Renal SystemRenal System

Case ScenarioCase Scenario

Case StudyCase StudyTia Smith is a 26 year old female patient who is 10 hours post-partum following an emergency C-section for twins. She was 33.5 weeks pregnant and had a difficult pregnancy with PIH (pregnancy induced hypertension) and frequent urinary tract infections. On admission Tia was diagnosed with HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) which necessitated immediate delivery of her babies. During the C-section Tia became hypovolemic resulting from massive hemorrhaging and required blood products and fluid replacements. Tia eventually developed hypovolemic shock and remained unstable for 2 hours. For the past nursing shift Tia has been hypotensive with blood pressures ranging from 59/37 to 95/52. Tia’s urinary output has been 2-12cc/hr of brown cloudy foul smelling urine. During your morning assessment you discover the following:

Case cont’dCase cont’d VS:VS: T: 37.4T: 37.4 P: 125bpmP: 125bpm R: 33R: 33 BP: 96/62BP: 96/62

  RespiratoryRespiratory:: Chest is clear fine crackles heard throughout all lung Chest is clear fine crackles heard throughout all lung fields, there is diminished A/E at the bottom of the R & L lobesfields, there is diminished A/E at the bottom of the R & L lobes

  CVCV: : S1, S2 audible with pericardial friction, bounding rapid pulse S1, S2 audible with pericardial friction, bounding rapid pulse   Mental StatusMental Status:: drowsy and with assistance will orient slowly to PPT, drowsy and with assistance will orient slowly to PPT,

pt c/o persistent hiccupspt c/o persistent hiccups   NeurovascularNeurovascular:: edema, skin cool & pale, bruises observed edema, skin cool & pale, bruises observed

throughout extremities, skin turgor poor, bilateral decreased throughout extremities, skin turgor poor, bilateral decreased sensation in feetsensation in feet

  GIGI:: pt c/o N&V pt c/o N&V   GenitourinaryGenitourinary:: pt has foley catheter draining brown cloudy foul pt has foley catheter draining brown cloudy foul

smelling urine at 2-12cc/hrsmelling urine at 2-12cc/hr   PsychosocialPsychosocial:: pt very emotional and crying at times because she pt very emotional and crying at times because she

cannot be with her newborn babies and is unable to breastfeed, she is cannot be with her newborn babies and is unable to breastfeed, she is concerned for their health, and does not understand how this concerned for their health, and does not understand how this happened to herhappened to her

So… What is Tia’s diagnosis?So… What is Tia’s diagnosis?

Acute Renal Acute Renal

Failure Failure

DefinitionDefinition

Acute renal failure (ARF) is an abrupt and Acute renal failure (ARF) is an abrupt and sudden reduction in renal function sudden reduction in renal function resulting in the inability to excrete resulting in the inability to excrete metabolic wastes and maintain proper metabolic wastes and maintain proper fluid & electrolyte balancefluid & electrolyte balance

It is usually associated with oliguria (urine It is usually associated with oliguria (urine output <30cc/hr or <400cc/day), although output <30cc/hr or <400cc/day), although urine output may be normal or increasedurine output may be normal or increased

BUN & creatinine values are elevated BUN & creatinine values are elevated

Statistics of ARFStatistics of ARF

Frequency:Frequency: condition develops in condition develops in 5% of hospitalized patients and 5% of hospitalized patients and 0.5% patients require dialysis0.5% patients require dialysis Elderly are at high riskElderly are at high risk Post-op patientsPost-op patients

Mortality:Mortality: the mortality rate the mortality rate estimates vary from 25-90%estimates vary from 25-90%

Race:Race: no racial predilection is no racial predilection is recognizedrecognized

Incidence of ARFIncidence of ARF

2-5% of all hospitalized patients2-5% of all hospitalized patients 10-20% are critically ill10-20% are critically ill Mortality Rate- 25% increases to Mortality Rate- 25% increases to

75% if complicated by other life 75% if complicated by other life threatening conditions threatening conditions

Anatomy of the KidneyAnatomy of the Kidney

Composition of the Renal Composition of the Renal SystemSystem

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings Figure 26.4a, b

Figure 26.4 The Structure of the Kidney

Renal artery Renal artery Segmental artery Segmental artery Lobar artery Lobar artery Interlobar arteries Interlobar arteries Arcuate arteries Arcuate arteries Small Small interlobular arteries interlobular arteries Smaller afferent arteries Smaller afferent arteries Capillary bed (Glomerulous) Capillary bed (Glomerulous) Efferent Efferent arteriole arteriole Peritubular capillaries Peritubular capillaries Interlobular Interlobular vein vein Arcuate vein Arcuate vein Renal vein Renal vein

Vascular Structure of the Nephron

NephronNephron

http://www.venofer.com/VenoferHCP/Venofer_kidneyFunction.html

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings

Figure 26.6 A Representative Nephron

Figure 26.6

Renal CorpuscleRenal Corpuscle Initial filtering component of the nephron.Initial filtering component of the nephron. Consists of glomerulus (small network of Consists of glomerulus (small network of

capillaries enclosed in a Bowman’s capillaries enclosed in a Bowman’s capsule).capsule).

Fluids from blood in the glomerulus is Fluids from blood in the glomerulus is collected in the Bowman’s capsule to collected in the Bowman’s capsule to form ‘glomerulus filtrate.form ‘glomerulus filtrate.

This is then further processed along the This is then further processed along the nephron to form urine.nephron to form urine.

Renal CorpuscleRenal Corpuscle

Glomerular CapsuleGlomerular Capsule

Not everything can pass throughNot everything can pass through What fits through?What fits through?

Na+, K+, Ca2+, Mg2+, Cl-, S04-, P042-Na+, K+, Ca2+, Mg2+, Cl-, S04-, P042- Hc03 and H+Hc03 and H+ Nutrients such as monomersNutrients such as monomers Wastes (nitrogenous wastes)Wastes (nitrogenous wastes) Small hormones Small hormones WATER!!!WATER!!!

Glomerular CapsuleGlomerular Capsule

What doesn’t fit through??What doesn’t fit through?? CellsCells Plasma proteinsPlasma proteins

Glomerular Filtration Rate Glomerular Filtration Rate (GFR)(GFR)

The speed with which we pass our blood The speed with which we pass our blood through our kidneys and filter it is through our kidneys and filter it is proportional to how well we can clean proportional to how well we can clean our blood. our blood.

Speed of filtration is the GFRSpeed of filtration is the GFR In one minute both kidneys using all In one minute both kidneys using all

their nephrons can filter their nephrons can filter 125ml/min=180 liters/day!!125ml/min=180 liters/day!!

We have on average 5 liters of blood in We have on average 5 liters of blood in our bodiesour bodies

Glomerular Filtration RateGlomerular Filtration Rate

Amount of filtration changes with Amount of filtration changes with blood pressureblood pressure

Built in regulatory systemBuilt in regulatory system

Glomerular Filtration Rate Glomerular Filtration Rate PressuresPressures

Out of the Blood (into the capsule)Out of the Blood (into the capsule)• Blood Pressure=60mm HgBlood Pressure=60mm Hg

Into the Blood (Out of the Capsule)Into the Blood (Out of the Capsule)• Osmotic Pressure=32mm HgOsmotic Pressure=32mm Hg• Capsular hydrostatic Capsular hydrostatic

pressure=18mm Hgpressure=18mm Hg

Glomerular Filtration RateGlomerular Filtration Rate

Net pressure on fluids within the Net pressure on fluids within the renal corpuscle.renal corpuscle.

60 mm Hg- (32 mm Hg + 18 mm Hg)= 10 mm 60 mm Hg- (32 mm Hg + 18 mm Hg)= 10 mm HgHg

Therefore, in the renal corpuscle, the Therefore, in the renal corpuscle, the net force on fluids is OUT of the blood net force on fluids is OUT of the blood (into the capsule) and this is called (into the capsule) and this is called the the filtration pressure filtration pressure

Specialized Cells of the Specialized Cells of the Proximal Convoluted Proximal Convoluted TubuleTubule

• Brush boarder cells

• Large surface area allowing for reabsorption of the filtrate into the blood stream

Key Feature: Highly permeable to water & many solutes

Specialized Cells of the Specialized Cells of the Descending Loop of HenleDescending Loop of Henle

•Simple squamous epithelial cells that lack brush boarders

•Small surface area resulting in a decrease in the amount of filtrate reabsorbed into the blood stream

Key feature: Highly permeable to water but not solutes

Ascending Loop of Ascending Loop of HenleHenle

Similar to those of the PCT except fewer Similar to those of the PCT except fewer microvillimicrovilli

Key featureKey feature: Highly permeable to solutes : Highly permeable to solutes (particularly sodium chloride), not (particularly sodium chloride), not permeablepermeable

to waterto water

Juxtaglomerular Juxtaglomerular ApparatusApparatus

Endocrine structure that secretes the hormones Endocrine structure that secretes the hormones erythropoietin and reninerythropoietin and renin

Key Feature: Key Feature: Renin triggers angiotensin to turn into Renin triggers angiotensin to turn into angiotensin I which turns to angiotensin II which angiotensin I which turns to angiotensin II which constricts the walls of arteries to increase BPconstricts the walls of arteries to increase BP

Erythopoietin stimulates the production of RBC Erythopoietin stimulates the production of RBC when kidneys are exposed to low O2 when kidneys are exposed to low O2 concentrationsconcentrations

Renin-Angiotensin SystemRenin-Angiotensin System

Specialized Cells of the Specialized Cells of the Late Distal Convoluted Late Distal Convoluted TubuleTubule

Cuboidal cells that fall into two Cuboidal cells that fall into two distinct regions, principle cells and distinct regions, principle cells and intercalated cellsintercalated cells

Key feature (principle cells):Key feature (principle cells): Permeable to water & solutes and Permeable to water & solutes and regulated by hormonesregulated by hormones

Key feature (intercalated cells):Key feature (intercalated cells): Involved in the secretion of H ions Involved in the secretion of H ions for acid/base balancefor acid/base balance

Specialized Cells of the Specialized Cells of the Medullary Collecting DuctMedullary Collecting Duct

Cuboidal cellsCuboidal cells Key feature:Key feature: Hormonally Hormonally

regulated permeability to regulated permeability to water and ureawater and urea

Normal Kidney Function Normal Kidney Function SummarySummary

Maintain HomeostasisMaintain Homeostasis How does it do this….How does it do this….

