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1 Nursing Care and Interventions in Managing Chronic Renal Failure Keith Rischer RN, MA, CEN.

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Presentation on theme: "1 Nursing Care and Interventions in Managing Chronic Renal Failure Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1 Nursing Care and Interventions in Managing Chronic Renal Failure Keith Rischer RN, MA, CEN

2 2 Todays Objectives…  Review the pathophysiology and causes of chronic renal failure (CRF).  Contrast lab findings and physiologic changes associated with acute vs. chronic renal failure.  Identify relevant nursing diagnosis statements and prioritize nursing care for clients with CRF including dietary modifications.  Compare and contrast the following treatment modalities: peritoneal dialysis, hemodialysis, and continuous renal replacement therapies.  Identify nursing care priorities with hemodialysis and peritoneal dialysis.  Prioritize teaching needs of clients with CRF.

3 3

4 4 Patho

5 5 Patho:Chronic Renal Failure  Progressive, irreversible kidney injury  Kidney function does not recover  Azotemia Increase nitrogenous wastes such as BUN Creatinine  Uremia azotemia with symptoms (chart 75-5 p.1739) Anorexia, N&V, fatigue, SOB  Uremic syndrome (urine in the blood) Altered fluid, lyte and acid-base balance clinical and lab manifestations of renal failure More severe weakness, lethargy, confusion…coma..death

6 6 Patho:Stages of Chronic Renal Failure  Diminished renal reserve  GFR ½ normal  Compensation w/healthy nephrons  Renal insufficiency  Nephrons destroyed…remaining adapt  BUN, creatinine, uric acid elevate  Priorities: fluid volume, diet, control of HTN,  End-stage renal disease  Severe fluid, acid-base imbalances  Dialysis needed or will die

7 7 Patho:Physiologic Changes Kidney Decreased GFR Poor H2O excretion Metabolic – BUN and creatinine increased Electrolytes – Sodium- later stages sodium retention – Potassium increased –EKG changes –Kayexelate Acid-base balance: metabolic acidosis Calcium decreased and phosphorus increased

8 8 Patho:Physiologic Changes Cardiac – Hypertension – Hyperlipidemia – Congestive heart failure – Uremic pericarditis Hematologic anemia Gastrointestinal Halitosis Stomatitis PUD

9 9 Patho:Physiologic Changes  Neurologic  lethargy  Uremic encephalopathy  Respiratory  pulmonary effusion  SOB  Urinary  proteinuria, oliguria, dilute  Skin  dry, pallor, pruritus, ecchymosis

10 10 Drug Therapy chart 75-3 p.1737  Cardioglycides  Digoxin/Lanoxin  Calcium channel blockers  Diuretics  Vitamins and minerals  Folic Acid  Ferrous Sulfate  Biologic response modifiers  Erthropoetin (Epogen)  Phosphate binders  Aluminum hydroxide  Stool softeners and laxatives

11 11 Patho of One Dialysis/ESRD Client  DM II  Retinopathy  ESRD…hemodialysis 3x/week  Anemia  CAD  PTCA 1994 w/redo 2005  AMI 2005-stent to LAD, Cx  CHF  25% EF w/global hypokinesis and severe inferior hypokinesis  AFib  AAA  Neuropathy  Obesity  Rt Femoral Bypass  Rt BKA Medications  ASA  Phoslo  Coumadin  Digoxin  Epoetin  Lantus insulin  Novolog per sliding scale  Lipitor  Neurontin  NTG subl prn

12 12 ED Renal Case Study  69yr female  HPI: Hemodialysis earlier in day. Found to have HR in the 40’s afterwards. Did not increase. Has no c/o lightheadedness. Has no other physical c/o  VS: T-97.8 P-42 (AFib) R-20 BP-122/76 sats 96% 3l per n/c

13 13 Labs

14 14 Excess Fluid Volume  Interventions:  Monitor I&O  Promote fluid balance Daily weights 1 kg=1liter fluid  Assess for manifestations of volume excess: Crackles in the bases of the lungs Edema Distended neck veins  Diuretics Contraindicated w/ESRD

