NCM Renal Disorders

8/3/2019 NCM Renal Disorders

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 44

Management of Patients WithRenal Disorders


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Acute Renal Failure

Acute renal failure (ARF) is a sudden and almostcomplete loss of kidney function (decreased GFR) over a

period of hours to days. Oliguria (less than 400 mL/day of urine) is the most

common clinical situation seen in ARF; anuria (less than50 mL/day of urine).

Increase serum creatinine and BUN levels and retentionof other metabolic waste products (azotemia) normallyexcreted by the kidneys.


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Causes of Acute Renal Failure

Hypovolemia

Hypotension

Reduced cardiac output and heart failure

Obstruction of the kidney or lower urinary tract

Obstruction of renal arteries or veins


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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins4

Acute Renal Failure Acute renal failure is a sudden, usually

reversible deterioration in normal renalfunction.

It can be classified according to underlyingcause as:

1. Prerenal:

a. Hypovolemia.

b. Impaired cardiac efficiency.

c. Vasodilatation.


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Acute Renal Failure (contd)

2. Postrenal obstruction:

a. Urinary tract obstruction.

b. Tumors.

3. Intrarenal:

a. Acute nephritis.

b. Antibiotics.

c. NSAIDs.


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Acute Renal Failure (contd)

Diagnostic Evaluation:

1. Serum creatinine levelthe most reliablemeasure of the GFR, found to be rising

2. Radionuclide studies to evaluate GFR and

renal

blood flow and distribution

3. Urinalysisreveals proteinuria, hematuria,

casts


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Phases of Acute Renal Failure



Initiation

Begins with the initial insult to the kidney



Oliguria Rise in the serum concentration of substances usuallyexcreted by the kidneys

urea, creatinine, uric acid, inorganic acids and the

intracellular cations (potassium and magnesium) Minimum needed for elimination of metabolic waste

products 400 ml / day

Uremic symptoms appear

Hypokalemia develops

Nonoliguric forms are found after nephrotoxicantibiotics, burns, traumatic injury, halogenatedanesthetic agents



DiuresisGradually the urinary output increases because

the glomerular filtration has started recovering

Laboratory values stop rising

Uremic symptoms may continue

Watch for dehydration



Recovery

Improvement in renal function

May take 3 to 12 months

Lab values return to normal gradually



Clinical Manifestations of ARF

appear critically ill and lethargic, with persistent nausea,vomiting, and diarrhea.

The skin and mucous membranes are dry fromdehydration, and the breath may have the odor of urine(uremic fetor).

Central nervous system signs and symptoms include

drowsiness, headache, muscle twitching, and seizures.



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Acute Renal Failure (contd) Treatment:

1. Correction of any reversible cause of acuterenal failure (ie, surgical relief ofobstruction)

2. Correction and control of fluid andelectrolyte imbalances

3. Restoration and maintenance of stable

vital signs

4. Maintenance of nutrition with low-sodium,low- potassium, low-phosphate, moderate-protein diet

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Nursing Management

MONITORING FLUID AND ELECTROLYTE BALANCE

paying careful attention to fluid intake (intravenousmedications should be administered in the smallestvolume possible), urine output, apparent edema,distention of the jugular veins, alterations in heartsounds and breath sounds, and increasing difficultyin breathing.

Accurate daily weights, as well as intake and outputrecords, are essential.



Nursing Management

MONITORING FLUID AND ELECTROLYTE BALANCE

Hyperkalemia is treated with glucose and insulin,calcium gluconate, cation-exchange resins(Kayexalate), or dialysis. Fluid and other electrolytedisturbances are often treated with hemodialysis,peritoneal dialysis, or other continuous renalreplacement therapies..



Nursing Management

REDUCING METABOLIC RATE

Bed rest may be indicated to reduce exertion and themetabolic rate during the most acute stage of thedisorder. Fever and infection, both of which increasethe metabolic rate and catabolism, are prevented ortreated promptly

PROMOTING PULMONARY FUNCTION assisted to turn, cough, and take deep breaths

frequently to prevent atelectasis and respiratory tractinfection.