10 Functions of the 10 Functions of the Kidney’sKidney’s

Urine FormationUrine Formation: Formed in the nephrons through a : Formed in the nephrons through a complex three-step process: GF, tubular reabsorption, complex three-step process: GF, tubular reabsorption, and tubular secretion and tubular secretion

Excretion of waste productsExcretion of waste products: eliminates the body’s : eliminates the body’s metabolic waste products (urea, creatinine, metabolic waste products (urea, creatinine, phosphates, sulfates)phosphates, sulfates)

Regulation of electrolytesRegulation of electrolytes: volume of electrolytes : volume of electrolytes excreted per day is exactly equal to the volume excreted per day is exactly equal to the volume ingested ingested Na – Na – allows the kidney to regulate the volume of body fluids, allows the kidney to regulate the volume of body fluids,

dependent on aldosterone (fosters renal reabsorption of Na)dependent on aldosterone (fosters renal reabsorption of Na) K – K – kidneys are responsible for excreting more than 90% of kidneys are responsible for excreting more than 90% of

total daily intaketotal daily intake RETENTION OF K IS THE MOST LIFE-THREATENING EFFECT RETENTION OF K IS THE MOST LIFE-THREATENING EFFECT

OF RENAL FAILUREOF RENAL FAILURE

Kidney Function con’tdKidney Function con’td Regulation of acid-base balance: Regulation of acid-base balance:

elimination of sulphuric and phosphoric elimination of sulphuric and phosphoric acidacid

Kidney function cont’dKidney function cont’d

Control of water balance: Control of water balance: Normal ingestion Normal ingestion of water daily is 1-2L and normally all but 400-of water daily is 1-2L and normally all but 400-500mL is excreted in the urine500mL is excreted in the urine Osmolality: Osmolality: degree of dilution or concentration of degree of dilution or concentration of

urine (#particles dissolved/kg urine (glucose & urine (#particles dissolved/kg urine (glucose & proteins are osmotically active agents)proteins are osmotically active agents)

Specific Gravity:Specific Gravity: measurement of the kidney’s measurement of the kidney’s ability to concentrate urine (weight of particles to the ability to concentrate urine (weight of particles to the weight of distilled water)weight of distilled water)

ADHADH: vasopressin – regulates water excretion and : vasopressin – regulates water excretion and urine concentration in the tubule by varying the urine concentration in the tubule by varying the amount of water reabsorbed.amount of water reabsorbed.

Still talking about kidney Still talking about kidney function…function… Control of blood pressureControl of blood pressure: BP monitored by the vasa : BP monitored by the vasa

recta. recta. Juxtaglomerular cells, afferent arteriole, distal tubule, Juxtaglomerular cells, afferent arteriole, distal tubule,

efferent arterioleefferent arteriole Renal clearanceRenal clearance: ability to clear solutes from plasma: ability to clear solutes from plasma

Dependent on… rate of filtration across the glomerulus, Dependent on… rate of filtration across the glomerulus, amount reabsorbed in the tubules, amount secreted into amount reabsorbed in the tubules, amount secreted into the tubulesthe tubules

Regulation of red blood cell productionRegulation of red blood cell production: Erythropoeitin : Erythropoeitin is released in response to decreased oxygen tension in is released in response to decreased oxygen tension in renal blood flow. This stimulates the productions of RBCs renal blood flow. This stimulates the productions of RBCs (increases amount of hemoglobin available to carry oxygen)(increases amount of hemoglobin available to carry oxygen)

Kidney function cont’dKidney function cont’d

Synthesis of vitamin D to active form: Synthesis of vitamin D to active form: final conversion of vit D into active form to final conversion of vit D into active form to maintain Ca balancemaintain Ca balance

Secretion of prostaglandins: Secretion of prostaglandins: important in important in maintaining renal blood flow (PGE & PGI). maintaining renal blood flow (PGE & PGI). They have a vasodilatory effectThey have a vasodilatory effect

Timeline of EventsTimeline of Events

PIH HELLP EMERGENCY C-SECTION

HEMORRHAGE

HYPOVOLEMIAHYPOVOLEMIC SHOCK

ACUTE RENAL FAILUREACUTE RENAL FAILURE

HELLPHELLP SYNDROME SYNDROME A syndrome featuring a combination of "H" for A syndrome featuring a combination of "H" for

hemolysishemolysis (breakage of red blood cells), "EL" for (breakage of red blood cells), "EL" for elevated liver enzymeselevated liver enzymes, and "LP" for , and "LP" for low platelet countlow platelet count (an essential blood clotting element).(an essential blood clotting element).

PREGNANCY COMPLICATION - occurring in PREGNANCY COMPLICATION - occurring in 25%25% of of pregnancies with toxemia or pre-eclampsia.pregnancies with toxemia or pre-eclampsia.

SymptomsSymptoms include- include- Shortness of breathShortness of breath H/AH/A Dimmed visionDimmed vision NauseaNausea Dizziness & FaintingDizziness & Fainting EdemaEdema Pain in the upper abdomenPain in the upper abdomen

Effects of Effects of HELLPHELLP on Mom & on Mom & BabyBaby

Mothers with HELLP are at increased Mothers with HELLP are at increased risk for:risk for: Liver rupture, DIC, abruptio placentae, and Liver rupture, DIC, abruptio placentae, and acute acute

renal failurerenal failure, stroke, seizure, ARD, pulmonary , stroke, seizure, ARD, pulmonary edemaedema

11stst order of tx is management of blood clotting order of tx is management of blood clotting issuesissues

Women with a hx of HELLP are considered at risk Women with a hx of HELLP are considered at risk for future pregnanciesfor future pregnancies

After delivery, mothers vitals are CLOSELY After delivery, mothers vitals are CLOSELY monitored to observe for complicationsmonitored to observe for complications

NURSING PROCESSNURSING PROCESS

Acute Renal FailureAcute Renal Failure

Definition:Definition:

“ “Acute Renal Failure is an abrupt Acute Renal Failure is an abrupt reduction in renal function.” reduction in renal function.”

Acute Renal FailureAcute Renal Failure

Three Stages to Renal FailureThree Stages to Renal Failure 1) Prerenal acute renal failure1) Prerenal acute renal failure 2) Intrarenal acute renal failure2) Intrarenal acute renal failure 3) Postrenal acute renal failure3) Postrenal acute renal failure

PathophysiologyPathophysiology

ARF may occur in 3 clinical settings:ARF may occur in 3 clinical settings: As an adaptive response to severe volume As an adaptive response to severe volume

depletion and hypotension, with depletion and hypotension, with structurally and functionally intact structurally and functionally intact nephrons nephrons (Prerenal)(Prerenal)

In response to cytotoxic or ischemic In response to cytotoxic or ischemic insults to the kidney, with structural and insults to the kidney, with structural and functional damage functional damage (Intrinsic or Intrarenal)(Intrinsic or Intrarenal)

Obstruction to the passage of urine Obstruction to the passage of urine (Postrenal)(Postrenal)

Acute Renal Failure: Classification

Prerenal Acute Renal Prerenal Acute Renal FailureFailure

60-70% of patients with Acute Renal 60-70% of patients with Acute Renal Failure are Prerenal.Failure are Prerenal.

GFR declines because of the decrease in GFR declines because of the decrease in filtration pressure. filtration pressure.

Poor perfusion results from renal Poor perfusion results from renal vasoconstriction, hypotension, vasoconstriction, hypotension, hypovolemiahypovolemia

Failure to restore blood volume or blood Failure to restore blood volume or blood pressure may cause acute tubular pressure may cause acute tubular necrosis or acute cortical necrosis. necrosis or acute cortical necrosis.

Prerenal acute renal Prerenal acute renal failurefailure

It is caused by impaired blood flow as a It is caused by impaired blood flow as a result of intravascular depletion, which result of intravascular depletion, which leads to decreased effective circulating leads to decreased effective circulating volume to the kidneys volume to the kidneys

In patients with prerenal ARF, the In patients with prerenal ARF, the parenchymal is undamaged, and the parenchymal is undamaged, and the kidneys respond as if volume depletion kidneys respond as if volume depletion has occurred. has occurred.

Prerenal ARFPrerenal ARF Causes include:Causes include:

Secondary to renal hypoperfusion which occurs in Secondary to renal hypoperfusion which occurs in setting of extracellular fluid losssetting of extracellular fluid loss

DiarrheaDiarrhea Vomiting Vomiting DiureticsDiuretics

Impaired/inadequate cardiac outputImpaired/inadequate cardiac output Drugs Drugs

NSAIDsNSAIDs ACE InhibitorsACE Inhibitors

HypovolemiaHypovolemia HemorrhageHemorrhage Renal vasoconstrictionRenal vasoconstriction

Intrarenal ARFIntrarenal ARF

May result from: Acute tubular May result from: Acute tubular necrosis (ATN), cortical necrosis, necrosis (ATN), cortical necrosis, acute glomerulonephritis, drug acute glomerulonephritis, drug allergy, .allergy, .

