Renal disorders

• Renal failure


  2 types: AKI & CKD or ESRD (end stage of kidney disease)

  
• Acute Kidney Injury (AKI)


  • Occurs quickly after an acute insult to the kidneys (hours or days)
  • Reversible with early treatment
  • Results in decreased glomerular filtration rate (GFR) and oliguria

  
• Causes of AKI


  • Hypovolemia
  • Hypotension
  • Reduced cardiac output and heart failure
  • Obstruction/stenosis of renal arteries or veins
  • Obstruction of the kidney(s) or lower urinary tract

  
• Categories of AKI


  • Prerenal
  • Internal
  • Postrenal
• Clinical manifestation of AKI

  1. Initiation Phase: initial insult, BUN and CR increase; decreased u/o

  2. Maintenance Phase: oliguria (u/o 400ml or less), Fluid Volume Excess, Waste Product Accumulation, Sodium Balance, Potassium Excess, Hematological Disorders, Calcium Deficit & Phosphate Excess, Neurological Disorders

  3. Recovery Phase: may experience a diuretic phase; can take weeks to 12 months
• Prevention of AKI


  • Monitor I/O; provide adequate hydration
  • Monitor lab values
  • Prevent and treat shock with blood and fluid replacement (begin blood transfusion asap)
  • Treat hypotension promptly
  • Prevent and treat infections promptly
  • Meticulous indwelling catheter care; remove ASAP
  • Monitor toxic drugs – pre and post-levels for antibiotics; blood levels for drugs excreted by the kidney

  
• Diagnostics for AKI


  • Monitor Urine output; ACCO of urine
  • Use, CT or MRI of abdomen/kidneys
  • KUB-old term, X-Ray
  • Retrograde pyelogram
  • Renal biopsy
  • Urinalysis, specific gravity, osmolality
  • Urine GFR
  • CBC, Electrolytes, BUN

  
• Nursing interventions for AKI

  • Strict intake and output, daily weights (edema)
  • Monitor electrolytes, hyperkalemia symptoms: malaise, anorexia, paresthesia, or muscle weakness, ECG changes
  • Nutritional therapy: replace protein, high carbohydrate, restricted potassium, phosphorous, and sodium
  • Bedrest
  • Promote pulmonary function (DB&C; turn q2h)
  • Prevent infection
  • Provide skin care
  • Provide psychosocial support
• Chronic Renal Failure (CRF)


  Progressive, permanent, irreversible damage to kidneys leading to failure of both kidneys

  
• Diagnosis of CRF


  • Gradual, progressive loss of renal function
  • Permanent renal replacement therapy required
  • Occasionally results from rapid progression of ARF
  • Symptoms occur when 75% of function is lost but is considered chronic if 90-95% loss of function
  • Glomerular filtration rate (GFR)- decrease
  • Structural/functional kidney abnormalities, with/without a decrease in GFR, lasting 3 months or more

  
• Risk factors for CRF

  • Diabetes (# 1 cause)
  • Hypertension, vascular disease
  • Toxic substances
  • Chronic glomerulonephritis
  • Pyelonephritis/infections
  • Smoking
  • Obesity
  • Family history
  • Socio-economic status
• Diagnostic tests for CRF

  • Glomerular Filtration Rate
  • Blood tests: Serum creatinine-most sensitive, BUN, sodium, phosphorous, calcium, ammonia, bicarb, CBC
  • Radiologic studies: X-rays of kidneys, ureters, bladder, renal ultrasound, CT scan of the abdomen, magnetic resonance imaging
  • Renal biopsy
  • Urinalysis: specific gravity, WBC, protein
• Clinical manifestations of CRF

  • High volume of blood leads to cardiac issues
  • Coagulation issues with blood may occur
  • Edema
• Complications of CRF


  • Electrolyte imbalances: hyperkalemia, calcium and phosphorous
  • Cardiovascular System: HTN, pericarditis, pericardial effusion, cardiac tamponade, CHF
  • Osteoporosis and metastatic calcifications
  • Hematologic System: Anemia; bleeding tendencies; infections
  • Gastrointestinal System: Anorexia, N&V, Malnutrition
  • Fluid retention: edema, HTN, ascites, effusions, CHF
  • Integumentary System: dry skin and itchiness
  • Neurological System: neuropathy, confusion, encephalopathy
  • Psychological Changes: personality and behavior changes
• Medical management of CRF

  • Restore fluid and electrolyte balance
  • Control blood sugar if diabetic
  • BP management: target 130/80, ACE is the primary choice
  • Cholesterol management
  • Avoid medications (NSAIDs, acetaminophen, contrast agents from procedures)
  • Dietary restrictions (aka renal diet)
  • Lifestyle changes
  • Fluid restriction
• Medications for CRF


  • Anemia: Erythropoietin(stimulates blood productions), iron supplements or vitamin B12
  • Nutritional balance: Multivitamin designed for RF
  • HTN Management: Agents such as ACE inhibitors
  • Hypocalcemia: Calcium supplements
  • Hyperkalemia- Kayexalate, retention enema, IV glucose and insulin
  • pH : Sodium bicarbonate
  • Hyperphosphatemia: Aluminum hydroxide (TUMS)
• Key nursing concerns for CRF

