CARE OF THE CLIENTS WITH ACUTE AND CHRONIC RENAL FAILURE

ACUTE AND CHRONIC
RENAL FAILURE
BY: ROMMEL LUIS C. ISRAEL III

KIDNEY SYSTEM
FUNCTIONS
1. Eliminate water-soluble nitrgoenous end- products of
protein metabolism; Excretion of waste products.
2. Maintain electrolyte balance in body fluids
3. Get rid of the excess electrolytes.
4. Discharge excess water in the urine.
5. Maintain acid-base balance in body fluids and tissue.
6. Control of blood pressure.
7. Regulation of red blood cell production.
8. Synthesis of vitamin D to active form.
9. Regulates calcium and phosphorus balance.
2

IMPORTANT LAB VALUES
BUN - Blood urea nitrogen.
 measure of the kidneys' ability to excrete urea, the chief
waste product of protein breakdown
 Elevated in renal failure and dehydration
 7 - 20 mg/dl
Creatinine: A waste product from protein in the diet and from
the muscles of the body.
 removed from the body by the kidneys
 Increased in kidney disease
 0.5 to 1.0 mg/dL
3

IMPORTANT TEST
Creatinine Clearance Test
• compares the level of creatinine in urine with the creatinine
level in the blood
• 24-hour urine sample
• Male: 97 to 137 ml/min.
• Female: 88 to 128 ml/min.
• estimate the glomerular filtration rate (GFR) -- the standard by
which kidney function is assessed range 90 - 120 mL/min
4

5

GFR
• GFR-Levels below 60 mL/min for 3 or
more months are a sign of chronic kidney
disease. Those with GFR results below 15
mL/min are a sign of kidney failure.
6

DEFINITIONS
Parenchyma - The key elements of an organ essential to
its functioning
Uremia –retention in the bloodstream of waste products
normally excreted in the urine, urea, creatinine and
other nitrogen containing waste products of proteins .
 Also called Azotemia.
 resulting from kidney disease
 Anuria - total urine output less than 50 mL in 24 h
Oliguria - total urine output less than 400 mL in 24 h
7

RISK FACTOR FOR ARF
• Increased age
• Preexisting renal disease
• Administration of several nephrotoxic agents
simultaneously
8

RENAL FAILURE
• Severe impairment or total lack of kidney
function
• Inability to excrete metabolic waste
products and water
• Classified as acute or chronic
• May manifest as oliguria, anuria, or
normal urine volume
9

ACUTE RENAL FAILURE
• Rapid decline in renal function
• Potentially reversible but does have high
mortality rate
• Nephrotoxins, Ischemia, Obstructions,
Most Common Causes
10

ACUTE RENAL FAILURE
•Progressive Azotemia- accumulation
off nitrogenous wastes (BUN)
•Increased serum Creatinine
•Oliguria
•↑K
11

ACUTE RENAL FAILURE
• Mechanisms:
• Pre-renal -- volume depletion, poor
cardiac efficiency, vasodilation
• Intra-renal -- prolonged ischemia,
myoglobinuria, infections, nephrotoxins,
glomerulonephritis
• Post-renal -- obstruction from stone,
tumor
12

ACUTE RENAL FAILURE
Mechanisms:
 Pre-renal -- volume depletion,
poor cardiac efficiency,
vasodilation
 Intra-renal -- prolonged
ischemia, myoglobinuria,
infections, nephrotoxins,
glomerulonephritis, trauma
 Post-renal -- obstruction from
stone, tumor MECHANICAL
OBSTRUCTION from the
tubules to urethra. BPH-most
common
13

TYPES OF RENAL FAILURE
• Prerenal -- Systemic Cause
• Hypo perfusion-↓ in blood pressure
• Hypovolemia R/T-hemorrhage
• Cardiogenic Shock
• Sepsis
14

• Intrarenal Causes: Direct Damage to the
Kidneys
• Ischemia from MI
• Myoglobinuria cause of Rhabdomylysis
• Hemoglobinuria
• Nephrotoxic Agents
• Acute plyleonephrirtis
15

• Post Renal Causes : Obstruction of Urine Flow
• Tumors
• STONES
• Clots
• Strictures
16