ATN caused by ischemia occurs most ATN caused by ischemia occurs most commonly after surgery (40%-50%)commonly after surgery (40%-50%)

ATN also caused by sepsis, severe ATN also caused by sepsis, severe burns, or traumaburns, or trauma

Can be caused by antibioticsCan be caused by antibiotics

Intrinsic acute renal failureIntrinsic acute renal failure

Is the result of actual parenchymal Is the result of actual parenchymal damage to the glomeruli or kidney damage to the glomeruli or kidney tubulestubules

A physiologic hallmark is failure to A physiologic hallmark is failure to maximally concentrate urinemaximally concentrate urine

Is divided into 4 categories:Is divided into 4 categories: Acute tubular disease Acute tubular disease Glomerular diseaseGlomerular disease Vascular diseaseVascular disease Interstitial diseaseInterstitial disease

Intrinsic ARFIntrinsic ARF Acute Tubular NecrosisAcute Tubular Necrosis

most common type of ARF, a more ischemic insult most common type of ARF, a more ischemic insult to the kidneys, usually induced by ischemia or to the kidneys, usually induced by ischemia or toxinstoxins

Caused by:Caused by: Burns, and crush injuries – myoglobin & hemoglobin Burns, and crush injuries – myoglobin & hemoglobin

are liberated causing renal toxicity or ischemiaare liberated causing renal toxicity or ischemia Drugs – NSAIDs, ACE inhibitors, aminoglycosidesDrugs – NSAIDs, ACE inhibitors, aminoglycosides InfectionsInfections Nephrotoxic agents – contrast agentNephrotoxic agents – contrast agent

Glomerulonephritis Glomerulonephritis uncommon cause, most associated with CRFuncommon cause, most associated with CRF Caused by:Caused by:

Can be a primary disorder or can occur secondary to Can be a primary disorder or can occur secondary to systemic diseasesystemic disease

Systemic lupus erythematosusSystemic lupus erythematosus

Intrinsic ARFIntrinsic ARF

Vascular DiseaseVascular Disease Can occur on microvascular and macrovascularCan occur on microvascular and macrovascular Caused by:Caused by:

Microvascular Microvascular – Hemolytic anemiaHemolytic anemia– ARF secondary to small vessel thrombosis or occlusionARF secondary to small vessel thrombosis or occlusion

MacrovascularMacrovascular– Suspected in elderlySuspected in elderly– Renal artery stenosis or thrombosisRenal artery stenosis or thrombosis– Atheroembolism secondary to atrial fibrillation and aortic Atheroembolism secondary to atrial fibrillation and aortic

diseasedisease Acute Interstitial NephritisAcute Interstitial Nephritis

Interstitial disturbance that leads to ARFInterstitial disturbance that leads to ARF Caused by:Caused by:

Allergic reaction to drugsAllergic reaction to drugs

Postrenal acute renal Postrenal acute renal failurefailure

Is rare and occurs with urinary Is rare and occurs with urinary tract obstruction that affects the tract obstruction that affects the kidneys bilaterallykidneys bilaterally

Pressure rises Pressure rises in the kidney in the kidney tubules, tubules, eventually the eventually the GFR decreases GFR decreases

Postrenal ARFPostrenal ARF

Causes include:Causes include: Bladder tract Bladder tract

obstructionobstruction Prostatic hypertrophyProstatic hypertrophy CathetersCatheters Neurogenic bladderNeurogenic bladder

Postrenal causes are typically Postrenal causes are typically reversiblereversible

Clinical Manifestations of Clinical Manifestations of ARFARF

CardiovascularCardiovascular ArrhythmiasArrhythmias BP, N, high or lowBP, N, high or low AnemiaAnemia P, rapid, bounding, or NP, rapid, bounding, or N Pericardial-type chest painPericardial-type chest pain

RespiratoryRespiratory DyspneaDyspnea CracklesCrackles TachypneaTachypnea Kussmaul’s respirationsKussmaul’s respirations

Mental StatusMental Status LethargyLethargy TremorsTremors Memory lossMemory loss ConfusionConfusion

MusculoskeletalMusculoskeletal Muscle spasmsMuscle spasms WeaknessWeakness

GenitourinaryGenitourinary OliguriaOliguria AnuriaAnuria abN urine colour, clarity, smellabN urine colour, clarity, smell

GIGI Moist tongue & increased Moist tongue & increased

saliva saliva Dry tongue & mucous Dry tongue & mucous

membranesmembranes N&VN&V

IntegumentaryIntegumentary Moist, warm skin & pitting Moist, warm skin & pitting

edemaedema Decreased skin turgorDecreased skin turgor bruisesbruises PallorPallor Thin, brittle hair & nailsThin, brittle hair & nails

Nursing Care PlanNursing Care Plan

Fluid volume deficit related to Fluid volume deficit related to hemorrhage (hypovolemic shock)hemorrhage (hypovolemic shock) Priority to restore fluid balance and circulationPriority to restore fluid balance and circulation

The patient will: The patient will: show stable vital signsshow stable vital signs have adequate urine output >30cc/hrhave adequate urine output >30cc/hr have strong peripheral pulses indicating have strong peripheral pulses indicating

tissue perfusiontissue perfusion display LOC normal for patientdisplay LOC normal for patient

Nursing Care PlanNursing Care Plan InterventionsInterventions

Bleeding reduction, fluid Bleeding reduction, fluid resuscitation, blood resuscitation, blood product administration, product administration, IV therapyIV therapy

Monitor VS q2hMonitor VS q2h Monitor weight dailyMonitor weight daily Skin & tongue turgorSkin & tongue turgor Monitor and document Monitor and document

I&OI&O Monitor CBC, ABG, Monitor CBC, ABG,

urinalysis, ECG urinalysis, ECG

RationalesRationales Early intervention can Early intervention can

prevent progression of prevent progression of hypovolemia to hypovolemia to hypovolemic shock that hypovolemic shock that may result in renal damage may result in renal damage

S&S correlate with the S&S correlate with the approximate percentage of approximate percentage of volume lossvolume loss

Medullary vasomotor center Medullary vasomotor center stimulation via the stimulation via the baroreceptor reflex baroreceptor reflex

ADHADH Foley catheter facilitates Foley catheter facilitates

monitoring of urine outputmonitoring of urine output Shock pt hemodynamically Shock pt hemodynamically

unstable with compromised unstable with compromised compensatory mechanisms, compensatory mechanisms, volume admin may cause volume admin may cause fld overloadfld overload

Nursing Care PlanNursing Care Plan

Electrolyte imbalance related to Electrolyte imbalance related to decreased electrolyte excretion, and decreased electrolyte excretion, and metabolic acidosismetabolic acidosis Priority to prevent complications of Priority to prevent complications of

electrolyte imbalance electrolyte imbalance Within 24h of admission and then Within 24h of admission and then

continuously, the pt will:continuously, the pt will: Maintain serum electrolyte levels within Maintain serum electrolyte levels within

acceptable limitsacceptable limits Have normal sinus rhythmHave normal sinus rhythm

Nursing Care PlanNursing Care Plan InterventionsInterventions

Monitor & document Monitor & document electrolyte levels q8-electrolyte levels q8-12h, especially:12h, especially:

K+, P, Ca, MgK+, P, Ca, Mg Monitor ABGMonitor ABG Monitor ECG especially:Monitor ECG especially:

High tented T waves, High tented T waves, prolonged PR interval or prolonged PR interval or widened QRS complexwidened QRS complex

Limit dietary & drug Limit dietary & drug intake of potassiumintake of potassium

RationalesRationales Kidneys’ ability to regulate Kidneys’ ability to regulate

electrolyte excretion & electrolyte excretion & reabsorption may result in reabsorption may result in high K+ & P, low Ca, & high K+ & P, low Ca, & high/low Mg levels. high/low Mg levels.

ARF causes metabolic ARF causes metabolic acidosis which may increase acidosis which may increase the release of K+ from cells the release of K+ from cells in exchange for H+ ionsin exchange for H+ ions

Electrolyte abN can trigger Electrolyte abN can trigger arrhythmias & cardiac arrestarrhythmias & cardiac arrest

When kidneys cannot When kidneys cannot excrete K+, excess intake excrete K+, excess intake can increase serum K+ to can increase serum K+ to dangerous levelsdangerous levels

Nursing Care PlanNursing Care Plan Knowledge deficit of acute renal failure Knowledge deficit of acute renal failure

related to lack of exposure to related to lack of exposure to information on management of information on management of complex conditioncomplex condition Priority to provide in depth information on acute Priority to provide in depth information on acute

renal failurerenal failure Upon discharge the patient will:Upon discharge the patient will:

Be able to identify signs and symptoms to report Be able to identify signs and symptoms to report to nurse or physicianto nurse or physician

Commitment to comply with treatments, Commitment to comply with treatments, including dialysis, dietary modifications, and including dialysis, dietary modifications, and activity restrictionsactivity restrictions

Nursing Care PlanNursing Care Plan InterventionsInterventions

Provide as appropriate Provide as appropriate information on the severity information on the severity of ARF & dialysisof ARF & dialysis

Stages of ARFStages of ARF Medications including Medications including

action and adverse effectsaction and adverse effects S&SS&S Procedures such as Procedures such as

dialysis including dialysis including schedule and adverse schedule and adverse effectseffects

Dietary modifications Dietary modifications including limitations of including limitations of proteins (catabolism), proteins (catabolism), electrolytes and fluidselectrolytes and fluids

Rest and activity Rest and activity restrictionsrestrictions

RationalesRationales The patient and family The patient and family

need assistance, need assistance, explanation, and support explanation, and support during this time. during this time.

Teaching may decrease Teaching may decrease anxiety and fear, and anxiety and fear, and enhance recovery to enhance recovery to patient and family patient and family members.members.

Continued assessment Continued assessment of the patient for of the patient for complications of ARF complications of ARF and of its precipitating and of its precipitating cause is essential.cause is essential.

Diagnostic Diagnostic TestingTesting

Measuring kidney Measuring kidney functionfunction

Diagnostic ToolsDiagnostic Tools

UrinalysisUrinalysis Blood WorkBlood Work X-rayX-ray Urogram (intravenious pyelogram)Urogram (intravenious pyelogram) UltrasoundUltrasound DopplerDoppler ScopesScopes BiopsiesBiopsies

The UrinalysisThe UrinalysisAlso called a routine UA (urinalysis)- gross and Also called a routine UA (urinalysis)- gross and

microscopic examination of urine to determine pH, microscopic examination of urine to determine pH, gravity and substancegravity and substance

Gross Assessment- appearance and odor of the urineGross Assessment- appearance and odor of the urine

Microscopic Assessment- bacteria, RBC, WBC, crystals, Microscopic Assessment- bacteria, RBC, WBC, crystals, casts.casts.