  • Monitor for complications
  • Monitor and treat fluid and electrolyte imbalances
  • Monitor response to treatment
  • Physical support
  • Emotional support
  • Education
• Nursing assessment for CRF

  • Complete history of any existing renal disease, family history
  • Long-term health problems
  • Dietary habits

  
• Nursing diagnoses for CRF

  • Excess fluid volume
  • Decreased functional ability
  • Imbalanced nutrition: less than body requirements
  • Deficient knowledge
  • Grieving
• Nursing planning for CRF

  • Demonstrate knowledge and ability to comply with therapeutic regimen
  • Participate in decision-making for the plan of care
  • Demonstrate effective coping strategies
  • Continue with activities of daily living within psychological limitations
• Nursing interventions for excess fluid volume in CRF

  • Monitor BP, periorbital, sacral and peripheral edema, and dyspnea
  • Monitor daily wt, I&O
  • Fluid restriction-all sources of fluid intake
  • Explain and assist the client and family in maintaining the fluid restriction
  • Provide or encourage frequent oral hygiene
• Nursing interventions for imbalanced nutrition in CRF

  • Assess nutritional status, weight changes, and laboratory data (dieticians will assist with this)
  • Assess the client's nutritional patterns and history; note food preferences
  • Encourage high-quality nutritional foods while maintaining nutritional restrictions
  • Assess and modify intake related to factors that contribute to altered nutritional intake, i.e. stomatitis or anorexia
  • Adjust medication times related to meals
• Nursing interventions for deficient knowledge in CRF

  • Assess understanding of the cause of renal failure, consequences and treatment
  • Provide an explanation at the client's and family's level of understanding of disease and its consequences
  • Assist client to incorporate changes into lifestyle
  • Provide information in a format client can understand
  • Other education needs: diet, fluids, medications
  • Emotional support
  • Dialysis
  • Palliative information

  
• Treatment options for renal failure

  • Hemodialysis-3X/week, approx. 4 hours, removes fluids and electrolytes, requires AV line
  • Peritoneal dialysis 4-6 times/day, fill the abdomen with dialysate, dwell, empty. Or done overnight with a machine
  • Continuous renal replacement therapies (CRRT)-done in critical care, slow dialysis

  
• Dialysis


  Movement of fluid and molecules across a semipermeable membrane from one compartment to another
• Purpose of dialysis


  • Removes excess fluid, excess electrolytes and waste products when the body is unable to
• Principles of dialysis


  • Diffusion
  • Osmosis
  • Ultrafiltration
• Types of dialysis


  • Hemodialysis
  • Peritoneal dialysis
  • Continuous renal replacement therapies (CRRT)

  
• Purpose of dialysis


  • Removes excess fluid, excess electrolytes and waste products when the body is unable to
• Dialysis is required several times a week and must schedule life around
• Dialysis is life-long unless a transplant is found
• Types of dialysis


  • Hemodialysis
  • Peritoneal dialysis
  • CRRT (Continuous Renal Replacement Therapy)

  
• Hemodialysis


  • Blood is taken from the right subclavian vein to attach to the dialysis machine
  • Done every other day
  • Machine uses an artificial kidney to filter fluid and waste from blood
  • Takes 3-4 hrs, 3-4 times per week
  • May have a fistula or catheter

  
• Hemodialysis complications


  • Hypotension
  • Muscle Cramps
  • Loss of Blood
  • Sepsis
• Peritoneal dialysis


  • Done via vein, fistula or graft
  • The tube is connected via the abdominal (peritoneum area)
  • Done 4 times a day
  • Fluid infused into peritoneal cavity through a catheter
  • Blood is filtered across the peritoneal membrane by diffusion and osmosis
  • Catheter is clamped, solution "dwells" for 1-4 hrs. then unclamped and drained
  • Used for stable clients and those who cannot tolerate HD
  • Client can perform independently at home: automated peritoneal dialysis (at night) or continuous ambulatory peritoneal dialysis (during the day at least 4 exchanges/day)

  
• Peritoneal dialysis complications


  • Peritonitis
  • Outflow Problems
  • Bleeding

  
• Nursing care for hospitalized client on dialysis

  • Protect vascular access; assess site for patency, signs of infection, do not use for blood pressure or blood draws
  • Monitor fluid balance, keep accurate I&O
  • Assess for S&S of uremia and electrolyte imbalance
  • Monitor cardiac and respiratory status
  • Monitor blood pressure; antihypertensive agents may be withheld on dialysis days to avoid hypotension
  • Monitor all medications and dosages carefully; avoid medications containing potassium and magnesium
  • 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
• Kidney transplant


  Only option to get off dialysis therapy
• Nearly 3,000 people are on the waiting list for kidney transplants
• In 2017, 242 patients died while waiting for an organ transplant