CLINICAL
MANIFESTATIONS
 Four clinical phases:
 Initiation: Initial insult to oliguria -≤400ML/24hrs
 Oliguria: ↑Bun/Creatinine, Rise in serum
concentration of substances excreted by kidney
K+, Magnesium, ↓U/O
 Diuresis: Gradually increasing U/O lab values
stabilize
 Recovery: Improvement of renal function
 3-12 months
 Permanent 1-3% reduction in GFR
17

CLINICAL
MANIFESTATIONS
 Every system of the body is affected
 CNS-Lethargy, Confusion, Headache ,Seizures
 CV-Congestive Heart Failure ,HTN
 Lungs- SOB
 Skin/Hair/Nails-Dry thin scaly
 GI- Diarhea ,Nausea, Vomiting, Uremic GI
lesions
 Gu-Oliguria Anuria Blood in urine
18

ABNORMAL LAB VALUES
• ↑BUN, Creatinine-Azotemia
• As a result of catabolism( breakdown of
protein) and impaired renal perfusion
• ↑Creatinine ↑Glomerular damage
19

ABNORMAL LAB VALUES
• Hyperkalemia as result of the ↓ in GFR
• Patients can not excrete K+ normally
• ↑Protein catabolism ↑K+ = in body fluid
• Can cause dysrhythmias and cardiac arrest
• Source of K+ is GI blood loss, dietary,
extracellular shift related to metabolic acidosis
20

ANEMIA
• ↓ RBC ,Hemoglobin/HCT
• R/T abnormally low production of red blood cells by
the bone marrow
• R/T inability of the failing kidneys to secrete the
hormone erythropoietin
• Uremic GI lesions
• Blood loss
• Reduced RBC life span
21

METABOLIC ACIDOSIS
• Related to oliguria
• unable to eliminate acids
• Normal renal buffering system fails
• Fall in CO2 combining power
• Progressive
• Can cause cardiac arrhythmias
22

CHANGES IN CALCIUM
AND PHOSPHORUS
• Increase in serum phosphate
• Decrease in calcium levels
• Decreased CA++ absorption from GI tract
• At risk for stress fractures
23

SUMMARY OF ARF CATEGORIES
Characteristics PreRenal Intrarenal Postrenal
Etiology Hypo-perfusion Parenchymal
damage
Obstruction
BUN Increased
(out of normal
20:1 proportion
to creatinine)
Increased Increased
Creatinine Increased Increased Increased
Urine output Decreased Varies, often
decreased
Varies, may be
decreased, or sudden
anuria
Urine sodium Decreased to
<20 mEq/L
Increased to >40
mEq/L
Varies, often decreased
to 20 mEq/L or less
Urinary
sediment
Normal, few
hyaline casts
Abnormal casts &
debris
Usually normal
Urine
osmolality
Increased to
500 mOsm
About 350 mOsm
similar to serum
Varies, increased or
equal to serum
Urine specific
gravity
Increased Low normal Varies
24

MEDICAL MANAGEMENT
• Restore normal electrolyte balance
• Prevent complications
• Prevent anuria if possible
• Allow kidneys time to regenerate until
normal kidney function resumes
25

TREATMENT
Pre-Renal Intra-Renal Post-Renal
Increase renal perfusion Supportive Remove obstruction
Blood loss – Blood
transfusion
Restrict meds that are
excreted by kidneys
Avoid Complications
Hypovolemia -Infuse
Albumin ,Normal Saline
Remove causative agent
Aggressive
Management of
prerenal and post renal
causes
Supportive Management
Fluid balance based on daily body weight, CVP, serum and urine
concentrations, losses, B/P
Measure all output
26

PRERENAL TREATMENT
•Increase renal perfusion
•Blood loss – Blood transfusion
•Hypovolemia -Infuse Albumin
,Normal Saline
27

INTRA RENAL TREATMENT
•Supportive
•Restrict meds that are excreted by
kidneys
•Remove causative agent
•Aggressive Management of prerenal
and post renal causes
28

