promote fluid balance Daily weights
1 kg=1liter fluid Assess for manifestations of volume excess:
Crackles in the bases of the lungs Edema Distended neck veins
Diuretics Contraindicated w/ESRD Slide 15 15 Decreased Cardiac
Output Interventions: Control hypertension calcium channel blockers
ACE inhibitors alpha- and beta-adrenergic blockers vasodilators.
Education: monitor blood pressure clients weight Diet Drug regimen
Slide 16 16 Potential for Pulmonary Edema Interventions: Assess for
early signs of pulmonary edema Restlessness/anxiety Tachycardia
Tachypnea oxygen saturation levels Crackles in bases Hypertension
Slide 17 17 Imbalanced Nutrition Interventions: Dietary evaluation
for: Protein Fluid Potassium Sodium Phosphorus Vitamin
supplementation Iron Water soluable vitamins Calcium Vitamin D
Slide 18 18 Risk for Infection Interventions: Meticulous skin care
Preventive skin care Inspection of vascular access site for
dialysis Monitoring of vital signs for manifestations of infection
Slide 19 19 Risk for Injury Interventions: Drug therapy Education
prevent fall Injury pathologic fractures bleeding toxic effects of
prescribed drugs Digoxin Narcotics Heparin or Coumadin Slide 20 20
Fatigue Interventions: Assess for vitamin deficiency Administer
vitamin and mineral supplements anemia Give iron supplements as
needed Erythropoietin therapy Buildup of urea Slide 21 21 Anxiety
Interventions: Health care team involvement Client and family
education Continuity of care Encouragement of client to ask
questions and discuss fears about the diagnosis of renal failure
Slide 22 22 Indications for Dialysis Uremia Persistent hyperkalemia
Uncompensated metabolic acidosis Fluid volume excess unresponsive
to diuretics Uremic pericarditis Uremic encephalopathy Slide 23 23
Hemodialysis Client selection Irreversible renal failure
Expectation for rehab Acceptance of regimen Dialysis settings
Acute-hospital Out patient centers Slide 24 24 Hemodialysis:Patho
Diffusion Dialysate Lytes and H2O Dialyzer Anticoagulation Heparin
to prevent blood clots in dialyzer or tubing Slide 25 25
Complications of Hemodialysis Dialysis disequilibrium syndrome
Infectious diseases Hepatitis B and C infections HIV exposureposes
some risk for clients undergoing dialysis Slide 26 26 Vascular
Access Arteriovenous fistula, or arteriovenous graft for long- term
permanent access Hemodialysis catheter, dual or triple lumen, or
arteriovenous shunt for temporary access Precautions Bruit &
thrill BP restrictions Complications Thrombosis CMS Slide 27 27
Hemodialysis: Nursing Interventions Predialysis care: Medications
to holdwhy? Postdialysis care: Monitor for complications such as
hypotension, headache, nausea, malaise, vomiting, dizziness, muscle
cramps. Monitor vital signs and weight. sepsis Avoid invasive
procedures 4 to 6 hours after dialysis. Continually monitor for
hemorrhage. Assess for thrill No BP or blood draws on arm Slide 28
28 Peritoneal Dialysis Slide 29 29 Peritoneal Dialysis Phases
Inflow Dwell Drain Contraindications history of abd surgeries
recurrent hernias excessive obesity preexisting vertebral disease
severe obstructive pulmonary disease Slide 30 30 Complications of
Peritoneal Dialysis Peritonitis (cloudy outflow) Pain Exit site and
tunnel infections Poor dialysate flow Dialysate leakage Monitor
color of outflow cloudy (peritonitis) brown (bowel) bloody (first
week OK) urine (bladder) Slide 31 31 Nursing Care During Peritoneal
Dialysis Pre PD: Vital signs pre and q 15-30 during Weight
laboratory tests Continually monitor the client for: respiratory
distress pain discomfort Monitor prescribed dwell time and initiate
outflow Observe outflow amount & pattern of fluid Slide 32 32
Education Priorities Pathophysiology and manifestations
Complications When to call the doctor Keep record of all labs Take
medications and follow plan of care set out by case manager Monitor
weight, fatigue levels closely
