Renal Failure Acute and Chronic NPN 200 Medical Surgical Nursing I

Renal FailureAcute and Chronic

NPN 200Medical Surgical Nursing I

Acute Renal FailureSudden interruption of kidney function resulting from obstruction, reduced circulation, or disease of the renal tissueResults in retention of toxins, fluids, and end products of metabolismUsually reversible with medical treatmentMay progress to end stage renal disease, uremic syndrome, and death without treatment

Acute Renal FailurePersons at Risks

Major surgeryMajor traumaReceiving nephrotoxic medicationsElderly

Acute Renal FailureCauses

PrerenalHypovolemia, shock, blood loss, embolism, pooling of fluid d/t ascites or burns, cardiovascular disorders, sepsis

Intrarenal Nephrotoxic agents, infections, ischemia and blockages, polycystic kidney disease

Postrenal Stones, blood clots, BPH, urethral edema from invasive procedures

Acute Renal FailureStages

Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOPOliguric – UOP < 400/d, ^BUN,Crest, Phos, K, may last up to 14 dDiuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this stage may begin to see improvementRecovery – things go back to normal or may remain insufficient and become chronic

Acute Renal FailureSubjective symptoms

NauseaLoss of appetiteHeadacheLethargyTingling in extremities

Acute Renal FailureObjective symptoms

Oliguric phase –vomiting disorientation, edema, ^K+ decrease Na ^ BUN and creatinineAcidosisuremic breath

CHF and pulmonary edema hypertension caused by hypovolemia, anorexia sudden drop in UOPconvulsions, comachanges in bowels

Acute Renal FailureObjective systoms

Diuretic phaseIncreased UOP Gradual decline in BUN and creatinineHypokalemiaHyponaturmiaTachycardiaImproved LOC

Acute Renal FailureDiagnostic tests

H&PBUN, creatinine, sodium, potassium. pH, bicarb. Hgb and HctUrine studiesUS of kidneysKUBABD and renal CT/MRIRetrograde pyloegram

Acute Renal FailureMedical treatment

Fluid and dietary restrictionsMaintain E-lytes D/C or change causeMay need dialysis to jump start renal functionMay need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.

Acute Renal FailureMedical treatment

HemodialysisSubclavian approachFemoral approach

Peritoneal dialysisContinous renal replacement therapy (CRRT)

Can be done continuouslyDoes not require dialysate

Acute Renal FailureNursing interventions

Monitor I/O, including all body fluidsMonitor lab resultsWatch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness, EKG changes watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions

Maintain nutritionSafety measuresMouth careDaily weightsAssess for signs of heart failureGCS and Denny BrownSkin integrity problems

Chronic Renal FailureResults form gradual, progressive loss of renal functionOccasionally results from rapid progression of acute renal failureSymptoms occur when 75% of function is lost but considered cohrnic if 90-95% loss of functionDialysis is necessary D/T accumulation or uremic toxins, which produce changes in major organs

Chronic Renal FailureSubjective symptoms are relatively same as acuteObjective symptoms

RenalHyponaturmiaDry mouthPoor skin turgorConfusion, salt overload, accumulation of K with muscle weaknessFluid overload and metabolic acidosisProteinuria, glycosuriaUrine = RBC’s, WBC’s, and casts

Chronic Renal FailureObjective symptoms

CardiovascularHypertensionArrythmiasPericardial effusionCHFPeripheral edema

NeurologicalBurning, pain, and itching, parestnesiaMotor nerve dysfunctionMuscle crampingShortened memory spanApathyDrowsy, confused, seizures, coma, EEG changes


GIStomatitisUlcersPancreatitisUremic fetorVomitingconsitpation

Respiratory^ chance of infectionPulmonary edemaPleural friction rub and effusionDyspneaKussmaul’s respirations from acidosis


EndocrineStunted growth in children

Amenorrhea

Male impotence

^ aldosterone secretion

Impaired glucose levels R/T impaired CHO metabolism

Thyroid and parathyroid abnormalities

HemopoieticAnemiaDecrease in RBC survival timeBlood loss from dialysis and GI bleedPlatelet deficitsBleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses


SkeletalMuscle and bone painBone demineralizationPathological fracturesBlood vessel calcifications in myocardium, joints, eyes, and brain

SkinYellow-bronze skin with pallorPuritusPurpuraUremic frostThin, brittle nailsDry, brittle hair, and may have color changes and alopecia

Chronic Renal FailureLab findings

BUN – indicator of glomerular filtration rate and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysisSerum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is time for dialysisCreatinine clearance is best determent of kidney function. Must be a 12-24 hour urine collection. Normal is > 100 ml/min

Chronic Renal FailureK+ -

The kidneys are means which K+ is excreted. Normal is 3.5-5.0 ,mEq/L. maintains muscle contraction and is essential for cardiac function. Both elevated and decreased can cause problems with cardiac rhythmHyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cellKayexalate is also used

Chronic Renal FailureCa

With disease in the kidney, the enzyme for utilization of Vit D is absentCa absorption depends upon Vit DBody moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it.Normal Ca level is 4.5-5.5 mEq/LHypocalcemia = tetany

Treat with calcium with Vit D and phosphateAvoid antacids with magnesium

Chronic Renal FailureOther abnormal findings

Metabolic acidosisFluid imbalanceInsulin resistanceAnemiaImmunoligical problems

Chronic Renal FailureMedical treatmentIV glucose and insulinNa bicarb, Ca, Vit D, phosphate bindersFluid restriction, diureticsIron supplements, blood, erythropoietinHigh carbs, low proteinDialysis - After all other methods have failed

Chronic Renal FailureHemodialysis

Vascular accessTemporary – subclavian or femoralPermanent – shunt, in arm

Care post insertion

Can be done rapidlyTakes about 4 hoursDone 3 x a week

Chronic Renal FailurePeritoneal dialysis

Semipermeable membraneCatheter inserted through abdominal wall into peritoneal cavityCost lessFewer restrictionsCan be done at homeRisk of peritonitis3 phases – inflow, dwell and outflow

Automated peritoneal dialysis

Done at home at nightMaybe 6-7 times /week

CAPDContinous ambulatory peritoneal dialysisDone as outpatientUsually 4 X/d

Chronic Renal FailureNursing care

Frequent monitoring Hydration and outputCardiovascular functionRespiratory statusE-lytesNutritionMental statusEmotional well being

Ensure proper medication regimenSkin careBleeding problemsCare of the shuntEducation to client and family

Chronic Renal FailureNursing diagnosis

Excess fluid volumeImbalanced nutritionIneffective copingRisk for infectionRisk for injury

Chronic Renal FailureTransplant

Must find donorWaiting period longGood survival rate – 1 year 95-97%Must take immunosuppressant’s for lifeRejection

Watch for fever, elevated B/P, and pain over site of new kidney

Chronic Renal FailurePost op care

ICUI/OB/PWeight changesElectrolytesMay have fluid volume deficitHigh risk for infection

Transplant MedsPatients have decreased resistance to infectionCorticosteroids – anti-inflammarory

DeltosoneMedrolSolu-Medrol

Cytotoxic – inhibit T and B lymphocytesImuranCytoxanCellcept

T-cell depressors - Cyclosporin

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Renal Failure Acute and Chronic NPN 200 Medical Surgical Nursing I