POST RENAL TREATMENT
•Remove obstruction
•Avoid Complications
29

MANAGEMENT
•Fluid balance based on daily body
weight, CVP, serum and urine
concentrations, losses, B/P
•Measure all output
30

DIETARY MODIFICATIONS
• Limit protein to 1g/kg during oliguric phase to
minimize protein breakdown and avoid
accumulation of toxic end products
• High carbohydrate protein sparing diet
provides energy and lets protein be used for
tissue healing
31

DIET MODIFICATIONS
• Foods with K+ are restricted including bananas,
citrus juices, coffee
• K+ intake restricted to 40-60 mEq/day Na
restricted to 2 g/day
• Oliguric phase may go for 20 days
• Protein may be increased after the diuretic
phase is over
32

MEDICAL MANAGEMENT
Hyperkalemia - Give Kayexalate (Sodium
Polystyrene Sulfonate) exchange Na for
K+ in the intestinal tract orally/ Retention
Enema
High Phosphate - Use aluminum base
antacid
33

NURSING MANAGEMENT
 Monitor fluid and electrolyte balance strict I/O
 Monitor V/S
 Reduce metabolic rate- catabolism releases K+ and
accumulates urea and creatinine
 Bed rest, treat fever promptly
 Promote pulmonary function- cough and deep breathe
 Prevent skin infection, skin care
34

NURSING MANAGEMENT
• Dialysis support
• Full Assessment –listen to lungs check for rales
check for edema at periorbital, sacral, pedal
areas
• Monitor for infection prevent where possible
• Monitor CVP Swan Ganz readings if available
35

STATISTICS ESRD
 Prevalence (2010): More than 10 percent of people, or more
than 20 million, ages 20 years and older in the United States
have CKD
 End-stage Renal Disease (ESRD)
Prevalence (2008): 547,982 U.S. residents were under treatment
as of the end of the calendar year.
 http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/
36

37

CAUSES OF CHRONIC
RENAL FAILURE
• Diabetes mellitus
• Hypertension
• Chronic glomerulonephritis
• Pyelonephritis or other infections
• Obstruction of urinary tract
• Hereditary lesions
• Vascular disorders
• Medications or toxic agents
38

CHRONIC RENAL FAILURE
• Rate of decline, progression of CRF related to underlying
disorder, hypertension, rate of protein excretion
• Manifestations: CV problems manifested in ESRD-
Hypertension, CHF, pulmonary edema, pericarditis,
pericardial friction rub, hyperkalemia,hyperlipidemia
39

CHRONIC RENAL FAILURE
•Progressive irreversible deterioration
in renal function
•Results in impaired fluid and
electrolyte imbalance
•Azotemia retention of nitrogenous
wastes in the blood
40

MANIFESTATIONS
 Periorbital edema
 GU - progressively less to no urine output
 CV- CHF HTN edema
 Pulmonary – rales, SOB, depressed cough reflex, ↑
respirations,
 GI- Nausea, Vomiting, metallic taste, mouth ulcerations,
and bleeding, constipation, diarrhea
 Skin- Puritits, grey bronze color, ecchymosis, thinning hair
 Hematologic – Anemia,Thrombocytopenia
 Musculoskeletal- muscle cramps Bone fractures
41

MANIFESTATIONS
• Calcium and Phosphorus imbalance
happens R/T decreased filtration rate there
is a increase in serum phosphate level and
decrease in serum calcium level
• Increased parathyrohormone abnormal
response with Calcium leaving bone causes
bone disease uremic bone disease renal
osteodystophy
42

COMPLICATIONS
• Hyperkalemia due to catabolism, excessive
intake of medications
• Pericarditis- pericardial effusion, tamponade
• Hypertension- malfunction of renin-angiotensin
aldosterone system
• Anemia- decreased RBC production and life
span at risk for GI bleeding
43

MANAGEMENT
• Reverse obstructions
• Epogen
• Iron
• Phosphate binding agents
• Calcium supplements
• Dialysis
• Antacids aluminum based bind to phosphorus calcium
carbonate with food avoid magnesium-based antacids
44

