2Renal Disorders Fluid and electrolyte imbalances Most accurate indicator of fluid loss or gain in an acutely ill patient is weight
3Causes of Acute Renal Failure HypovolemiaHypotensionReduced cardiac output and heart failureObstruction of the kidney or lower urinary tractObstruction of renal arteries or veins
4Acute Renal Failure: Categories of ARF: Mnifestations: Is a sudden and almost complete loss of kidney function ( decreased GFR)Mnifestations:OliguriaAnurianormal urine volume.Categories of ARF:Prerenal: as a result of impaired blood flow to the kidneyInterrenal: as a result of actual parenchymal damage to the glomeruli and kidney tubule.Post renal: as a result of obstruction somewhere distal to the kidney, such as Ureterovesical reflux.
5Phases of ARF: Initial period: begins with initial insult The oliguria period( less than 400ml/day): Characterized by increase serum urea, creatinine, K, uric acid, organic acids, and magnesium. The uremic symptoms first appears which is life-threatening such as Hyperkalemia.The diuresis period: gradually increasing urine output, lab values stop rising and start to decreaseThe recovery period: signals the improvement of renal function and may take 3-12 months, lab results return to the normal levels
6Clinical manifestations: Oliguria, anuria (less than 50 ml/day), or normal urine output are not as common.Increased serum creatinine, and BUN levelPt may appear critically ill and lethargic, with nausea, vomiting, and diarrhea.Skin and mucous membrane are dry from dehydration and the breath may have the odor of the urine (uremic fetor)Drowsiness, headache, muscle twitching, and seizures
7Assessment and diagnostic findings: Changes in the urineChanges in the kidney contour ( ultrasound)Increase BUN and creatinine levelsHyperkalemia, hypocalcemia, hyperphosphoremiaAnemiaMetabolic acidosis
8Medical management: Manage fluid and electrolyte imbalance Diuretics may be givenAdequate blood flow to the kidney ( by low doses of dopamine 1-3 microgram/kg)Dialysis may be initiated to prevent serious complications of ARFTreat Hyperkalemia:administer Kayexalate ( orally or by retention edema)intravenouse glucose and insulin or calcium gluconatesodium bicharbonate to elevate plasma PH which cause potassium to move into the cell.Finally decrease the dietary intake of potassiumCorrection of Acidosis and elevated phosphorus level ( by aluminum hydroxide---- phosphate binding agent)Nutritional therapy
9Nursing Management Monitor fluid and electrolyte balance Reduce metabolic ratePromote pulmonary functionPrevent infectionProvide skin careProvide support
10Chronic renal failure: Or ESRD is a progressive irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia ( retention of urea and other nitrogenous wastes in the blood)May caused by systemic disease such as DM, hypertension, chronic glomerulonephritis… etc
11Causes of Chronic Renal Failure Diabetes mellitusHypertensionChronic glomerulonephritis,Pyelonephritis or other infectionsObstruction of urinary tractHereditary lesionsVascular disordersMedications or toxic agents
12Clinical manifestations: Neurologic: Weakness, fatigue, confusion, inability to concentrate, tremors, seizures, behavior changesIntegumentary: gray-bronze color skin, dry, pruritis, ecchymosis, thin brittle nailsCardiovascular: hypertension, pitting edema, periorbital edema, pericardial friction rub, engorged neck veins, pericarditis, pericardial effusion, hyperkalemia, hyperlipidemiaPulmonary: signs of pulmonary edemaGastrointestinal: Ammonia odor to breath, mouth ulceration and bleeding, anorexia, constipation or diarrheaHematology: anemiaMusculoskeletal: muscle cramps, loss of muscle strength, bone pain, bone fracture
13Assessment and diagnostic findings GFR: by obtaining a 24 hr urine collection for creatinine clearance.Na and water retentionAcidosisAnemiaCa and Ph imbalanceComplications:HyperkalemiaHypertensionanemia, Bone disease
14Medical management:Antacids: To treat hyperphosphatemia and hypocalcemia (Aluminum-based antiacide bind with phosphorus in the GI tract)antihypertensive cardiovascular agentsAntiseizure agentsErythropoietinNutritional therapyDialysis
15Glomerular Diseases An inflammation of the glomerular capillaries Acute nephritic syndromeChronic glomerulonephritisNephrotic syndrome
16Acute Glomerulonephritis: Is inflammation of the glomerular capillaries.Is primarily disease of children older than 2 yrs, but can appear at nearly any agePathophysiology: Throat infection with hemolytic sterptococcal, acute viral infection (upper RTI, mumps, hepatitis B), and antigens outside the body such as medications, foreign serum
17Clinical manifestation: 1. Hematuria (primary feature),2. Cola-colored appearance of the urine (RBC’s, protein plugs)3. Proteinuria, BUN and serum creatinine levels may rises as urine output drops4. The patient may be anemic, edema and hypertension, headache, malaise, and flank painElderly pt. may c/o circulatory overload with dyspnea, engorged neck veins, cardiomegaly and pulmonary edema.