Normal Findings of Urinalysis:

pH- 4.5-8.0

Gravity-1.001 to 1.030

Protein- Negative

RBC/WBC- Negative

Glucose- Negative

Ketones- Negative

Nitrates- Negative

The UrinalysisThe Urinalysis Normal Normal

inorganic material such as NA+, Cl-, Mg+, SO4-, PO4-, and inorganic material such as NA+, Cl-, Mg+, SO4-, PO4-, and NH4+ and organic materials such as urea, creatinine, and NH4+ and organic materials such as urea, creatinine, and uric acid in the urine. uric acid in the urine.

Abnormal Abnormal RBCs, WBCs, bacteria protein, glucose, ketonesRBCs, WBCs, bacteria protein, glucose, ketones

Urinalysis involves evaluation of color, turbidity, Urinalysis involves evaluation of color, turbidity, protein, pH, specific gravity, sedimentprotein, pH, specific gravity, sediment

Presence of bacteria, RBCs, WBCs, casts or crystals Presence of bacteria, RBCs, WBCs, casts or crystals in the urine sediment may indicate a renal disorder.in the urine sediment may indicate a renal disorder.

Assessing UrineAssessing Urine The first morning void is considered ideal The first morning void is considered ideal

as it has the greatest concentration and as it has the greatest concentration and lowest pH (maximizing the ability to lowest pH (maximizing the ability to detect formed elements).detect formed elements).

A regular void (with appropriate washing A regular void (with appropriate washing of the genitals) is usually satisfactory.of the genitals) is usually satisfactory.

A midstream or catheterized specimen is A midstream or catheterized specimen is more appropriate for culture and bacteria more appropriate for culture and bacteria count.count.

Assessing BloodAssessing Blood

Why assess the blood?Why assess the blood? Electrolyte balanceElectrolyte balance Acid-base homeostasisAcid-base homeostasis Regulates serum concentrations of Regulates serum concentrations of

BUN and CreatinineBUN and Creatinine Produce erythropoietinProduce erythropoietin

BUN, creatinine, creatinine BUN, creatinine, creatinine clearance presentation by studentsclearance presentation by students

Normal Blood and Serum Lab Values

Sodium 135- 145 mEq/L

Potassium 3.5- 5.3 mEq/L

Chloride 98- 106 mEq/L

BUN 10- 20mg/dL

Creatinine 60-110 umol/L (Female)

70-120 umol/L (Male)

Phosphorus 0.8- 1.4 mmol/L

Calcium 2.0- 2.6 mmol/L

Magnesium 1.6- 2.6 mg/dL

Hemoglobin 120-140g/L (Female)

140-160g/L (Male)

Lab Tests for Renal Function:Lab Tests for Renal Function:Blood TestsBlood Tests Blood Urea NitrogenBlood Urea Nitrogen

Measures the Measures the concentration of urea in concentration of urea in the bloodthe blood

Urea is formed from Urea is formed from protein metabolism and is protein metabolism and is elevated when glomerular elevated when glomerular filtration is reducedfiltration is reduced

BUN rises in states of BUN rises in states of dehydration and acute dehydration and acute chronic renal failure chronic renal failure because passage through because passage through tubules is slowedtubules is slowed

Serum Creatinine Serum Creatinine LevelLevel Should be a stable valueShould be a stable value When creatinine levels When creatinine levels

rise and accumulate in rise and accumulate in the plasma:the plasma:

Double Double renal renal function is about half function is about half of Normalof Normal

Tripled Tripled ~ 75% of RF ~ 75% of RF is lostis lost

Represents a decrease in GRF

Estimating GFR and Creatinine Estimating GFR and Creatinine ClearanceClearance

GFR- Filtration rate/min at the glomerulus. GFR- Filtration rate/min at the glomerulus.

170 x Serum Creatinine concentration^-0.999170 x Serum Creatinine concentration^-0.999 X age^-0.176X age^-0.176 X 0.762 (if female)X 0.762 (if female) X 1.18 (if race is African)X 1.18 (if race is African) X blood urea nitrogen concentration^-0.17X blood urea nitrogen concentration^-0.17 X serum albumin concentration^-0.318X serum albumin concentration^-0.318 = GRF in Adults= GRF in Adults

Creatinine Clearance- The clearance rate in mL/min Creatinine Clearance- The clearance rate in mL/min of the waste product creatinine.of the waste product creatinine.

0.55 x Length/ Serum Creatinine0.55 x Length/ Serum Creatinine

INTERVENTIONINTERVENTION

Medications for ARFMedications for ARF

Pharmacologic treatment of ARF has been Pharmacologic treatment of ARF has been attempted on an empirical basis, with attempted on an empirical basis, with varying success rates. Several promising varying success rates. Several promising experimental therapies in animal models experimental therapies in animal models are awaiting human trialsare awaiting human trials

It is critical to adjust (decrease or It is critical to adjust (decrease or discontinue) medication dosages for patient discontinue) medication dosages for patient in acute renal failure. Administering the in acute renal failure. Administering the average dose to patient in renal failure can average dose to patient in renal failure can kill a patient.kill a patient.

Medications for ARF Medications for ARF continuedcontinued

Immediate goal is to retain fluid volume deficit Immediate goal is to retain fluid volume deficit through use of blood products and crystalloidsthrough use of blood products and crystalloids

Normal Saline (0.9% Na)Normal Saline (0.9% Na) – only one that is – only one that is compatible with blood transfusionscompatible with blood transfusions Restores fluid lossRestores fluid loss Provides electrolytes resembling those of plasmaProvides electrolytes resembling those of plasma

Packed RBCPacked RBC To increase blood volumeTo increase blood volume To restore blood to kidneysTo restore blood to kidneys

Medications for ARF Medications for ARF continuedcontinued

Diuretics Diuretics Furosemide (Lasix) only given with severe Furosemide (Lasix) only given with severe fluid overloadfluid overload

Increases excretion of water by interfering with Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the thick inhibits sodium and chloride reabsorption in the thick ascending loop of Henle and the distal renal tubule ascending loop of Henle and the distal renal tubule

Adult dose: 20-80 mg PO/IV once; repeat 6-8h Adult dose: 20-80 mg PO/IV once; repeat 6-8h prn or dose may be increased by 20-40 mg no prn or dose may be increased by 20-40 mg no sooner than 6- 8h after previous dose until sooner than 6- 8h after previous dose until desired effectdesired effectNursing Assessments: Watch for hypokalemia, Nursing Assessments: Watch for hypokalemia, assess BP before and during therapy can cause assess BP before and during therapy can cause hypotensionhypotension

Medications for ARF Medications for ARF continuedcontinued

Vasodilators Vasodilators Dopamine Dopamine

In small doses causes selective dilatation of the renal In small doses causes selective dilatation of the renal vasculature, enhancing renal perfusion. vasculature, enhancing renal perfusion.

Reduces sodium absorption, thereby decreasing the Reduces sodium absorption, thereby decreasing the energy requirement of the tubules. This enhances energy requirement of the tubules. This enhances urine flow, which, in turn, helps prevent tubular cast urine flow, which, in turn, helps prevent tubular cast obstruction. obstruction.

Adult dose: 2-5 mcg/kg/minAdult dose: 2-5 mcg/kg/min Nursing Assessments: Monitor BP during Nursing Assessments: Monitor BP during

administration, stop infusion if BP drops 30mm administration, stop infusion if BP drops 30mm Hg, Monitor I&OHg, Monitor I&O

Medications for ARF Medications for ARF continuedcontinued

AlkalinizerAlkalinizer Sodium BicarbonateSodium Bicarbonate Increases plasma bicarbonate, which buffers Hydrogen Increases plasma bicarbonate, which buffers Hydrogen

ion concentration; reverses acidosision concentration; reverses acidosis Adult Dose: Initial dose IV bolus 1 mEq/kg, then infuse Adult Dose: Initial dose IV bolus 1 mEq/kg, then infuse

2-5 mEq/kg over 4-8 hr depending on CO2, pH2-5 mEq/kg over 4-8 hr depending on CO2, pH Dilute with equal amounts of NS, 2-5 mEq/kgDilute with equal amounts of NS, 2-5 mEq/kg

Nursing assessments: Assess resp. and pulse Nursing assessments: Assess resp. and pulse rate, rhythm, depth, lung sounds, monitor rate, rhythm, depth, lung sounds, monitor I&O, electrolytes, blood pH, PO2, HCO3, I&O, electrolytes, blood pH, PO2, HCO3, monitor urine pH, and UO during beginning of monitor urine pH, and UO during beginning of treatment, monitor for alkalosis, monitor treatment, monitor for alkalosis, monitor ABGs and blood studiesABGs and blood studies

13 13 have passed and now Tia have passed and now Tia is diagnosed withis diagnosed with……

Chronic Renal FailureChronic Renal Failure 13 years have passed 13 years have passed Tia is now 39 years of Tia is now 39 years of

age and has been experiencing declining renal age and has been experiencing declining renal function over the past 13 years. Tia has lost function over the past 13 years. Tia has lost 15lbs on her already small frame, she feels 15lbs on her already small frame, she feels generally ill most of the time with frequent generally ill most of the time with frequent N&V, she suffers from fatigue, muscle twitching N&V, she suffers from fatigue, muscle twitching & cramps decreased sensation in her hands and & cramps decreased sensation in her hands and feet and generalized puritus. The Physician has feet and generalized puritus. The Physician has diagnosed Tia with ESRD and has determined diagnosed Tia with ESRD and has determined that long term dialysis will be required.that long term dialysis will be required.

