Care of Patients with Acute Renal Failure and Chronic Kidney Disease Igg Chapter 71 pgs.

1600-1608 Acute Renal Failure (can be reversed) Kidneys do Acid/base balance FVO, FVE, -salt balance Hormone balance Filtering Rapid decrease in kidney function Types of acute renal failure include: Prerenal-reduced blood flow to the kidneys (before the kidneys) Intrarenal-damage to the glomeruli, interstitial tissue or tubules (inside the kidney) Postrenal-obstruction of renal flow (after the Kidneys) Prerenal Prerenal azotemiarenal failure caused by poor blood flow to the kidneys the kidneys compensates by constricting renal blood vessels, activating the reninangiotension-aldosterone pathway and releasing ADH. these responses increase blood volume and improve kidney perfusion however these also reduce urine output (oliguria less then 400 ml/day) and build up of waste products (azotemia) Toxins can cause blood vessels to constrict in the kidney, leading to reduced renal blood flow and renal ischemia Most commonly caused by hypovolemic shock and heart failure Can be reversed by correcting blood volume, increasing BP and improving cardiac output When reduced blood flow is prolonged the kidney is severely damaged and intrarenal failure results Intrarenal Other names- acute tubular necrosis and lower nephron nephrosis Causes- infections, drugs and invading tumors, inflammation of the glomeruli or of the small vessels of the kidneys or an obstruction of renal blood flow Postrenal Obstruction of the urine collecting system anywhere from the calyces to the urethral meatus (out flow) (obstruction of the ureter must be bilateral to cause postrenal failure unless only one kidney is functional) Phases of Acute Renal Failure Phases of rapid decrease in renal function lead to the collection of metabolic wastes in the body. Need 30ml/hr oliguria =less then 400 ml/day Micturation =urination Anormia= no output Phases include: Onset phase

 Oliguric phase Diuretic phase Recovery phase Acute syndrome may be reversible with prompt intervention. Health Promotion and Maintenance Severe blood volume depletion can lead to renal failure even in people who have no known kidney problems avoid dehydration drink 2-3L a day (2000-3000ml) Continual assessment of I&O, blood volume depletion (low BP, dizzy, weak pulse, cool skin), laboratory values(BUN 5-25, Creat 0.5-1.2), use of nephrotoxic substances (medications- contrast dye, NSAIDS) Pg 1605 chart 71-2 Assessment chart 71-1 pg 1604 History Surgery trauma transfusions recent exposure to nephrotoxins acute illness (flu, colds, gastroenteritis and sore throats) medical history (hypertension, DM, Lupus, Ask about urination problems Medications (where are they excrated?) Physical assessment/clinical manifestations Laboratory assessment Specific gravity not concentrating 1.005 to 1.030 Renal tubular damage (intra) Imaging assessment Other diagnostic tests Physical Assessment Pg 1604 chart 71-1 & pg 1603 Manifestations of ARF are related to the build up of nitrogenous wastes (azotemia) as well as the underlying cause Pre- Hypotension, tachy, urine output, lethergy, cardiac output, central venous pressure may look like a pt with dehydration or heart faliure Intra- (intrinsic)rentention of fluid (edema) oligura( urine output) to anureia(no urine output)hypertenstion, tachy, SOB, respiratory crackles, distended neck veins, weight gain, anorexia, N/V, lethergy, change in LOC & electrolyte imbalances ( K & calcium) & ECG changes Post- oligura- type of stream, starting of stream (oligura to intermittent anuria, symptoms of uremia) lethergy ARF Labs Rising BUN and serum creatinine ( both) Abnormal blood electrolytes ( k+ & calcium) ARF usually do not have the anemia associated with CKD Urine sodium levels ( or ) (10 to 20 mEq/L)

 Specific gravity greater than 1.030 (concentrated because not filtering) Urine sediment (common- RBC casts) ARF Diagnostics Flat plate X-rays Renal ultrasonography CT Renal Biopsy Drug Therapy- pg 1605 Patients with ARF receive many drugs Drug dosages change with kidney function changes Be knowledgeable about the site of drug metabolism Constantly monitor for possible side effects and interactions of the drugs Fluid Challenges In prerenal azotemia, fluid challenges and diuretics are often used to promote renal blood flow In patient without volume excess 500-1000 mL of normal saline may be infused over 1 hour The patient responds to the fluid challenge by producing urine soon after the initial bolus Diuretics like Lasix may be prescribed along with a fluid bolus If oliguric renal failure is dx the fluid challenges and diuretics are DCd Constant CVP for accurate evaluation of their hemodynamic status Carefully monitor for signs of possible fluid overload Drug Therapy pg 1606 chart 71-3 Cardioglycosides-Digoxin Vitamins and minerals-folic acid, ferrous sulfate Synthetic erythropoietin- Epogen (intra renal) Phosphate binders- Amphogel Diuretics Calcium Channel Blockers (improve the GFR by improving renal blood flow) Treatment-Nutrition Therapy With ARF there is a high rate of protein breakdown Nutritionist will calculate the patients caloric needs- with specified amts of protein, sodium and fluids For patients who do not require dialysis 0.6g/kg of body wt or 40 g/day of protein For patient who do require dialysis- protein levels of 1 to 1.5g/kg Nutrition Therapy Sodium intake ranges from 60-90 mEq If potassium levels are high, dietary potassium is restricted to 60-70 mEq Amount of fluid permitted is equal to the urine volume plus the insensible loss volume of 500 mL Assess oral intake every shift Many patients are too ill or have a poor appetite- use nutritional support -TPN Dialysis for ARF pg 1607 Indicators: Presence of uremia

