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

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 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

4 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

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

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

7 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

8 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

9 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

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

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

12 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

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

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

15 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

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

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

Hemodialysis:Patho 18  Diffusion  Dialysate  Lytes and H2O  Dialyzer  Anticoagulation  Heparin to prevent blood clots in dialyzer or tubing

Vascular Access 19  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

20 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

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

22 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)

23 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

24 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