19Assessment and diagnostic findings: Kidneys become large, swollen, and congestedKidney biopsyElevated serum IgAComplications:Hypertensive Encephalopathy,heart failure,ESRFpulmonary edema
20Medical management Nursing Management: Antibiotic, Corticosteroids and immunosuppressant medication,Dietary protein is restricted when renal impairment developedSodium restriction (in hypertensive Pt, edema, and heart failure)Loop diureticsAntihypertensive medication may given.Nursing Management:Give enough CHO to reduce catabolism of proteinI&Oeducation for safe and effective self-care at home
21Chronic Glomerulonephritis Causes include repeated episodes of acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage.Symptoms vary; may be asymptomatic for years, as glomerular damage increases, before signs and symptoms develop of renal insufficiency/failure.Abnormal laboratory tests include urine with fixed specific gravity, casts, and proteinuria; and electrolyte imbalances and hypoalbuminemia.Medical management is determined by symptoms.
23Renal FailureResults when the kidneys cannot remove wastes or perform regulatory functionsA systemic disorder that results from many different causesAcute renal failure is a reversible syndrome that results in decreased GFR and oliguriaChronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia
24Nursing Process: The Care of the Patient with Renal Failure—Assessment Fluid statusNutritional statusPatient knowledgeActivity toleranceSelf-esteemPotential complications
25Nursing Process: The Care of the Patient with Renal Failure—Diagnoses Excess fluid volumeImbalanced nutritionDeficient knowledgeRisk for situational low self-esteem
26Collaborative Problems/Potential Complications HyperkalemiaPericarditisPericardial effusionPericardial tamponadeHypertensionAnemiaBone disease and metastatic calcifications
27Nursing Process: The Care of the Patient with Renal Failure—Planning Goals may include maintaining of IBW without excess fluid, maintenance of adequate nutritional intake, increased knowledge, participation of activity within tolerance improved self-esteem, and absence of complications.
28Excess Fluid VolumeAssess for signs and symptoms of fluid volume excess, and keep accurate I&O and daily weightsLimit fluid to prescribe amountsIdentify sources of fluidExplain to patient and family the rationale for the restrictionAssist patient to cope with the fluid restrictionProvide or encourage frequent oral hygiene
29Imbalanced NutritionAssess nutritional status; weight changes and lab dataAssess patient nutritional patterns and history; note food preferencesProvide food preferences within restrictionsEncourage high-quality nutritional foods while maintaining nutritional restrictionsAssess and modify intake related to factors that contribute to altered nutritional intake, eg, stomatitis or anorexiaAdjust medication times related to meals
30Risk for Situational Low Self Esteem Assess patient and family responses to illness and treatmentAssess relationships and coping patternsEncourage open discussion about changes and concernsExplore alternate ways of sexual expressionDiscuss role of giving and receiving love, warmth, and affection
31Dialysis: Indications: Is the process used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.Indications:Acute dialysis: is indicated when there is a high and rising level of serum potassium, fluid overload, impeding pulmonary edema, increased acidosis, pericarditis, and sever confusion. May also used to remove toxin from the blood.Chronic or maintenance dialysis: is indicated in ESRD, in the presence of uremic signs and symptoms affecting all the body systems ( nausea, vomiting, sever anorexia, increasing lethargy, mental confusion). Hyperkalemia, fluid overload not responsive to diuretics and fluid restriction.
32Hemodialysis The objective of Hemodialysis are to extract toxic nitrogenous substances from the bloodand to remove excess water.Indicated for:the patient who are acutely ill and require short-term dialysis (day to weak)and for patient with ESRD who require long-term or permanent therapy.A dialyzer or artificial kidney serves as a synthetic, semipermeable membrane.