INTERNAL AV FISTULA
AND GRAFT
45

DIALYSIS
• Used to remove fluid and uremic waste products when the
kidneys can not do so
• Used to treat edema (severe) hyperkalemia, hypercalcemia,
Hypertension, hepatic coma and uremia
-Types-Hemodialysis, Peritoneal, (CRRT) Contiuous Renal
Replacement Therapy
46

DIALYSIS
• Hemodialysis most common
• 3-4 times a week for 3-4 hrs
• Wastes removed by diffusion excess fluid
by osmosis
• Access achieved via double lumen catheter
Into Femoral, Subclavian, Internal Jugular, Veins
47

INTERNAL ARTERIOVENOUS
FISTULA AND GRAFT
48

HEMODIALYSIS
• Permanent access via surgically created
synthetic graft between artery and vein
• Or a Fistula by joining an artery to a vein
-Needles inserted into vessel
-Arterial segment used for arterial flow
-Venous for reinfusion of dialyzed blood
- 4-6 weeks for Fistula to mature
49

CARE OF
FISTULAS/GRAFTS
• No Blood pressure on affected arm
• Monitor for infection
• Feel for thrill as part of daily assessment
• Listen for Bruit with stethoscope as part of daily
assessment “Whooshing Sound”
50

COMPLICATIONS OF
HEMODIALYSIS
CV-CHF,CAD, Dysrthymias
Pulmonary- SOB, Rales
GU- Infections
GI-Gastric Ulcers, Nausea/Vomiting
Hematological- Anemia,↑Tryglycerides,
Thrombocytopenia
51

COMPLICATIONS OF
HEMODIALYSIS
• Disconnect from tubing pt can bleed out
• Malnourishment
• Painful muscle cramping
• Pruritis
• Fluid overload
• Hypotension
52

NURSING MANAGEMENT
 Protect vascular access
◦ assess for patency and signs of infection
◦ do not use it for BP or blood draws
 Bruit, or “thrill,” at least every 8 hours
 Monitor fluid balance indicators & IV therapy carefully; keep
accurate I&O and IV administration pump records
 Assess for signs and symptoms of uremia and electrolyte
imbalance; regularly check lab data
 Monitor cardiac and respiratory status carefully
 Monitor BP; antihypertensive agents must be held on
dialysis days to avoid hypotension
53

MANAGEMENT
• Reverse obstructions
• Epogen
• Iron
• Phosphate binding agents
• Calcium supplements
• Dialysis
• Antacids aluminum based bind to phosphorus calcium
carbonate with food avoid magnesium-based antacids
54

QUESTION
Tell whether the following statement is true
or false.
Hypercalcemia is the most life-threatening
of the fluid and electrolyte changes that
occur in patients with renal disturbances
55

PERITONEAL DIALYSIS
 Peritoneal membrane that covers the abdominal organs and lines the
abdominal wall serves as the semipermeable membrane
 More gradual change
 Sterile dialysate fluid
◦ Medications added
◦ Warmed
◦ infused by gravity into the peritoneal cavity
◦ 5 to 10 minutes is usually required to infuse 2 to 3 L of fluid
◦ Prepare tubing to prevent air entering catheter
 Abdominal catheter
◦ Catheters for long-term use (Tenckhoff, Swan, Cruz)
◦ have three sections and two cuffs
 stabilize the catheter, limit movement, prevent leaks, and provide
a barrier against microorganisms.
56

PERITONEAL DIALYSIS
 The patient must be alert
and have good fine motor
skills Pt must be
independently able to
perform dialysis at home
 Risk of peritonitis from
introduction of bacteria
into the peritoneal cavity
 The higher the dialysate
the greater the osmotic
gradient the more water is
removed
 Solutions used 1.5% 2.5%
4.25%
57

CAPD
 C Continuous Dialysis carries on all the time. A
Ambulatory Unlike Haemodialysis you can
move around as normal and carry out your
daily activities.
 P Peritoneal An enclosed layer of tissue where
Dialysis takes place. The Peritoneal surrounds
your intestines.
 D Dialysis Dialysis removes waste products
from your blood.
58