Nursing Management

PREVENTING INFECTION

Asepsis is essential with invasive lines and cathetersto minimize the risk of infection and increasedmetabolism.

An indwelling urinary catheter is avoided wheneverpossible because of the high risk for UTI associated

with its use.


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Nursing Management

PROVIDING SKIN CARE

Massaging bony prominences, turning the patientfrequently, and bathing the patient with cool water

are often comforting and prevent skin breakdown. PROVIDING SUPPORT

The purpose and rationale of the treatments areexplained to the patient and family by the physician.

High levels of anxiety and fear, however, maynecessitate repeated explanation and clarification bythe nurse.

The family members may initially be afraid to touchand talk to the patient during the procedure but

should be encouraged and assisted to do so.


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Chronic Renal Failure

Chronic renal failure is irreversible destructionof nephrons so that they are no longer

capable of maintaining normal fluid andelectrolyte balance.

Causes:

1. Recurrent UTIs.

2. Toxic agents.

3. Diabetic nephropathy.


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Chronic Renal Failure (contd)

Complications:

1. Azotemia/uremianitrogen waste productsaccumulating in blood. Toxic levels manifestthemselves in many ways such as coma,

headache, gastrointestinal disturbances,neuromuscular disturbances.

2. Metabolic acidosisas a result of decreasingGFR

3. Electrolyte imbalance

4. Severe anemiakidneys unable to stimulateerythropoietin; uremic toxins depleteerythrocytes; nutritional deficiencies.

5. Hypertensionrenal ischemia stimulates


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Clinical Manifestations:

1. Decreased appetite and energy level

2. Increased urinary output and fluidintake

3. Bone or joint pain

4. Delayed or absent sexual maturation

5. Growth retardation


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Diagnostic Evaluation:

Determine extent of disease; monitorprogression.

1. Serum studies

a. Decreased hematocrit, hemoglobin, Na+,Ca++;

increased K+, phosphorous

b. As renal function declines, BUN, uric acid,


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2. Urine studies:

a. Specific gravityincreased or decreased

b. 24-hour urine for creatinine clearance isdecreased

(increased creatinine in urine) reflectingdecreased

GFR.

c. Changes in total output


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Treatment:

1. Correction of calcium phosphorousimbalance. Administer activated vitamin D toincrease calcium absorption and calciumphosphate binders with meals to bind

phosphate in the gastrointestinal tract.

2. Correction of acidosis with buffers such asBicitra

3. Diets should meet caloric needs of the child


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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 27


4. Correction of anemia through the use oferythropoietin (Epogen) administered

subcutaneously at home

5. Growth retardation should be evaluated forpossible use of growth hormone.

6. Treatment options for end-stage renaldisease are hemodialysis, peritoneal dialysis,or transplantation.

7. Institute dialysis therapy while transplant-


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Nursing Management:

A. Ensuring Safety

1. Protect the patient from the effects ofdecreased

level of consciousness and involuntarymovements

by maintaining crib or bed side rails upand padded,

as necessary.


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B. Educating About Chronic RenalFailure

1. Because numerous issues may interferewith the

patient's psychological and socialdevelopment and

education, help the patient and familyto cope with:

a. Uncertainty regarding the course of thedisease and

ultimate prognosis.


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Nursing Process: The Care of the Patientwith Renal FailureDiagnoses

Excess fluid volume

Imbalanced nutrition

Deficient knowledge

Risk for situational low self-esteem


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Nursing Process: The Care of the Patientwith Renal FailurePlanning

Goals may include maintaining of IBW without excessfluid, maintenance of adequate nutritional intake,

increased knowledge, participation of activity withintolerance improved self-esteem, and absence ofcomplications.


