1. Renal Failure

2. Characterized by the inability of the kidneys to remove wastes, concentrate urine, and conserve or eliminate electrolytes

3. Etiology/Incidence/ Contributing Factors
Diabetes mellitus is the most common cause accounting
for > 40% of new cases
-Other predisposing concurrent illnesses include:
-Burns
-Trauma
-Renal Disease
-Heart failure
-Volume Depletion

4. Nursing interventions to prevent renal failure -Adequate hydration
-Prevention of infections
-Monitoring for signs of shock
-Teaching drug side effects to report immediately

5. -Kidney function may be altered by interference with the
Etiology/Pathology
-Kidney function may be altered by interference with the
kidney’s ability to be selective in filtering blood or by an
actual decrease in blood flow to the kidneys
-Conditions leading to Acute Renal Failure (ARF)
-Hemorrhage
-Trauma
-Infection
-Decreased cardiac output

6. Acute Renal Failure
ARF course is in 2 phases: Oliguric, Diuretic
-Oliguric: serum BUN and Cr rise while urine output
decreases
-may last from several days to 4-6 weeks
-Diuretic: blood chemistry levels begin to return to
normal and urine output increases
Additionally, a Recovery Phase occurs when kidneys return to normal or near normal function

7. Acute Renal Failure

8. Acute Renal Failure Clinical Manifestations
-Anorexia, nausea/vomiting, edema, and associated signs
of diminished renal function
-Subjective data: patient report of experiencing lethargy,
loss of appetite, nausea and headache
-Objective data: assess for dry mucous membranes, poor
skin turgor, urine output of less than 400 mL/24 hours,
vomiting, diarrhea, and anasarca; CNS manifestations of
drowsiness, muscle twitching and seizures

9. Acute Renal Failure Medical Management
-Diagnostic test: Blood chemistry
-Administration of fluids and osmotic preparations to
prevent decreased renal perfusion, manage fluid volume,
and treat electrolyte imbalances
-Renal dialysis may be necessary to manage systemic fluid
shifts, especially cardiac and respiratory, and remove
some nephrotoxins
-Diet: protein sparing, high in CHO, and low in K+ and
Na+

10. Acute Renal Failure Drug Therapy
-Diuretics- to increase urine output; Furosemide/Lasix,
Hydrochlorothiazide (HCTZ)
-Potassium lowering agents to remove K+ through the GI
tract (Kayexelate)
-Antibiotics to treat the infection
-Dosage and administration times will require adjustment
according to the level of kidney function

11. Acute Renal Failure Nursing Interventions
-Accurate urine output documentation to identify level of
renal function
-Track lab results
-watch for results that indicate azotemia
-watch patient with azotemia for changes in level of
consciousness
-Monitor fluid status, vital signs, response to therapies
-Frequent skin care to remove urea crystals
-See Box 10-4, pg. 502 AHN

12. Acute Renal Failure -Patient Teaching
-Identify preventable environmental or health
factors contributing to the illness (HTN,
nephrotoxic drugs)
-Dietary restrictions
-Medication regime
-Reporting the signs of infection and of returning
renal failure
-Ongoing follow up care

13. Acute Renal Failure -Nutritional support with specialized enteral
formulas, which may contain essential amino
acids and minerals, in addition to replacement of
electrolytes ( especially Na+ to match the
insensible loss) and provision of caloric needs
-Nutritional assessment with appropriate
modifications are made daily

14. Chronic Renal Failure

15. Chronic Renal Failure (End Stage Renal Disease-ESRD)
Etiology/Pathophysiology
_Exists when kidneys are unable to regain normal
function
_Develops slowly as a result of kidney disease or other
disease processes and compromise renal blood
perfusion
_Most common causes: pyelonephritis, chronic
glomerulonephritis, glomerulosclerosis, chronic
urinary obstruction, severe hypertension, DM, gout,
and polycystic kidney disease
_Dialysis or kidney transplantation will be needed to maintain
life

16. Chronic Renal Failure Clinical Manifestations
_Vague, gradual onset of symptoms, may seem
insignificant to the patient when first noticed
_Common symptoms:
-Headache, lethargy, asthenia (decreased strength,
energy)
-Anorexia, pruritis
-Elimination changes, anuria ( urine output < 100 mL/
day)
-Muscle cramps or twitching
-Impotence
-Dusky yellow-tan or gray skin color
-CNS changes such as disorientation and mental lapses