PERITONEAL DIALYSIS
• Usually takes 36 to 48 hrs to achieve what hemodialysis
accomplishes in 6 to 8 hrs
• Diffusion and osmosis
• Ultrafiltration (water removal) occurs in peritoneal dialysis
through an osmotic gradient created by using a dialysate
fluid with a higher glucose concentration.
• Signed consent
• Baseline vital signs, weight, and serum electrolyte levels
• The patient is encouraged to empty the bladder and bowel
• Aseptic technique
59

COMPLICATIONS OF
PERITONEAL DIALYSIS
• # 1 Peritonitis: evidenced by cloudy
drainage, ABD pain, fever, rebound
tenderness
• Leakage causing infections and skin
ulceration
• Bleeding
• Hernias
60

NURSING MANAGEMENT
 Monitor all medications and medication dosages
carefully; avoid medications containing K & Mg
 Address pain and discomfort
 Implement stringent infection control measures
 Monitor dietary sodium, potassium, protein, and fluid;
address individual nutritional needs
 Provide skin care: prevent pruritus; keep skin clean and
well moisturized; trim nails and avoid scratching
 Provide CAPD catheter care
61

QUESTION
A patient receiving peritoneal dialysis is complaining of pain
with rebound tenderness. The dialysate drainage is cloudy.
This symptom is indicative of which acute complication?
a. Hernia
b. Bleeding
c. Leakage
d. Peritonitis
62

NURSING MANAGEMENT
• Teaching regarding disease process
• Teaching regarding diet
• Teaching regarding Meds
• Teaching regarding technique especially for
Peritoneal Dialysis Evaluation of teaching via
return demonstration
63

NURSING DIAGNOSIS
• Fluid volume overload
• Fluid volume deficit
• Alteration in elimination
• Alteration in skin integrity
• Alteration in respiration
64

KIDNEY SURGERY
• Preoperative considerations
• Perioperative concerns
• Postoperative management
• Potential hemorrhage and shock
• Potential abdominal distention and paralytic
ileus
• Potential infection
• Potential thromboembolism
65

PATIENT POSITIONING AND INCISIONAL
APPROACHES
66

RENAL TRANSPLANTATION
67

TYPES OF TRANSPLANTS
• Living Donor- Relative
• Cadaver
• Living Donor- Non Relative
68

INTERVENTIONS
 Pain relief measures and analgesic medications
 Promote airway clearance and effective breathing pattern by
appropriate pain relief, deep-breathing coughing exercises, and
incentive spirometry and positioning
 Monitor UO and maintain patency of urinary drainage systems
 Monitor for signs and symptoms of bleeding
 Encourage leg exercises, early ambulation, and monitor for signs
of DVT
69

IMMUNOSUPPRESSIVE DRUGS
POST TRANSPLANT
• MUST STAY ON FOR LIFE!
• Cyclosporine: Block T cell communication
• Corticosteroids Also blocks T cell communication
• Azathioprine: Slows production of T cells
• Newer antirejection drugs include:
• Sirolimus ,tacrolimus
70

71

CASE STUDY
 A 52 year old male with PMH of HTN and DM presents for a
diagnostic Cardiac Catherization S/P a positive stress test. The
patient has a stent placed in his RCA. After the procedure his BUN
and Creatnine begin to rise and his urine output begins to decline
 What type of renal failure is this patient experiencing?
 What lab values are most important to evaluate and why?
 What are the phases of renal failure?
 What physical assessment changes would be expected?
 What interventions might you expect?
 What are your nursing priorities/ diagnosis?
72

TRUE/FALSE
• Although there has been a recent decrease in the
number of cases, peritonitis is the most common and
serious complication of peritoneal dialysis.
• Because of protein loss with continuous peritoneal
dialysis, the patient is instructed to eat a high-
protein well-balanced diet.
• Hypotension, a result of oversecretion of rennin, is
common in renal failure
73

The critical care nurse is caring for a patient with acute renal
failure in the oliguric phase. The nurse will closely monitor the
patient for which commonly experienced electrolyte
imbalance?
 A) Hyperkalemia
 B) Hypercalcemia
 C) Hyperlipidemia
 D) Hyperbilirubinemia
74

CARE OF THE CLIENTS WITH ACUTE AND CHRONIC RENAL FAILURE

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