Chronic Renal FailureChronic Renal Failure

ESRFESRF

DefinitionDefinition

Also known as End-Stage Renal Failure Also known as End-Stage Renal Failure (ESRF), is a progressive deterioration in (ESRF), is a progressive deterioration in renal function in which the body’s ability to renal function in which the body’s ability to maintain metabolic and fluid and maintain metabolic and fluid and electrolyte balance fails, resulting in electrolyte balance fails, resulting in uremia (retention of urea and other uremia (retention of urea and other nitrogenous wastes in the blood).nitrogenous wastes in the blood).

decreased kidney glomerular filtration rate decreased kidney glomerular filtration rate (GFR) of <60 mL/min/1.73 m2 for 3 or (GFR) of <60 mL/min/1.73 m2 for 3 or more months more months

Alterations-Acute Renal Alterations-Acute Renal FailureFailureRenal Impairment50% of Normal

GFR- 50mL/Min

Serum Creatinine: less than 2 mg/dL

BUN: High normal

Renal Insufficiency25% of Normal

GFR 25-40mL/min

Serum Creatinine: 1.5-3.0 mg/dL

(mildly elevated)

BUN: Mild azotemia

Renal Failure< 20% of renal fcn remains

GFR < 25mL/min

Serum Creatinine: > than 3.0 mg/dL

Electrolyte imbalances

End stage renal disease (ESRD)< 10% of renal fcn remains

GFR < 10 mL/min

Creatinine and BUN: marked increase

Electrolyte imbalances

Acidosis

StatisticsStatistics In the U.S. In the U.S. The US Renal Data System (USRDS) The US Renal Data System (USRDS)

has shown a dramatic increase in patients with has shown a dramatic increase in patients with CRF who require chronic dialysis or CRF who require chronic dialysis or transplantation. In 1999, there were 340,000 such transplantation. In 1999, there were 340,000 such patients, but, by 2010, this number is projected to patients, but, by 2010, this number is projected to reach 651,000. reach 651,000.

Internationally: Internationally: The incidence rates of end-The incidence rates of end-stage renal disease (ESRD) have increased steadily stage renal disease (ESRD) have increased steadily internationally since 1989. The United States has internationally since 1989. The United States has the highest incident rate of ESRD, followed by the highest incident rate of ESRD, followed by Japan. Japan has the highest prevalence per million Japan. Japan has the highest prevalence per million population, with the United States taking second population, with the United States taking second place. place.

Statistics Cont’dStatistics Cont’d

Mortality /Morbidity: Mortality /Morbidity: CRF is a major CRF is a major cause of morbidity and mortality, particularly cause of morbidity and mortality, particularly at the later stages. The 5-year survival rate for at the later stages. The 5-year survival rate for a patient undergoing chronic dialysis is a patient undergoing chronic dialysis is approximately 35%. This is approximately 25% approximately 35%. This is approximately 25% in patients with diabetes. The most common in patients with diabetes. The most common cause of death in the dialysis population is cause of death in the dialysis population is cardiovascular disease. cardiovascular disease.

Race: Race: Affects all racesAffects all races

Chronic Renal Failure

“Slow, progressive, (months to years) irreversible loss of renal function.”

PathophysiologyPathophysiology As renal function declines, the end products of protein As renal function declines, the end products of protein

metabolism (which are normally excreted in the urine), metabolism (which are normally excreted in the urine), accumulate in the blood. Uremia develops and adversely effects accumulate in the blood. Uremia develops and adversely effects every system in the body. every system in the body.

The greater the buildup of waste products, the more severe the The greater the buildup of waste products, the more severe the symptoms.symptoms.

Approximately 1 million nephrons are present in each kidney, Approximately 1 million nephrons are present in each kidney, each contributing to the total GFR. Regardless of the etiology of each contributing to the total GFR. Regardless of the etiology of renal injury, with progressive destruction of nephrons, the kidney renal injury, with progressive destruction of nephrons, the kidney has an innate ability to maintain GFR by hyperfiltration and has an innate ability to maintain GFR by hyperfiltration and compensatory hypertrophy of the remaining healthy nephrons.compensatory hypertrophy of the remaining healthy nephrons.

This nephron adaptability allows for continued normal clearance This nephron adaptability allows for continued normal clearance of plasma solutes such that substances such as urea and of plasma solutes such that substances such as urea and creatinine start to show significant increases in plasma levels only creatinine start to show significant increases in plasma levels only after total GFR has decreased to 50%, when the renal reserve has after total GFR has decreased to 50%, when the renal reserve has been exhausted. The plasma creatinine value will double with a been exhausted. The plasma creatinine value will double with a 50% reduction in GFR. 50% reduction in GFR.

Stages of Chronic Renal Stages of Chronic Renal DiseaseDisease

3 stages in nephron function3 stages in nephron function

Stage 1: Reduced Renal ReserveStage 1: Reduced Renal Reserve Characterized by a 40%-75% loss of Characterized by a 40%-75% loss of

nephron funtion. The patient is usually nephron funtion. The patient is usually asymptomatic because the remaining asymptomatic because the remaining nephrons are able to carry out normal nephrons are able to carry out normal function of the kidneyfunction of the kidney

Stage 2 of Renal DiseaseStage 2 of Renal Disease

Stage 2: Renal Insufficiency Stage 2: Renal Insufficiency Occurs when 75%-90% of nephron Occurs when 75%-90% of nephron

function is lost. At this point, the serum function is lost. At this point, the serum creatinine and BUN rise, the kidney creatinine and BUN rise, the kidney loses its ability to concentrate urine and loses its ability to concentrate urine and anemia develops. The patient may anemia develops. The patient may report polyuria and nocturiareport polyuria and nocturia

Stage 3 of Renal DiseaseStage 3 of Renal Disease

Stage 3: End-Stage Renal DiseaseStage 3: End-Stage Renal Disease The final stage, occurs when there is less The final stage, occurs when there is less

than 10% of nephron function remaining. than 10% of nephron function remaining. All normal regulatory, excretory, and All normal regulatory, excretory, and hormonal functions of the kidneys are hormonal functions of the kidneys are severely impaired. ESRD is evidenced by severely impaired. ESRD is evidenced by elevated creatinine and BUN levels as elevated creatinine and BUN levels as well as electrolyte imbalances. well as electrolyte imbalances.

Dialysis is usually indicated at this point. Dialysis is usually indicated at this point.

Glomular Filtration RateGlomular Filtration Rate GFR: a Kidney GFR: a Kidney

function test in which function test in which results can be results can be determined from determined from amount of ultrafiltrate amount of ultrafiltrate formed by plasma formed by plasma flowing through the flowing through the glomeruli of the glomeruli of the kidney.kidney.

As glomular filtration As glomular filtration decreases, the serum decreases, the serum creatinine and BUN creatinine and BUN levels increase.levels increase.

CausesCauses Type 1 and type 2 diabetes Type 1 and type 2 diabetes

mellitus cause a condition called mellitus cause a condition called diabetic nephropathy, which is diabetic nephropathy, which is the leading cause of kidney the leading cause of kidney disease in the United States.   disease in the United States.  

High Blood Pressure High Blood Pressure (hypertension), if not controlled, (hypertension), if not controlled, can damage the kidneys over can damage the kidneys over time. time.

Glomerulonephritis is the Glomerulonephritis is the inflammation and damage of the inflammation and damage of the filtration system of the kidney filtration system of the kidney and can cause kidney failure. and can cause kidney failure. Postinfectious conditions and Postinfectious conditions and Lupus are among the many Lupus are among the many causes of glomerulonephritis. causes of glomerulonephritis.

More CausesMore Causes Polycystic Kidney Disease is an example of a hereditary cause of Polycystic Kidney Disease is an example of a hereditary cause of

chronic kidney disease wherein both kidneys have multiple chronic kidney disease wherein both kidneys have multiple cysts  cysts 

Use of analgesics such as acetaminophen (Tylenol) and Use of analgesics such as acetaminophen (Tylenol) and ibuprophen regularly over long durations of time can cause ibuprophen regularly over long durations of time can cause analgesic nephropathy, another cause of kidney disease. Certain analgesic nephropathy, another cause of kidney disease. Certain other medications can also damage the kidneys. other medications can also damage the kidneys.

Clogging and hardening of the arteries (atherosclerosis) leading Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a condition called ischemic nephropathy, to the kidneys causes a condition called ischemic nephropathy, which is another cause  of progressive kidney damage. which is another cause  of progressive kidney damage.

Obstruction of the flow of urine such as by stones, an enlarged Obstruction of the flow of urine such as by stones, an enlarged prostate, strictures (narrowings), or cancers may also cause prostate, strictures (narrowings), or cancers may also cause kidney disease kidney disease

Clinical ManifestationClinical Manifestation

Patients with CRF stage 3 or lower (GFR Patients with CRF stage 3 or lower (GFR >30 mL/min) generally are >30 mL/min) generally are asymptomatic and do not experience asymptomatic and do not experience clinically evident disturbances in water clinically evident disturbances in water or electrolyte balance or or electrolyte balance or endocrine/metabolic disturbances.endocrine/metabolic disturbances.

Generally, these disturbances clinically Generally, these disturbances clinically manifest with CRF stages 4 and 5 (GFR manifest with CRF stages 4 and 5 (GFR <30 mL/min).<30 mL/min).

Clinical ManifestationsClinical Manifestations Hyperkalemia usually develops Hyperkalemia usually develops

when GFR falls to less than 20-25 when GFR falls to less than 20-25 mL/min because of the decreased mL/min because of the decreased ability of the kidneys to excrete ability of the kidneys to excrete potassium. potassium.

Metabolic acidosis because the Metabolic acidosis because the kidney cannot excrete increased kidney cannot excrete increased loads of acid. loads of acid.

Clinical ManifestationsClinical Manifestations Extracellular volume expansion and total-Extracellular volume expansion and total-

body volume overload results from failure body volume overload results from failure of sodium and free water excretion. of sodium and free water excretion.

Anemia principally develops from Anemia principally develops from decreased renal synthesis of erythropoietin, decreased renal synthesis of erythropoietin, the hormone responsible for bone marrow the hormone responsible for bone marrow stimulation for red blood cell (RBC). stimulation for red blood cell (RBC).

Calcium and Phosphorus imbalance occurs Calcium and Phosphorus imbalance occurs because of a disorder in metabolism. They because of a disorder in metabolism. They have a reciprocal relationship in the body; have a reciprocal relationship in the body; as one rises, the other decreases. as one rises, the other decreases.

Signs and SymptomsSigns and Symptoms NeurologicNeurologic

weakness, fatigue, confusion, weakness, fatigue, confusion, disorientation, tremors, disorientation, tremors, seizures, restlessness of legs, seizures, restlessness of legs, burning of soles of feet, burning of soles of feet, behavioral changes.behavioral changes.

