Renal Failure

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

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

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

-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

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

Acute Renal Failure http://www.youtube.com/watch?v=-qrW6EZWKZM

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

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+

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

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

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

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

Chronic Renal Failure http://www.youtube.com/watch?v=Ydzo0ypudQM

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

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

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)

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)

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 -2500-3500 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

Hemodialysis http://www.youtube.com/watch?v=cTzYLAsiFBI

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

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.

-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

Nursing Interventions _Maintain access sites _Preventing/managing infections _Patient teaching _See nursing care plan, pg. 504-505, AHN

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 30-40 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

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

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

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

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

- CHO –liberal, generous; helps combat breakdown of tissue protein and prevent starvation ketosis -Na+ -If decreased urine output, restrict to 500-1000 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

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)

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

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)

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

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

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+- 1-3 GM./day -K+- limited to 1500-3000 mg/day -Vitamins- water soluble B and C replace loss from dialysis

Chronic Renal Failure -Peritoneal Dialysis _Protein- increase _ Phosphorus- limit _K+- increase, 2000-4000 mg/day _Fluids- liberal _Avoid sweets and fats to control triglycerides and LDL

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.)

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 12-24 hours

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

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

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: 50-100 mg 4 times a day to treatment for UTI; long term therapy: 50-100 mg at HS

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

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