Persistent high potassium levels Metabolic acidosis Continued fluid volume excess Uremic pericarditis- bulid up of waste is affecting the heart Encephalopathy

Immediate Vascular Access Dual or triple lumen catheter specific for hemodialysis Outflow lumen Inflow lumen Lumen for access for drawing blood or giving drugs & fluid without interrupting dialysis Subclavian or internal jugular vein-long term Femoral-short term xray to check placement Dialysis Therapies Continuous renal replacement therapy (CCRT) (standard for ARF due to they are usually for short term) Continuous arteriovenous hemofiltration (CAVH) used for pt with FVO & resistant to diuretics, unstable BP & cardiac output Continuous arteriovenous hemodialysis and filtration (CAVHD) Hemodialysis Peritoneal dialysis Continuous Renal Replacement Therapy Standard treatment Dialysate solution (composed of H2o, glucose, sodium, chloride, potassium, magnesium, calcium, bicarbonte) Vascular access Types Continuous arteriovenoous hemodialysis (CAVH) Continuous arteriovenous hemodialysis and filtration (CAVHD) Posthospital Care If renal failure is resolving, follow-up care may be done with the nephrologist or family MD that consults with the specialist. There may be permanent renal damage and the need for chronic dialysis or even transplantation. Temporary dialysis is appropriate for some patients. Teaching type of dialysis care of the site dietary restrictions, fluid restrictions prevention of complications home care help social work assistance

Care of Patients with Chronic Kidney Disease Igg Chapter 71 pgs.1608-1636

Chronic Kidney Disease Progressive, irreversible kidney injury; kidney function does not recover End-stage renal disease (ESRD) Azotemia (build up of waste ) Uremia- S&S in chart 71-4 azotemia with clinical symptoms Uremic syndrome -table 71-1 Five Stages of Chronic Kidney Disease At Risk Reduced renal reserve (GFR 90ml/min) Mild Chronic Kidney Disease (GFR 60-89ml/min) Moderate Chronic Kidney Disease (GFR 30-59ml/min) Severe Chronic Kidney Disease (GFR 15-29ml/min) End-stage Kidney disease (GFR 15ml/min Stages of Chronic Kidney Disease Changes - pg 1609 & 1610 Kidney changes abnormal urine production poor water excreation electrolyte imbalances metabolic abnormalitlies Metabolic changes: Urea and creatinine () creatinine is derived from proteins present in skeletal muscle and depends on muscle mass, activity, diet Urea is protein metabolism Electrolytes changes: Sodium Potassium Acid-base balance changes- metabolic Calcium and phosphorus changes Early hypo - late hyper Cardiac changes: Hypertension cause or result of Hyperlipidemia Heart failure workload due to fluid = death because of the CKD Pericarditis- inflamed by the uremic toxins or infection Hematologic changes-anemic due to the erythropoietin level that RBC production GI changes halitosis-bad breath stomatitis-mouth inflammation peptic ulcer

Etiology and Genetic Risk Many causes Two main causes HTN and DM Complex Table 71-6 pg 1611 African Americans patients are 4X more likely to develop ESKD and 7X more likely to have HTN Incidence/Prevalence 2008 US Renal Data System more than 340,000 people in the US are receiving dialysis treatment for ESKD More than 24% of patients with ESKD die within the first year of treatment ESKD occurs more often in men than in women Health Promotion and Maintenance Focus on controlling the diseases that lead to CKD development-like DM and HTN Identify patients at risk Teach adherence to drug and diet therapy Regular physical exercise Keep blood glucose levels within normal Compliance with drug therapy Yearly testing for microalbuminuria for DM and HTN patients Treat renal and urinary infections Avoid abusing NSAIDs Drink 3 liters of water daily Chart 71-5 History Assessment Focus on manifestations of CKD Patients age and gender Accurately measure wt and ht-asking about usual wt and any recent gains or losses Renal or urologic disorders, long term health problems, drug use and current health problems Current OTC and prescription drug use and past hx Dietary habits Energy levels Urine elimination Clinical Manifestations chart 71-6 pg 1613 Neurologic Cardiovascular Respiratory Hematologic Gastrointestinal Skeletal Urinary Skin Assessments