IntegumentaryIntegumentaryGray-bronze skin colour, dry, Gray-bronze skin colour, dry,

flaky skin, pruritus, flaky skin, pruritus, ecchymosis, thin brittle nails, ecchymosis, thin brittle nails, coarse, thinning haircoarse, thinning hair

PulmonaryPulmonaryCrackles, thick tenacious Crackles, thick tenacious

sputum, depressed cough sputum, depressed cough reflex, pleuritic pain, reflex, pleuritic pain, shortness of breath, engorged shortness of breath, engorged neck veins, tachypnea, uremic neck veins, tachypnea, uremic pneumonitis, “uremic lung” pneumonitis, “uremic lung”

GastrointestinalGastrointestinalAmmonia odour to breath, Ammonia odour to breath,

metallic taste, mouth metallic taste, mouth ulcerations and bleeding, ulcerations and bleeding, anorexia, N&V, hiccups, anorexia, N&V, hiccups, constipation or diarrhea, constipation or diarrhea, bleeding from GI tract.bleeding from GI tract.

HematologicHematologicAnemia, thrombocytopeniaAnemia, thrombocytopenia MusculoskeletalMusculoskeletalMuscle cramps, loss of Muscle cramps, loss of

muscle strength, renal muscle strength, renal osteodystrophy, bone osteodystrophy, bone pain, bone fractures, foot pain, bone fractures, foot dropdrop

Nursing Care PlanNursing Care Plan Excess fluid volume r/t Excess fluid volume r/t

decreased urine output, and decreased urine output, and retention of sodium and waterretention of sodium and water

GoalGoal is maintenance of ideal body is maintenance of ideal body weight without access fluidweight without access fluid

Nursing Interventions Nursing Interventions Assess fluid StatusAssess fluid Status Daily weightDaily weight I & OI & O Skin turgour & edemaSkin turgour & edema Distention of neck veinsDistention of neck veins BP, P, RBP, P, R Limit fluid intake to prescribed Limit fluid intake to prescribed

volumevolume Explain to pt and family Explain to pt and family

rationale for restriction of foodrationale for restriction of food Provide or encourage frequent Provide or encourage frequent

oral careoral care

RationaleRationale Assessment provides baseline and Assessment provides baseline and

ongoing database for monitoring ongoing database for monitoring changes and evaluating interventionschanges and evaluating interventions

Fluid restriction will determine on the Fluid restriction will determine on the basis of weight, urine output, and basis of weight, urine output, and response of therapyresponse of therapy

Understanding promotes pt and family Understanding promotes pt and family cooperation with fluid restrictionscooperation with fluid restrictions

Oral hygiene minimizes dryness of oral Oral hygiene minimizes dryness of oral mucous membranesmucous membranes

Expected OutcomesExpected Outcomes Demonstrates no rapid weight Demonstrates no rapid weight

changeschanges Maintains dietary and fluid restrictionsMaintains dietary and fluid restrictions Exhibits normal skin turgour without Exhibits normal skin turgour without

edemaedema Normal vitalsNormal vitals Reports no difficulty breathing or Reports no difficulty breathing or

shortness of breathshortness of breath Reports decrease dryness of oral Reports decrease dryness of oral

mucous membranes.mucous membranes.

Nursing Care PlanNursing Care Plan Hyperkalemia, Hyperkalemia,

pericarditis, pericardial pericarditis, pericardial effusion and temponade, effusion and temponade, hypertension, anemia, hypertension, anemia, bone diseasebone disease

Goal:Goal: Patient experiences Patient experiences and absence of and absence of complicationscomplications

Nursing InterventionsNursing Interventions HyperkalemiaHyperkalemia Monitor serum K levels and Monitor serum K levels and

notify physician if greater notify physician if greater than 5.5 mEq/L.than 5.5 mEq/L.

Assess patient for muscle Assess patient for muscle weakness, diarrhea, ECG weakness, diarrhea, ECG changes( tall tented Twaves, changes( tall tented Twaves, widened QRS).widened QRS).

RationaleRationale Hyperkalemia causes Hyperkalemia causes

potentially life-threatening potentially life-threatening changes to the bodychanges to the body

Cardiovascular S & S are Cardiovascular S & S are characteristic of characteristic of hyperkalemiahyperkalemia

Expected OutcomesExpected Outcomes Pt has normal K levelPt has normal K level Experiences no muscle Experiences no muscle

weakness or diarrhea, weakness or diarrhea, Exhibits normal ECG Exhibits normal ECG

patternpattern Vital signs are within Vital signs are within

normal limitsnormal limits

Pericarditis, Pericarditis, Pericardial effusion, Pericardial effusion, tamponadetamponade

Assess for fever, chills, Assess for fever, chills, chest pain and chest pain and pericardial friction rub pericardial friction rub (signs of pericarditis).(signs of pericarditis).

If pt has pericarditis, ax If pt has pericarditis, ax q 4 hrsq 4 hrs

Extreme hypotensionExtreme hypotension Weak of absent Weak of absent

peripheral pulses, peripheral pulses, altered level of altered level of consciousness, bulging consciousness, bulging neck veins.neck veins.

RationaleRationale About 30-50% of CRF pts develop About 30-50% of CRF pts develop

pericarditis due to uremia; pericarditis due to uremia; fever ,chest pain, and pericardial fever ,chest pain, and pericardial friction rub are classic signsfriction rub are classic signs

Pericardial effusion is common Pericardial effusion is common following pericarditis. Signs of following pericarditis. Signs of effusion: paradoxical pulse (> 10 effusion: paradoxical pulse (> 10 mm drop in BP during inspiration) mm drop in BP during inspiration) and signs of shock d/t and signs of shock d/t compression of the heart by a compression of the heart by a large effusion.large effusion.

Cardiac tamponade exists when Cardiac tamponade exists when the pt is severely compromised the pt is severely compromised hemodynamicallyhemodynamically

OutcomesOutcomes Has strong and equal peripheral Has strong and equal peripheral

pulsepulse Absence of paradoxical pulseAbsence of paradoxical pulse Absence of pericardial effusion, or Absence of pericardial effusion, or

tamponadetamponade

HypertensionHypertension Monitor and record blood Monitor and record blood

pressurepressure Administer Administer

antihypertensives as antihypertensives as prescribesprescribes

Encourage compliance Encourage compliance with dietary and fluid with dietary and fluid restriction therapyrestriction therapy

Teach pt report signs of Teach pt report signs of fluid overload, vision fluid overload, vision changes, headaches, changes, headaches, edema, seizuresedema, seizures

RationaleRationale Antihypertensives play a key Antihypertensives play a key

role in tx of hypertension role in tx of hypertension associated with CRF.associated with CRF.

Adherence to diet and fluid Adherence to diet and fluid restrictions prevents excess restrictions prevents excess fluid and sodium accumulationfluid and sodium accumulation

These are indications of These are indications of inadequate control of inadequate control of hypertension, and need to alter hypertension, and need to alter therapytherapy

OutcomesOutcomes BP is within normal limitsBP is within normal limits No headaches, visual problems No headaches, visual problems

or seizuresor seizures No edemaNo edema Demonstrates compliance with Demonstrates compliance with

dietary and fluid restrictionsdietary and fluid restrictions

AnemiaAnemia Monitor RBC count, Hg, Monitor RBC count, Hg,

and HCT levelsand HCT levels Administer prescribes Administer prescribes

meds: iron and folic acidmeds: iron and folic acid Avoid drawing Avoid drawing

unnecessary blood unnecessary blood specimensspecimens

Teach pt to prevent Teach pt to prevent bleeding; avoid vigorous bleeding; avoid vigorous nose blowingnose blowing

Administer blood Administer blood component therapycomponent therapy

RationaleRationale Provides Ax of degree of Provides Ax of degree of

anemiaanemia RBCs need iron and folic acid RBCs need iron and folic acid

to be produced.to be produced. Anemia is worsened by Anemia is worsened by

drawing numerous specimensdrawing numerous specimens Blood component therapy Blood component therapy

may be needed if pt has may be needed if pt has symptomssymptoms

OutcomesOutcomes Pt has normal colour without Pt has normal colour without

pallorpallor Hematology values are within Hematology values are within

acceptable limitsacceptable limits Experiences not bleeding Experiences not bleeding

form any site.form any site.

Bone DiseaseBone Disease Administer the Administer the

following meds as following meds as prescribed: prescribed: phosphate binders, phosphate binders, calcium supplements, calcium supplements, vit D supplementsvit D supplements

Monitor serum lab Monitor serum lab values ( calcium, values ( calcium, phosphorus, phosphorus, aluminum)aluminum)

Assist pt with Assist pt with exercise programexercise program

RationaleRationale CRF causes numerous CRF causes numerous

physiologic changes affecting physiologic changes affecting calcium, phosphorus and vit D calcium, phosphorus and vit D metabolism.metabolism.

Hyperphophatemia, Hyperphophatemia, hypocalcemia, and excess hypocalcemia, and excess aluminum accumulation are aluminum accumulation are commoncommon

Bone demineraliztion decreases Bone demineraliztion decreases with immobility.with immobility.

OutcomesOutcomes Serum calcium, phosphorus, Serum calcium, phosphorus,

and aluminum levels are within and aluminum levels are within acceptable ranges.acceptable ranges.

Has no bone demineralizationHas no bone demineralization Discuss importance of Discuss importance of

maintaining activity level and maintaining activity level and exercise program.exercise program.

DietDiet Protein restriction b/c urea, uric acid and organic acids- the Protein restriction b/c urea, uric acid and organic acids- the

breakdown product of dietary and tissue proteins- accumulate breakdown product of dietary and tissue proteins- accumulate rapidly in the blood when there is impaired renal clearance. rapidly in the blood when there is impaired renal clearance.

The allowed protein must be of high biologic value (diary The allowed protein must be of high biologic value (diary products, eggs, meats). These proteins are those that are products, eggs, meats). These proteins are those that are complete proteins and supply the essential amino acids complete proteins and supply the essential amino acids necessary for cell growth and repair; also maintenance of fluid necessary for cell growth and repair; also maintenance of fluid balance, healing and skin integrity, and maintenance of balance, healing and skin integrity, and maintenance of immune function.immune function.