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Excess Fluid Volume

Assess for signs and symptoms of fluid volume excess,and keep accurate I&O and daily weights

Limit fluid to prescribe amounts

Identify sources of fluid

Explain to patient and family the rationale for therestriction

Assist patient to cope with the fluid restriction

Provide or encourage frequent oral hygiene


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Imbalanced Nutrition

Assess nutritional status; weight changes and lab data

Assess patient nutritional patterns and history; note foodpreferences

Provide food preferences within restrictions

Encourage high-quality nutritional foods whilemaintaining nutritional restrictions

Assess and modify intake related to factors thatcontribute to altered nutritional intake, eg, stomatitis oranorexia

Adjust medication times related to meals


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Risk for Situational Low Self Esteem

Assess patient and family responses to illness andtreatment

Assess relationships and coping patterns

Encourage open discussion about changes and concerns

Explore alternate ways of sexual expression

Discuss role of giving and receiving love, warmth, andaffection


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DIALYSIS

used to remove fluid and uremic waste products from thebody when the kidneys cannot do so.

The need for dialysis may be acute or chronic.

Acute dialysis is indicated when there is a high and risinglevel of serum potassium, fluid overload, or impendingpulmonary edema, increasing acidosis, pericarditis, and

severe confusion. It may also be used to remove certainmedications or other toxins (poisoning or medicationoverdose) from the blood.


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DIALYSIS

Chronic or maintenance dialysis is indicated in chronicrenal failure, known as end-stage renal disease (ESRD),

in the following instances: the presence of uremic signsand symptoms affecting all body systems (nausea andvomiting, severe anorexia, increasing lethargy, mentalconfusion), hyperkalemia, fluid overload not responsiveto diuretics and fluid restriction, and a general lack ofwell-being.


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HEMODIALYSIS

most commonly used method of dialysis

It is used for patients who are acutely ill and require

short-term dialysis (days to weeks) and for patients withESRD who require long-term or permanent therapy. Adialyzer (once referred to as an artificial kidney) servesas a synthetic semipermeable membrane, replacing therenal glomeruli and tubules as the filter for the impaired

kidneys.

Treatments usually occur three times a week for at least3 to 4 hours per treatment


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HEMODIALYSIS

Diffusion, osmosis, and ultrafiltration are the principleson which hemodialysis is based.

The toxins and wastes in the blood are removed bydiffusionthat is, they move from an area of higherconcentration in the blood to an area of lowerconcentration in the dialysate.

The dialysate is a solution made up of all the importantelectrolytes in their ideal extracellular concentrations.


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HEMODIALYSIS

Excess water is removed from the blood by osmosis, inwhich water moves from an area of higher solute

concentration (the blood) to an area of lower soluteconcentration (the dialysate bath).

Ultrafiltration is defined as water moving under highpressure to an area of lower pressure. This process ismuch more efficient at water removal than osmosis.

Because patients with renal disease usually cannotexcrete water, this force is necessary to remove fluid toachieve fluid balance.


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HEMODIALYSIS

Dialyzers, or artificial kidneys, are either flat-platedialyzers or hollow-fiber artificial kidneys that contain

thousands of tiny cellophane tubules that act assemipermeable membranes. T

he blood flows through the tubules, while a solution (thedialysate) circulates around the tubules. The exchange ofwastes from the blood to the dialysate occurs through

the semipermeable membrane of the tubules .


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Hemodialysis System


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VASCULAR ACCESS

Access to the patients vascular system must beestablished to allow blood to be removed, cleansed, and

returned to the patients vascular system at ratesbetween 200 and 800 mL/minute.


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VASCULAR ACCESS

SUBCLAVIAN, INTERNAL, JUGULAR, AND FEMORALCATHETERS

Immediate access to the patients circulation for acutehemodialysis is achieved by inserting a double-lumen ormultilumen catheter into the subclavian, internal jugular,or femoral vein.

Although this method of vascular access involves somerisk (eg, hematoma, pneumothorax, infection,thrombosis of the subclavian vein, and inadequate flow),it can be used for several weeks.


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Hemodialysis Catheter


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VASCULAR ACCESS

FISTULA

A more permanent access, known as a fistula, is created

surgically (usually in the forearm) by joining(anastomosing) an artery to a vein, either side to side orend to side

The fistula takes 4 to 6 weeks to mature before it is

ready for use.