17. Chronic Renal Failure Assessment
-Subjective data: Note patient complaining of joint pain
and edema: severe headaches, nausea, intermittent chest
pain, weakness and fatigue, intractable hiccoughs,
decreased libido, menstrual irregularities, and impaired
concentration
-Objective data: nursing assessment may be
unremarkable except for patient report
-Observe for reduction in mental alertness, respiration
pattern, change in level of consciousness, breath with
a urine odor, and a uremic “frost” on the skin (white
powder)

18. Chronic Renal Failure Medical Management
-Diagnostic Tests: BUN (elevation of 50mg/dL), serum
Cr level of > 5mg/dL and electrolyte imbalance confirms
diagnosis
-Conserve renal function as long as possible
-Renal dialysis
-Transplantation
-Drug therapy
Anticonvulsants, anti-emetics, vitamin supplements and
biological response modifiers to stimulate production
of RBCs (Epogen)

19. Chronic Renal Failure Nursing Interventions and Patient Teaching
-Measures to control fluid and electrolyte balance
-Nutrition therapy
-Aimed at preserving protein stores and preventing the
production o additional protein waste products
-High CHO
cal/day
-Potassium restriction, Na+ adjustments
-Possibly restricted fluid intake
-Emotional support for the patient facing role changes and
invasive treatments
-Safety measures PRN, seizure precautions PRN
-Maintain skin integrity
Safety to avoid trauma and infection

20. Hemodialysis

21. Care of the Patient Requiring Dialysis
Dialysis: a medical procedure for the removal of certain elements from the blood through an external semipermeable membrane (hemodialysis)
-In case of peritoneal dialysis removal of certain
elements is through the peritoneum.
-Mimics kidney function
-Helps restore balance

22. Hemodialysis -Requires access to the patient’s circultory system to
route blood through the artificial kidney (dialyzer) for
removal of wastes, fluid, and electrolytes and the return
the blood to the patients’ body.
-Temporary access methods include:
-Subclavian or femoral catheter
-External shunt in non-dominant forearm
_Arterio-venous fistula which is preferred for
permanent access.

23. -Usually scheduled 3x/week for 3-6 hours
-Patients can be maintained on dialysis therapy
indefinitely
-Medical Management
-Close monitoring of blood levels of drugs
excreted by the kidneys to maintain therapeutic
levels and prevent toxic accumulation
-Medications may include:
Antihypertensives, cardiac glycosides,
antibiotics and anti-arrhythmias
Instruct patient not to take OTCs without
consulting with their MD

24. Nursing Interventions
_Maintain access sites
_Preventing/managing infections
_Patient teaching
_See nursing care plan, pg , AHN

25. Care of the Patient Requiring Dialysis
Peritoneal Dialysis
- can be performed with minimum equipment and by the
patient who is ambulatory
-performed 4x/day, 7 days/week, one exchange cycle
usually takes minutes
-principle of osmosis and diffusion through a
semi-permeable membrane; peritoneum is used as the
semi-permeable membrane rather than the artificial
kidney
-physician places a catheter into the peritoneal space
under aseptic conditions. Dialyzing fluid is instilled
and then drained

27. Care of the Patient Requiring Dialysis
Nursing Interventions
-Monitor the vital signs for hypotension due to
excessive sodium and fluid removal
-Monitor for signs of sepsis and peritonitis
-Pain and hemorrhage may accompany
instillation of dialysate
-Review p. 508 Box 10-5 for specific guidelines

28. Nutritional Therapy in Renal Disease
Dietary considerations are based
on the nature of the disease
process and individual responses

29. Nutritional therapy depends on the length of the
disease:
-Short term acute illness: nutritional therapy is aimed toward optimal nutritional support for
healing and normal growth
-Chronic disease: the extent of nephrons destroyed
affects the extent of the nutritional therapy to help
maintain renal function as long as possible

30. Glomerulonephritis
-Optimal nutritional support with adequate protein
-Salt is usually not restricted
-Fluid is adjusted to output
-If the disease process is advanced:
_PROTEIN: restricted if BUN is elevated, and
urine output is decreased

31. - CHO –liberal, generous; helps combat breakdown
of tissue protein and prevent starvation ketosis
-Na+ -If decreased urine output, restrict to
mg/day. As recovery occurs, can
resume normal 2-3 Gm Na+/day
-K+ - If oliguria becomes severe, renal clearance of
K+ is impaired, restrict. Monitor carefully.
-Water – restricted according to urine output