Fluid restrictions: fluid allowance is usually 500-600 ml more Fluid restrictions: fluid allowance is usually 500-600 ml more than the previous day’s 24 hr output. than the previous day’s 24 hr output.

Calories are supplied by carbs and fats to prevent wasting and Calories are supplied by carbs and fats to prevent wasting and malnutritionmalnutrition

Vitamin supplementation because a protein restricted diet Vitamin supplementation because a protein restricted diet does provide the necessary amounts of vitamins and the pt on does provide the necessary amounts of vitamins and the pt on dialysis may lose water soluble vitamins from the blood during dialysis may lose water soluble vitamins from the blood during treatment.treatment.

Nursing DiagnosesNursing Diagnoses

Altered fluid volume (excess) Altered fluid volume (excess) related to compromised regulatory related to compromised regulatory mechanism (renal failure) with mechanism (renal failure) with retention of water as evidenced by retention of water as evidenced by intake greater then output intake greater then output (oliguria)(oliguria)

Nursing DiagnosesNursing Diagnoses

Risk for Altered cardiac output: decrease Risk for Altered cardiac output: decrease related to fluid overloadrelated to fluid overload

Assessments:Assessments:-Monitor BP & HR-Monitor BP & HR-Assess color of skin, mucous -Assess color of skin, mucous membranes and nail bedsmembranes and nail beds-Note occurrence of slow pulse, hypotension,-Note occurrence of slow pulse, hypotension,

flushing, nausea/vomiting and flushing, nausea/vomiting and depressed depressed level of consciousnesslevel of consciousness

-Maintain bed rest-Maintain bed rest

Assessments continuedAssessments continued

Monitor lab resultsMonitor lab results Potassium, Calcium, magnesium, Potassium, Calcium, magnesium,

phosphatephosphate

Nursing DiagnosisNursing Diagnosis

Altered nutrition: less than body Altered nutrition: less than body requirements related to ulcerations requirements related to ulcerations of oral mucousa of oral mucousa

Patient Outcomes:Patient Outcomes: Maintains/regains weight Maintains/regains weight

Altered nutrition continuedAltered nutrition continued

Assessments/InterventionsAssessments/Interventions Document dietary intakeDocument dietary intake Provide frequent, small feedingsProvide frequent, small feedings Offer frequent mouth care if possible Offer frequent mouth care if possible

with dilute (25%) acetic acid solution.with dilute (25%) acetic acid solution. Consult with dietician/nutritional Consult with dietician/nutritional

support teamsupport team Restrict K, Na, and phosphorus intake Restrict K, Na, and phosphorus intake

as indicatedas indicated

Nursing DiagnosisNursing Diagnosis

This one is for the familyThis one is for the family

Potential knowledge deficit related Potential knowledge deficit related to unfamiliarity with information to unfamiliarity with information resources as evidenced by resources as evidenced by questions/request for informationquestions/request for information

Knowledge Deficit Knowledge Deficit continuedcontinued

Review disease process, prognosis, Review disease process, prognosis, and precipitating factorsand precipitating factors

Discuss dietary plan/restrictions. Discuss dietary plan/restrictions.

Medications for CRFMedications for CRF Diuretics Diuretics

Furosemide (Lasix) only given with Furosemide (Lasix) only given with severe fluid overloadsevere fluid overload

Increases excretion of water by interfering with Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the inhibits sodium and chloride reabsorption in the thick ascending loop of Henle and the distal renal thick ascending loop of Henle and the distal renal tubule tubule

Adult dose: 20-80 mg PO/IV once; Adult dose: 20-80 mg PO/IV once; repeat 6-8h prn or dose may be repeat 6-8h prn or dose may be increased by 20-40 mg no sooner than increased by 20-40 mg no sooner than 6-8h after previous dose until desired 6-8h after previous dose until desired effecteffect

Nursing Assessments: Watch for Nursing Assessments: Watch for hypokalemia, assess BP before and hypokalemia, assess BP before and during therapy can cause hypotensionduring therapy can cause hypotension

Medications for CRF Medications for CRF continuedcontinued Phosphate-lowering agentsPhosphate-lowering agents

Calcium acetate (Calphron, PhosLo)Calcium acetate (Calphron, PhosLo) Combines with dietary phosphorus to form insoluble Combines with dietary phosphorus to form insoluble

calcium phosphate, which is excreted in feces.calcium phosphate, which is excreted in feces. Adult dose: 1-2 g PO bid-tid with each meal; Adult dose: 1-2 g PO bid-tid with each meal;

increase to bring serum phosphate value to 6 increase to bring serum phosphate value to 6 mg/dL as long as hypercalcemia does not develop; mg/dL as long as hypercalcemia does not develop;

Calcium carbonate (Caltrate, Apo-Cal, Tums)Calcium carbonate (Caltrate, Apo-Cal, Tums) Successfully normalizes phosphate concentrationsSuccessfully normalizes phosphate concentrations Neutralizes gastric acidity, increase serum CaNeutralizes gastric acidity, increase serum Ca

Adult dose: 1-2 g PO divided bid-tid; with meals as Adult dose: 1-2 g PO divided bid-tid; with meals as a phosphorous binder; between meals as a calcium a phosphorous binder; between meals as a calcium supplement supplement

Phosphate-lowering Phosphate-lowering agentsagents

Calcitriol (Rocaltrol, Calcijex)Calcitriol (Rocaltrol, Calcijex) Increases intestinal absorption of calcium for treatment Increases intestinal absorption of calcium for treatment

of hypocalcemia and increases renal tubular resorption of hypocalcemia and increases renal tubular resorption of phosphateof phosphate

Adult dose for hypocalcemia during chronic Adult dose for hypocalcemia during chronic dialysis:dialysis:

0.25 mcg/day or every other day, may require 0.5-1 0.25 mcg/day or every other day, may require 0.5-1 mcg/day PO mcg/day PO

Sevelamer (Renagel)Sevelamer (Renagel) Indicated for the reduction of serum phosphorous in Indicated for the reduction of serum phosphorous in

patients with ESRD. patients with ESRD. Adult dose: Initial: 800-1600 mg PO tid with Adult dose: Initial: 800-1600 mg PO tid with

mealsmealsMaintenance: Increase or decrease by 400-800 Maintenance: Increase or decrease by 400-800 mg per meal q2wk to maintain serum mg per meal q2wk to maintain serum phosphorous at 6 mg/dL or lessphosphorous at 6 mg/dL or less

Phosphate-lowering Phosphate-lowering agentsagents Lanthanum carbonate Lanthanum carbonate

(Fosrenal) (Fosrenal) for reduction of high for reduction of high

phosphorus levels in phosphorus levels in patients with ESRD patients with ESRD

Adult dose: Initial: 250-Adult dose: Initial: 250-500 mg PO tid pc 500 mg PO tid pc (chewable tabs); adjust (chewable tabs); adjust dose q2-3wk to target dose q2-3wk to target serum phosphorus levelserum phosphorus levelMaintenance: 500-1000 Maintenance: 500-1000 mg PO tid pcmg PO tid pc

Phosphate-lowering Phosphate-lowering agentsagents

Doxercalciferol (Hectorol)Doxercalciferol (Hectorol) To lower parathyroid hormone levels in patients To lower parathyroid hormone levels in patients

undergoing chronic kidney dialysis. Increases undergoing chronic kidney dialysis. Increases serum Caserum Ca

Adult dose: 10 mcg PO 3 times/wk at dialysis; Adult dose: 10 mcg PO 3 times/wk at dialysis; increase dose by 2.5 mcg/8 wk if iPTH is not increase dose by 2.5 mcg/8 wk if iPTH is not lowered by 50% and fails to reach the target lowered by 50% and fails to reach the target range; not to exceed 20 mcg/3 times/wkrange; not to exceed 20 mcg/3 times/wkAlternatively, 4 mcg IV 3 times/wk; may adjust Alternatively, 4 mcg IV 3 times/wk; may adjust dose by 1-2 mcg/8 wk to maintain iPTH levels dose by 1-2 mcg/8 wk to maintain iPTH levels

Nursing Assessment for all phosphate Nursing Assessment for all phosphate lowering agents: Monitor BUN, creatinine, lowering agents: Monitor BUN, creatinine, chloride, electrolytes, urine pH, urinary chloride, electrolytes, urine pH, urinary calcium, mg, phosphate, urinalysis urinary Ca calcium, mg, phosphate, urinalysis urinary Ca should be 9-10mg/dl, assess for should be 9-10mg/dl, assess for hypocalcemia: headache, N/V, confusionhypocalcemia: headache, N/V, confusion

Medications for CRF Medications for CRF continuedcontinued

AnemiaAnemia Epoetin alfa (Epogen, Procrit)Epoetin alfa (Epogen, Procrit)

Stimulates RBC productionStimulates RBC production Adult dose: 50 -150 U/kg IV/SC 3 times per Adult dose: 50 -150 U/kg IV/SC 3 times per

week, then adjust dose by 25 U/kg/dose to week, then adjust dose by 25 U/kg/dose to maintain appropriate Hct; maintenance maintain appropriate Hct; maintenance 12.5-25 U/kg, titrate to target Hct, 12.5-25 U/kg, titrate to target Hct,

Nursing Assessment: Monitor renal studies: Nursing Assessment: Monitor renal studies: urinalysis, protein, blood, BUN, creatinine; urinalysis, protein, blood, BUN, creatinine; I&O. Monitor blood studies, Hgb, Hct, RBC, I&O. Monitor blood studies, Hgb, Hct, RBC, WBC, INR, PTTWBC, INR, PTT

Medications for CRF Medications for CRF continuedcontinued

Darbepoetin (Aranesp)Darbepoetin (Aranesp) Stimulates erythropoiesis Stimulates erythropoiesis

Adult dose: 0.45 ug/kg IV/SC as a Adult dose: 0.45 ug/kg IV/SC as a single injection, titrate not to exceed single injection, titrate not to exceed a target Hgb of 12 g/dla target Hgb of 12 g/dl

Has a longer half-life than epoetin Has a longer half-life than epoetin alfaalfa

Nursing Assessments: Assess blood Nursing Assessments: Assess blood studies, renal studies; assess BP, studies, renal studies; assess BP, check for rising BP as Hct risescheck for rising BP as Hct rises