15 15 Decreased Cardiac Output  Interventions:  Control hypertension calcium channel blockers ACE inhibitors alpha- and beta-adrenergic blockers vasodilators.  Education: monitor blood pressure client’s weight Diet Drug regimen

16 16 Potential for Pulmonary Edema  Interventions:  Assess for early signs of pulmonary edema Restlessness/anxiety Tachycardia Tachypnea oxygen saturation levels Crackles in bases  Hypertension

17 17 Imbalanced Nutrition  Interventions:  Dietary evaluation for: Protein Fluid Potassium Sodium Phosphorus  Vitamin supplementation Iron Water soluable vitamins Calcium Vitamin D

18 18 Risk for Infection  Interventions:  Meticulous skin care  Preventive skin care  Inspection of vascular access site for dialysis  Monitoring of vital signs for manifestations of infection

19 19 Risk for Injury  Interventions:  Drug therapy  Education prevent fall Injury pathologic fractures bleeding toxic effects of prescribed drugs –Digoxin –Narcotics –Heparin or Coumadin

20 20 Fatigue  Interventions:  Assess for vitamin deficiency Administer vitamin and mineral supplements  anemia Give iron supplements as needed Erythropoietin therapy  Buildup of urea

21 21 Anxiety  Interventions:  Health care team involvement  Client and family education  Continuity of care  Encouragement of client to ask questions and discuss fears about the diagnosis of renal failure

22 22 Indications for Dialysis  Uremia  Persistent hyperkalemia  Uncompensated metabolic acidosis  Fluid volume excess unresponsive to diuretics  Uremic pericarditis  Uremic encephalopathy

23 23 Hemodialysis  Client selection  Irreversible renal failure  Expectation for rehab  Acceptance of regimen  Dialysis settings  Acute-hospital  Out patient centers

24 24 Hemodialysis:Patho  Diffusion  Dialysate  Lytes and H2O  Dialyzer  Anticoagulation  Heparin to prevent blood clots in dialyzer or tubing

25 25 Complications of Hemodialysis  Dialysis disequilibrium syndrome  Infectious diseases  Hepatitis B and C infections  HIV exposure—poses some risk for clients undergoing dialysis

26 26 Vascular Access  Arteriovenous fistula, or arteriovenous graft for long- term permanent access  Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for temporary access  Precautions  Bruit & thrill  BP restrictions  Complications  Thrombosis  CMS

27 27 Hemodialysis: Nursing Interventions  Predialysis care:  Medications to hold…why?  Postdialysis care:  Monitor for complications such as hypotension, headache, nausea, malaise, vomiting, dizziness, muscle cramps.  Monitor vital signs and weight. sepsis  Avoid invasive procedures 4 to 6 hours after dialysis.  Continually monitor for hemorrhage.  Assess for thrill  No BP or blood draws on arm

28 28 Peritoneal Dialysis

29 29 Peritoneal Dialysis  Phases  Inflow  Dwell  Drain  Contraindications  history of abd surgeries  recurrent hernias  excessive obesity  preexisting vertebral disease  severe obstructive pulmonary disease

30 30 Complications of Peritoneal Dialysis  Peritonitis (cloudy outflow)  Pain  Exit site and tunnel infections  Poor dialysate flow  Dialysate leakage  Monitor color of outflow  cloudy (peritonitis)  brown (bowel)  bloody (first week OK)  urine (bladder)

31 31 Nursing Care During Peritoneal Dialysis  Pre PD:  Vital signs pre and q 15-30” during  Weight  laboratory tests  Continually monitor the client for:  respiratory distress  pain  discomfort  Monitor prescribed dwell time and initiate outflow  Observe outflow amount & pattern of fluid

32 32 Education Priorities  Pathophysiology and manifestations  Complications  When to call the doctor  Keep record of all labs  Take medications and follow plan of care set out by case manager  Monitor weight, fatigue levels closely


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