32. Nephrotic Syndrome (nephrosis)
-Primary damage is to the filtering membrane of the
glomerulus which allows large amounts of protein to pass
to the tubule
-Nutritional Therapy: directed toward controlling
symptoms resulting form massive protein losses (edema,
malnutrition)

33. Nutritional Therapy
-Protein-enough to meet nutritional and growth
need without excess
-CHO-energy, sufficient to free protein for tissue
rebuilding
-Na+- Moderate restriction (1-3 Gm/day)
-Other minerals/vitamins: No K+ restriction;
iron and vitamin supplements helpful

34. Renal Failure -Nutritional Therapy- major challenge is to improve or
maintain nutritional status while the patient is faced with
marked catabolism. Loss of appetite is common.
-TPN may be required
-Protein intake is determined by glomular filtration rate
(GFR)

35. Chronic Renal Failure -Nutritional Therapy:
_Protein-provide enough to maintain tissue integrity
while avoiding damaging excess
_Amino Acid Support- mixture of amino acid: precursor
needed for protein supplementation for low protein
diet. Nitrogen-free “copies” of essential amino acids
_CHO and Fat- energy; to supply non-protein
kilocalories to spare protein for tissue synthesis
_Water- for non-dialysis patients. Sufficient to maintain
adequate urine volumes

36. _Na+- restricted if HNT and edema; 500-
2000 mg/day
_K+- restricted
-Phosphorous and Calcium- moderate restriction

37. Hemodialysis patients
-Protein- enough for nutritional needs, to maintain a positive
nitrogen balance, does not produce excessive nitrogenous waste,
and replace amino acids lost during dialysis
_High biological value proteins: eggs meat, fish, poultry
_Milk restricted
-Energy- generous amounts CHO, some fats
-Water balance- limited to 1000mL a day
-Na GM./day
-K+- limited to mg/day
-Vitamins- water soluble B and C replace loss from dialysis

38. Chronic Renal Failure -Peritoneal Dialysis _Protein- increase
_ Phosphorus- limit
_K+- increase, mg/day
_Fluids- liberal
_Avoid sweets and fats to control triglycerides and LDL

39. Pharmacological Therapy in Renal Disease
Urinary Tract Anti-Infectives
- Uncomplicated: A UTI in which no structural or
neurological abnormality of the urinary tract interferes
with normal urine flow
-Complicated: some impairment that interferes with the
ability of the urinary tract to wash bacteria out of the
system ( a congenital distortion of the urinary tract, a
kidney stone, an enlarged prostate gland, etc.)

40. Pharmacological Therapy in Renal Disease
-Trimethoprim, (Proloprim, Tripex) and
-Trimethoprim/Sulfmethoxazole (Bactrim, Septra,
Septra DS
-most commonly used is the combination agent
TMP/SMZ
-Blocks the bacteria’s ability to synthesize folate,
interfering with the ability of the bacteria to form
nucleic acids.
-For those clients with allergies to sulfa, Trimethoprim
may be prescribed in the single drug form
-Adult dose: 1 tablet every hours

41. Nalidixic Acid (NegGram)
-A urinary antiseptic
-Exerts a bacteriocidal action on most gram-
negative bacteria but interfering with their ability
to transmit genetic information
-Adult dose: initially 1 Gm 4 times a day for 1-2
weeks, then 500 mg 4 times a day.
-Adverse reactions: infrequent- GI distress,
drowsiness, dizziness, skin rashes

42. Cinoxacin (Cinobac Pulvules)
-Chemically and pharmacologically related to Nalidixic
acid
-Less likely to result in development of bacterial
resistance and has longer duration
-Monitor for skin rash and GI distress

43. Nitrofurantoin (Furadantin, Macrodantin)
_Interferes with the CHO metabolism of bacteria
_Administered orally
_Therapy should be maintained for 3 days after a sterile
urine is collected
_Monitor for GI distress; may produce a yellow-brown
discoloration to the urine
_Adult dose: mg 4 times a day to treatment for
UTI; long term therapy: mg at HS

44. Methenamine Products
-Urinary antiseptic
-Common: Mandelamine (methenamine mandalate)
-If the pH of the urine is acid enough (>5.5), this drug
is converted to formaldehyde which exerts a local
bacteriocidal effect in the urinary tract
-Take after meals to reduce symptoms of GI distress

45. Other agents used in the treatment of UTIs
-Phenazopyrydine HCL (Pyridium)
-Exerts a topical analgesic effect on the mucosal
lining of the urinary tract
-Often used in conjunction with anti-infective therapy
-Relives pain and discomfort