 Psychosocial assessment Laboratory assessment BUN 10-20 Creat 0.5-1.2 Potassium 3.5-5.0 Mag 1.3-2.1 Sodium 135-145 calcium 9.0-10.5 Imaging assessment Imbalanced Nutrition: Less Than Body Requirements Interventions include: Dietary evaluation for: Protein Fluid Potassium Sodium Phosphorus Vitamin supplementation Excess Fluid Volume Interventions: Monitor intake and output. Promote fluid balance. Assess for manifestations of volume excess: Crackles in the bases of the lungs Edema Distended neck veins Drug therapy includes diuretics. Decreased Cardiac Output Interventions: Control hypertension with calcium channel blockers (improve renal blood flow & GFR), ACE inhibitors(slow the progression), alpha- and beta-adrenergic blockers, and vasodilators. Instruct patient and family to monitor blood pressure, patients weight, diet, and drug therapy. Risk for Infection Interventions include: Meticulous skin care Preventive skin care Inspection of vascular access site for dialysis Monitoring of vital signs for manifestations of infection HAND WASHING Risk for Injury Interventions include: Drug therapy

 Education to prevent fall or injury, pathologic fractures, bleeding, and toxic effects of prescribed drugs Fatigue Interventions: Assess for vitamin deficiency, anemia, and buildup of urea. Administer vitamin and mineral supplements. Administer erythropoietin therapy for bone marrow production. Give iron supplements as needed. Anxiety Interventions include: Health care team involvement Patient and family education Continuity of care Encouragement of patient to ask questions and discuss fears about the diagnosis of renal failure Potential for Pulmonary Edema Interventions: Assess the patient for early signs of pulmonary edema. Monitor serum electrolyte levels, vital signs, oxygen saturation levels, hypertension. Hemodialysis Patient selection presence of irreversible kidney failure absence of illness that would seriously complicate HD expectation of rehabilitation pt acceptance of the regimen Dialysis settings many settings Hospital, clinic, home Procedure diffusion Anticoagulation needed for HD Heparin is used to prevent clots from forming when blood comes in to contact with foreign surfaces protamine sulfate antidote for heparin

Hemodialysis Circuit

Vascular Access

 Arteriovenous fistula or arteriovenous graft for long-term permanent access Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for temporary access due to need for large blood flow 250-300ml/min for 3-4 hr Precautions AV fistulas need adequate circulation in the area and the lower arm. check for bruit or thrill Complications thrombosis or stenosis infection aneurysm ischemia heart failure

Subclavian Dialysis Catheters

Caring for the Vascular Access Assess for adequate circulation in the fistula or graft and in the lower portion of the arm Check for a bruit or a thrill by auscultation or palpation over the access site Avoid repeated compression Chart 71-8 Caring for fistula, graft or shunt Table 71-10 Prevention of Complications Hemodialysis Nursing Care Drugs table 71-11 Post-dialysis assess for hypotension, headache, nausea, malaise, vomiting, dizziness, and muscle cramps or bleeding Complications of Hemodialysis Dialysis disequilibrium syndrome rapid in fluid volume and BUN levels durning HD can cause cerebral edema, intracranial pressure Infectious disease Hepatitis B & C, HIV

Peritoneal Dialysis

 Procedure involves siliconized rubber catheter placed into the abdominal cavity for infusion of dialysate. Types of peritoneal dialysis: Continuous ambulatory peritoneal dialysis (CAPD) Automated peritoneal dialysis (acute care setting, out pt, pt home) can be done at night Intermittent peritoneal dialysis Continuous-cycle peritoneal dialysis (done at night while pt sleeps)

Peritoneal Dialysis Exchange Continuous Ambulatory Peritoneal Dialysis (CAPD) Automated Peritoneal Dialysis

Complications of Peritoneal Dialysis Peritonitis (connection site contamination) (cloudy outflow= infection) Pain (at the start is common- cold solution can cause pain) Exit site and tunnel infections - due to not maintaining an clean dry area, leakage of solution, pulling or twisting of the catherter Poor dialysate flow -position, kink in tubing, constipation Dialysate leakage Other complications- bleeding,

perforation Nursing Care Durning Peritoneal Dialysis Before treating, evaluate baseline vital signs, weight, and laboratory tests. Continually monitor the patient for respiratory distress, pain, and discomfort. Monitor prescribed dwell time, and initiate outflow.

 Observe the outflow amount and pattern of fluid. one PD exchange is a fill, dwell & outflow Renal Transplantation table 71-13 Candidate selection criteria Donors Preoperative care Immunologic studies Surgical team Operative procedure Transplanted Kidney

Postoperative Care Urologic management Assessment of urine output hourly for 48 hr Complications include: Rejection Acute tubular necrosis Thrombosis Renal artery stenosis Other complications Immunosuppressive drug therapy cyclosporin long term to protect the kidney increased risk for infection (viral, bacterial, protozoal) Community-Based Care pg 1635 Home care management Health teaching Psychosocial preparation Health care resources