34Principles of Hemodialysis: Diffusion principle: dialysate ( is a solution made up of all the important electrolytes in their ideal Extracellular concentrate.Osmosis principle:Ultrafiltration principle
35Preprocedure:A predialysis assessment include: patient’s history and clinical findings, response to previous dialysis treatment, and laboratory resultsEvaluates fluid balance before dialysis treatment so that corrective measures may be initiated at the beginning of the procedure: blood pressure, pulse, Wt, intake and output, tissue turgor, dry Wt or ideal WT
36Procedure: .. Check the equipment Access to the circulation is gained by inserting two large gauge needles to a graft or fistulaBlood being to flow through the tubing, assisted by the blood pumpA clamped saline bag always is attached to the circuit, just before the blood pump to use it if hypotension occurredHeparin infusion can be attached to the circuit
37Cont…Blood flows into the compartment of the dialyzer, where exchange of fluid and waste products takes placeBlood leaving the dialyzer passes through an air detector that shuts down the blood pump if any air is detectedAfter the located time finished, dialysis is terminated by clamping off blood from the patient, opening the saline line, and rinsing the circuit to return the patient’s bloodThe nurse should monitor, support, assessing, and educating the patients.
38Vascular Access:Subclavian, internal Juglar, and femoral catheter (venous catheter)Arteriovenous Fistula: created surgically, provide long-term access for hemodialysis, the fistula takes 4-6 weeks to mature before it is ready for use, the patient instructed to perform exercise to increase the size of these vessels, venipunctures is contraindicated in the arm with fistula, assess for the thrill.
403. Synthetic graft:An arteriovenous graft can be created by subcutaneously interposing a biological, semibiologic, or synthetic graft material between an artery and veinThe graft is created when the patient’s vessels are not suitable for a fistula ( DM)Graft usualy placed in the forearm, upper arm, or upper thighComplication such as thrombosis, infection, aneurysm formation and stenosis at the site of anastomosis are more frequent than fistula
42Complication of Hemodialysis: Atherosclerotic cardiovascular disease an, Angina and fatigueDisturbance of lipid metabolism (hypertriglyceridemia)StrokePeripheral vascular insufficiencyGastric ulcerDisturbed calcium metabolism that lead to bone pain and fractures
43Cont…Sleep problemFluid overload, malnutrition, infection, neuropathy and pruritisHypotension, nausea, vomiting, Dysrhythmias, chest painPainful muscle crampingAir embolismDialysis disequilibrium result from cerebral fluid shift ( headache, nausea, vomiting, restlessness, decrease level of consciousness and seizures
44Long term management for Hemodialysis: Pharmacologic therapy: the dosage of medications need to adjust for patient undergoing hemodialysis and monitored closely to ensure that blood and tissue levels of these medications are maintained without toxic accumulation.Example are antihypertensive medication which should not be taking at the day of dialysis to prevent hypotension.II. Nutritional and fluid therapy:To minimize uremic symptoms and fluid and electrolyte imbalances.To maintain good nutrition status through adequate protein calories, vitamin, and minerals intake
45Sodium is usually restricted to 2-3 g/day Cont…..3. To enable patient to eat a palatable and enjoyable diet.Protein intake should be restricted to about 1 g/kg ideal body wt/day, High biologic quality protein ( contain essential amino acids) should be taken ( eggs, milk, meat, poultry, and fish)Sodium is usually restricted to 2-3 g/dayFluids are restricted to amount equal to the urine output plus 500ml to keep interdialytic wt gain under 1.5 kg.Potassium restriction ( Average 1.5 to 2.5 g/day).
46Nursing Management of the Hospitalized Patient on Dialysis Protect vascular access; assess site for patency and signs of potential infection, and do not use it for blood pressure or blood drawsMonitor fluid balance indicators and monitor IV therapy carefully; keep accurate I&O and IV administration pump recordsAssess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab dataMonitor cardiac and respiratory status carefullyMonitor blood pressure; antihypertensive agents must be held on dialysis days to avoid hypotension
47Address pain and discomfort Cont……..Monitor all medications and medication dosages carefully; avoid medications containing potassium and magnesiumAddress pain and discomfortImplement stringent infection control measuresMonitor dietary sodium, potassium, protein, and fluid; address individual nutritional needsProvide skin care: prevent pruritus; keep skin clean and well moisturized; trim nails and avoid scratching
48Nursing Management:I. Meeting psychosocial needs: Give the patient and their Families the opportunity to express feelings of anger and concern over the limitations that disease and treatment impose.Treatment of depression with antidepressant agentsReferring the pt and family to clinical nurse specialists, and psychologistAssess noncompliant pt for the impact of renal failure and it’s treatment on the pt and family and the coping strategies that may useHelps pt to identify safe, effective coping strategies to cope with ever-present problems and fears
49Cont… II. Teaching patient self care: III. Teaching patient about HemodialysisIV. Continuing care.The five E’s: Bridges to Renal rehabilitation:Encouragement,Education,Exercise,Employment, andEvaluation
50Peritoneal Dialysis:The goals are to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance.May be treatment of choice for:Patient with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation.An initial treatment for renal failure while patient is being evaluated for a hemodialysis program, or when access to the blood stream is not possible
51Cont…3. Patient who are susceptible to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis ( pt with DM, Cardiovascular diseases, older patients, and those who may be at risk for adverse effects of systemic heparin).4. Pt with sever hypertension, congestive heart failure, and pulmonary edema ( not responsive to usual treatment regimens)
54Principles underlying peritoneal dialysis: In peritoneal dialysis, the peritoneal serves as the semi permeable membrane ( provide about 22,000 square cm surface area)Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals.Urea, creatinine, metabolic end products are cleared from the body by diffusion and osmosis
55Cont…It is usually takes hours to achieve with peritoneal dialysis what hemodialysis achieve in 6-8 hoursUrea is cleared at rate of ml/min where creatinine is removed more slowlyUltrafiltration (water removal) occurs in peritoneal dialysis through an osmotic gradient created by using a dialysate fluid with dextrose concentration.