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VASCULAR ACCESS

GRAFT

An arteriovenous graft can be created by subcutaneously

interposing a biologic, semibiologic, or synthetic graftmaterial between an artery and vein

The most commonly used synthetic graft material isexpanded polytetrafluoroethylene (PTFE).

Grafts are usually placed in the forearm, upper arm, orupper thigh.

Infection and thrombosis are the most commoncomplications of arteriovenous grafts


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Internal Arteriovenous Fistula and Graft


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COMPLICATIONS OF HEMODIALYSIS

atherosclerotic cardiovascular disease, heart failure,coronary heart disease and anginal pain, stroke, andperipheral vascular insufficiency, anemia and fatigue,gastric ulcers and other gastrointestinal problems occurfrom the physiologic stress of chronic illness, medication,sleep problems


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Hypotension may occur during the treatment as fluid isremoved. Nausea and vomiting, diaphoresis, tachycardia,and dizziness are common signs of hypotension.

Painful muscle cramping may occur, usually late indialysis as fluid and electrolytes rapidly leave theextracellular space.

Exsanguination may occur if blood lines separate ordialysis needles accidentally become dislodged.

Dysrhythmias may result from electrolyte and pHchanges or from removal of antiarrhythmic medicationsduring dialysis.


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Air embolism is rare but can occur if air enters thevascular system.

Chest pain may occur in patients with anemia orarteriosclerotic heart disease.

Dialysis disequilibrium results from cerebral fluid shifts.

Signs and symptoms include headache, nausea and

vomiting, restlessness, decreased level of consciousness,and seizures. It is more likely to occur in acute renalfailure or when blood urea nitrogen levels are very high(exceeding 150 mg/dL)


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NURSING MANAGEMENT

MEETING PSYCHOSOCIAL NEEDS

give the patient and family the opportunity to

express feelings of anger and concern over thelimitations that the disease and treatment imposeand over possible financial problems and jobinsecurity.

PROMOTING HOME AND COMMUNITY-BASED CARE

Good communication between the dialysis staff (inthe hospital and outpatient clinic), unit staff, andhome care nurses is essential for providing sound,continuous care.


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Peritoneal Dialysis

The goals of peritoneal dialysis are to remove toxicsubstances and metabolic wastes and to re-establishnormal fluid and electrolyte balance.

Patients with diabetes or cardiovascular disease, manyolder patients, and those who may be at risk for adverseeffects of systemic heparin are likely candidates forperitoneal dialysis.

With this method, instead of being cleaned by an artificialmembrane outside the body, the blood is cleaned insidethe body, through the Peritoneum. This is the thinmembrane that surrounds the outside of the organs inthe abdomen.
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Peritoneal Dialysis

The peritoneum allows waste products to pass through itand is very rich in small blood vessels. By running adialysis fluid into the peritoneal cavity, through a tubecalled a Tenckhoff Catheter - and then out again - wastecan be filtered from the blood.

What is the Peritoneal Dialysis Fluid?

Peritoneal dialysis fluid is a sugar (glucose) solutioncontaining other salts. Bags come in 3 strengths (1.36%,2.27% and 3.86% or light, medium and heavy) - the"heavier" the bag (ie.3.86%), more water will beremoved from the body.
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Peritoneal Dialysis

If you have a lot of fluid in the body, you would useheavy bags to remove fluid. If you are dehydrated, youwould use some light bags so that the dialysis does notremove fluid.

The sugar solution can be a problem for diabetic patientsand changes in therapy may be needed. New solutionsare being developed - Protein or starch.
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Peritoneal Dialysis


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Peritoneal Dialysis


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Complications of Peritoneal Dialysis

Peritonitis (inflammation of the peritoneum) is the mostcommon and most serious complication of peritonealdialysis.

characterized by cloudy dialysate drainage, diffuseabdominal pain, and rebound tenderness.

one to three rapid exchanges with a 1.5% dextrosesolution without added medications are completed towash out mediators of inflammation and to reduceabdominal pain.

Antibiotic therapy continues for 10 to 14 days.


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LEAKAGE

Leakage of dialysate through the catheter site may occur

immediately after the catheter is inserted.

dialysis is withheld for several days to give the incisionand exit site time to heal.