56Preprocedure:Prepare the patient for catheter insertion and the dialysis procedure by giving a thorough explanation of the procedureConsent form may be signed according to hospital policyAssess the pt’s anxiety, and provide support instructionTake the pat’s history, identifying abdominal surgery or traumaExamine the abdomen before the catheter is inserted.Ask the patient to empty the bladder and bowel just before the procedure to avoid accidental puncture with the trocarGive a preoperative medication, as ordered, to enhance relaxation during the procedure
57Broad spectrum antibiotic agent may be given to prevent infection Cont………..Broad spectrum antibiotic agent may be given to prevent infectionTake and record baseline vital signs and body wtWarm the dialyzing fluid to body temperature or slightly warmer to prevent hypothermia, increase urea clearance, prevent abd pain, and dilate the vessels of the peritoneum.Prepare the proper concentration of dialysate and the medication to be added ( Heparin, Potassium chloride, antibiotic, and insulin may be added) as doctor order
58Cont…Immediately before initiating the dialysis, the nurse assembles the administrating set and tubing. The tube is filled with the prepared dialysate to reduce the amount of air entering the peritoneal cavity.Preparation of equipment:Peritoneal dialysis administration set,peritoneal dialysis catheter set,Trocar set, andmedication such as heparin, local anesthesia, KCL, and broad spectrum antibiotics
59Performing the exchange: Peritoneal dialysis involves a series of exchanges or cycles. This cycle is repeated through the course of the dialysis which varies from hours1. Infusion phase: the dialysate is infused by gravity into the peritoneum. Period about 5-10 min is usually required to infuse 2 L of fluid.2. Dwell or equilibrium phase: is the time allows diffusion and osmosis to occur.3. Drainage phase: the tube is unclamped and the solution drains from the peritoneal cavity by gravity through closed system. Usually completed in min. the drainage fluid is normally colorless or straw-colored and should not be cloudy
60Cont…The entire cycle (exchange) takes 1 to 4 hours, depending on the prescribed dwell timeThe removal of excess water is achieved by using a hypertonic dialysate with a high dextrose concentration that creates an osmotic gradient (1.5%, 2.5% and 4.25% are available in several volumes from ml).
61Postprocedure:Maintain accurate records of intake and output, and weightMonitor BP and pulse frequently. Orthostatic blood pressure changes, and increased pulse rate are valuable clues that help the nurse evaluate the pt’s volume statusDetect S/S of peritonitis early ( low-grade fever, diffuse abd pain, rebound tenderness, and cloudy peritoneal fluid)Maintain sterility of the peritoneal systemDetect and correct technical difficulties early
62Assess for the presence of complications Cont….Prevent constipation which decreases the clearance of waste product and cause the patient more discomfortAssess for the presence of complicationsPeritonitis ( inflammation of the peritoneum) : most commonLeakage:BleedingLong-term complications: abdominal hernia, hypertriglyceridemia, cardiovascular diseases, low back pain, and anorexia
63Nursing Management of the Hospitalized Patient on Dialysis (1 of 2) Protection of vascular access; assess site for patency and signs of potential infection, and do not use for blood pressure or blood draws.Monitor fluid balance indicators and monitor IV therapy carefully; accurate I&O, IV administration pump.Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data.Monitor cardiac and respiratory status carefully.Hypertension: monitor blood pressure, antihypertensive agents must be held on dialysis days to avoid hypotension.
64Nursing 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, and fluid; address individual nutritional needs.Skin care: pruritis is a common problem; keep skin clean and well moisturized, and trim nails and avoid scratching.CAPD catheter care.