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BLEEDING

A bloody effluent (drainage) may be observed

occasionally

The hypertonic fluid pulls blood from the uterus, throughthe opening in the fallopian tubes, and into the peritonealcavity.) Bleeding is common during the first fewexchanges after a new catheter insertion because someblood exists in the abdominal cavity from the procedure.


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Question

Is the following statement True or False?

Failure of the temporary dialysis access accounts for mosthospital admissions of patients undergoing chronichemodialysis.


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Answer

False

Failure of the permanent, not the temporary, dialysisaccess accounts for most hospital admissions of patientsundergoing chronic hemodialysis.


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Nursing Management of the Hospitalized

Patient on Dialysis (1 of 2)

Protection of vascular access; assess site for patency andsigns of potential infection, and do not use for bloodpressure or blood draws.

Monitor fluid balance indicators and monitor IV therapycarefully; accurate I&O, IV administration pump.

Assess for signs and symptoms of uremia and electrolyteimbalance; regularly check lab data.

Monitor cardiac and respiratory status carefully.

Hypertension: monitor blood pressure,antihypertensive agents must be held on dialysisdays to avoid hypotension.


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Nursing Management of the Hospitalized

Patient on Dialysis (2 of 2)

Monitor all medications and medication dosages carefully.Avoid medications containing potassium and magnesium.

Address pain and discomfort.

Stringent infection control measures.

Dietary considerations: sodium, potassium, protein, andfluid; address individual nutritional needs.

Skin care: pruritis is a common problem; keep skin cleanand well moisturized, and trim nails and avoid scratching.

CAPD catheter care.


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Kidney Surgery

A patient may undergo surgery to remove obstructionsthat affect the kidney (tumors or calculi), to insert atube for draining the kidney (nephrostomy,ureterostomy), or to remove the kidney involved inunilateral kidney disease, renal carcinoma, orkidney transplantation.


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Kidney Surgery

Preoperative considerations Patient preparation to ensure that optimal renal

function is maintained is mandatory.

Fluids are encouraged to promote increased

excretion of waste products before surgery, unlesscontraindicated

If kidney infection is present preoperatively, wide-spectrum antimicrobial agents may be prescribed toprevent bacteremia. Antibiotic agents must be given

with extreme care because many are toxic to thekidneys.

Coagulation studies (prothrombin time, partialthromboplastin time, platelet count) may be

indicated if the patient has a history of bruising andbleeding.


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Kidney Surgery

Perioperative concerns

Renal surgery requires various patient positions to

expose the surgical site adequately.

Postoperative management

Potential hemorrhage and shock

Because the kidney is a highly vascular organ Fluid and blood component replacement is

frequently necessary in the immediatepostoperative period to treat intraoperative bloodloss


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Kidney Surgery

Potential abdominal distention and paralytic ileus

Abdominal distention is relieved by decompression

through a nasogastric tube

Oral fluids are permitted when the passage offlatus is noted

Potential infection

Potential thromboembolism

Low-dose heparin therapy may be initiated


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Patient Positioning and Incisional

Approaches


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Renal Transplantation


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Postoperative Nursing Management

Assessment: include all body systems, pain, fluid andelectrolyte status, and patency and adequacy of urinarydrainage system

Diagnoses: ineffective airway clearance, ineffectivebreathing pattern, acute pain, fear and anxiety, impairedurinary elimination, and risk for fluid imbalance

Complications: bleeding , pneumonia, infection, and DVT


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Interventions

Pain relief measures and analgesic medications

Promote airway clearance and effective breathing patternby appropriate pain relief, deep breathing coughingexercises, and incentive spirometry and positioning

Monitor UO and maintain potency of urinary drainagesystems

Use strict asepsis with catheter and appropriatetechnique in providing all care

Monitor for signs and symptoms of bleeding

Encourage leg exercises, early ambulation, and monitorfor signs of DVT


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Patient Teaching

Instruct both patient and family

Drainage system care

Strategies to prevent complications

Signs and symptoms

Follow-up care

Fluid intake

Health promotion and health screening

Documents

NCM Renal Disorders