Medications for CRF Medications for CRF continuedcontinued

Iron SaltsIron Salts To treat anemiaTo treat anemia Ferrous sulfate (Feosol, Feratab, Slow Ferrous sulfate (Feosol, Feratab, Slow

FE)FE) Replaces iron stores need for RBC developmentReplaces iron stores need for RBC development

Adult dose: 100-200mg tidAdult dose: 100-200mg tid Iron sucrose (Venofer)Iron sucrose (Venofer)

Used to treat iron deficiency dute to chronic Used to treat iron deficiency dute to chronic hemodialysishemodialysis

Adult dose: IV 5ml (100mg of elemental iron) Adult dose: IV 5ml (100mg of elemental iron) given during dialysis, most will need 1000mg given during dialysis, most will need 1000mg of elemental iron over 10 dialysisof elemental iron over 10 dialysis

Nursing Assessments: Monitor blood Nursing Assessments: Monitor blood studies, Hct, Hgb, total Fe, monthly. studies, Hct, Hgb, total Fe, monthly. Assess bowel elimination for constipationAssess bowel elimination for constipation

Tia’s kidney function continues to Tia’s kidney function continues to decline and she is forced to begin decline and she is forced to begin dialysisdialysis

DialysisDialysis

What is Dialysis?What is Dialysis? Dialysis is a type of renal replacement therapy which is used to Dialysis is a type of renal replacement therapy which is used to

provide artificial replacement for lost kidney function due to acute or provide artificial replacement for lost kidney function due to acute or chronic kidney failurechronic kidney failure

It is a life support treatment, it does not cure acute or chronic renal It is a life support treatment, it does not cure acute or chronic renal failurefailure

May be used for very sick clients who have suddenly lost kidney May be used for very sick clients who have suddenly lost kidney function function

May be used for stable clients who have permanently lost kidney May be used for stable clients who have permanently lost kidney functionfunction

Healthy kidneys remove waste products (potassium, acid, urea) from Healthy kidneys remove waste products (potassium, acid, urea) from the blood and they also remove excess fluid in the form of urinethe blood and they also remove excess fluid in the form of urine

Dialysis has to duplicate both of these functionsDialysis has to duplicate both of these functions Dialysis – waste removalDialysis – waste removal Ultrafiltration – fluid removalUltrafiltration – fluid removal

Principle of DialysisPrinciple of Dialysis Dialysis works on the principle of diffusion Dialysis works on the principle of diffusion

of solutes along a concentration gradient of solutes along a concentration gradient across a semipermiable membraneacross a semipermiable membrane

Blood passes on one side of the Blood passes on one side of the semipermeable membrane, and a dialysis semipermeable membrane, and a dialysis fluid is passed on the other sidefluid is passed on the other side

By altering the composition of the dialysis By altering the composition of the dialysis fluid, the concentrations of the undesired fluid, the concentrations of the undesired solutes (potassium, urea) in the fluid are solutes (potassium, urea) in the fluid are low, but the desired solutes (sodium) are low, but the desired solutes (sodium) are at their natural concentration found in at their natural concentration found in healthy bloodhealthy blood

Prescription for DialysisPrescription for Dialysis

A prescription for dialysis is given A prescription for dialysis is given by a physician who specializes in by a physician who specializes in the kidney (nephrologist)the kidney (nephrologist)

The MD will set various parameters The MD will set various parameters for the treatmentfor the treatment Time and duration of the dialysis Time and duration of the dialysis

sessionssessions Size of the dialyzerSize of the dialyzer Rate of blood flowRate of blood flow

Types of DialysisTypes of Dialysis1. Hemodialysis1. Hemodialysis

2. Peritoneal 2. Peritoneal DialysisDialysis

HemodialysisHemodialysis

What is Hemodialysis What is Hemodialysis (HD)?(HD)?

Client’s blood is passed through a system of Client’s blood is passed through a system of tubing (dialysis circuit) via a machine to a tubing (dialysis circuit) via a machine to a semipermeable membrane (dialyzer) which has semipermeable membrane (dialyzer) which has the dialysis fluid running on the other sidethe dialysis fluid running on the other side

The cleansed blood is then returned via the The cleansed blood is then returned via the circuit back to the bodycircuit back to the body

The dialysis process is very efficient (much The dialysis process is very efficient (much higher than in the natural kidneys), which allows higher than in the natural kidneys), which allows treatments to take place intermittently (usually treatments to take place intermittently (usually 3 times a week), but fairly large volumes of fluid 3 times a week), but fairly large volumes of fluid must be removed in a single treatment which must be removed in a single treatment which can be very demanding on a clientcan be very demanding on a client

Side Effects of HDSide Effects of HD The side effects are proportionate to the The side effects are proportionate to the

amount of fluid being removedamount of fluid being removed Decreased blood pressureDecreased blood pressure FatigueFatigue Chest painsChest pains Leg crampsLeg cramps HeadachesHeadaches Electrolyte imbalanceElectrolyte imbalance N&VN&V Reaction to the dialyzer Reaction to the dialyzer Air embolismAir embolism

Complications of HDComplications of HD Because HD requires access to the circulatory Because HD requires access to the circulatory

system, clients have a portal of entry for system, clients have a portal of entry for microbes, which could lead to infectionmicrobes, which could lead to infection The risk of infection depends on the type of access The risk of infection depends on the type of access

usedused Bleeding may also occur at the access siteBleeding may also occur at the access site Blood clotting was a serious problem in the Blood clotting was a serious problem in the

past, but the incidence of this has decreased past, but the incidence of this has decreased with the routine use of anticoagulants (Heparin with the routine use of anticoagulants (Heparin is the most common)is the most common) Anticoagulants also come with their own risk of side Anticoagulants also come with their own risk of side

effects and complicationseffects and complications

Rare Complication of HDRare Complication of HD On the rare occasion, a client may have On the rare occasion, a client may have

a severe anaphylactic reactiona severe anaphylactic reaction SneezingSneezing WheezingWheezing SOBSOB Back painBack pain Chest painChest pain Sudden deathSudden death

This can be caused by the sterilant in This can be caused by the sterilant in the dialyzer or the material in the the dialyzer or the material in the membrane itselfmembrane itself

Hemodialysis ~ The Hemodialysis ~ The “Integra”“Integra”

Three Types of Access for Three Types of Access for HDHD

IV catheterIV catheter Arteriovenous (AV) fistulaArteriovenous (AV) fistula Synthetic graftSynthetic graft The type of access is influenced by The type of access is influenced by

factors such as expected time course of factors such as expected time course of the clients renal failure and the the clients renal failure and the condition of the clients vasculaturecondition of the clients vasculature

Some clients may have multiple Some clients may have multiple accesses, usually because an AV fistula accesses, usually because an AV fistula or a graft is maturing and an IV catheter or a graft is maturing and an IV catheter is still being usedis still being used

IV Catheter IV Catheter (Central Venous Catheter)(Central Venous Catheter)

Consists of a plastic catheter with two lumens which is Consists of a plastic catheter with two lumens which is inserted into a large vein (vena cava via the internal inserted into a large vein (vena cava via the internal jugular vein) to allow large flows of blood to be jugular vein) to allow large flows of blood to be withdrawn from the first lumenwithdrawn from the first lumen

The blood goes into the dialysis circuit, and is returned The blood goes into the dialysis circuit, and is returned to the body via the second lumento the body via the second lumen Non-tunneledNon-tunneled TunneledTunneled

This type of access is used for clients who need rapid This type of access is used for clients who need rapid access for immediate dialysisaccess for immediate dialysis Clients who are likely to recover from ARFClients who are likely to recover from ARF Client with end-stage renal failureClient with end-stage renal failure Clients waiting for other sites to matureClients waiting for other sites to mature

This type of access is very popular for clients because it This type of access is very popular for clients because it doesn’t involve needles for each treatmentdoesn’t involve needles for each treatment

Complications of an IV Complications of an IV CatheterCatheter

Venous StenosisVenous Stenosis This is the abnormal narrowing of the This is the abnormal narrowing of the

blood vesselblood vessel Because the catheter is a foreign Because the catheter is a foreign

body in the vessel, it often provokes body in the vessel, it often provokes an inflammatory reaction in the vein an inflammatory reaction in the vein wallwall

This results in scarring and narrowing This results in scarring and narrowing of the vein, often to the point where of the vein, often to the point where the vein occludesthe vein occludes

AV FistulaAV Fistula This access is recognized as the preferred access This access is recognized as the preferred access

methodmethod To create a fistula a vascular surgeon joins an artery To create a fistula a vascular surgeon joins an artery

and a vein togetherand a vein together Since this bypasses the capillaries, blood flows at a Since this bypasses the capillaries, blood flows at a

very high rate through the fistulavery high rate through the fistula This can be felt by placing a finger over a mature fistula This can be felt by placing a finger over a mature fistula

(thrill)(thrill) Usually created in the non-dominant handUsually created in the non-dominant hand It can be situated on the hand, forearm or the elbowIt can be situated on the hand, forearm or the elbow It will take approximately 4-6 weeks to matureIt will take approximately 4-6 weeks to mature During treatment, 2 needles are inserted, one to During treatment, 2 needles are inserted, one to

draw blood out of the body and the other to return draw blood out of the body and the other to return blood to the bodyblood to the body

Advantages of an AV Advantages of an AV FistulaFistula

Decreased infection rateDecreased infection rate Increased blood flow rates, Increased blood flow rates,

therefore a more effective dialysis therefore a more effective dialysis treatmenttreatment

Decreased incidence of thrombosisDecreased incidence of thrombosis

Complications of an AV Complications of an AV FistulaFistula

If an AV fistula has a very high flow rate and the If an AV fistula has a very high flow rate and the vasculature that supplies the rest of the limb is vasculature that supplies the rest of the limb is poor, than a ‘steal syndrome’ can occurpoor, than a ‘steal syndrome’ can occur Blood that enters the limb is drawn into the fistula and Blood that enters the limb is drawn into the fistula and

returned to the general circulation without entering the returned to the general circulation without entering the capillaries of the limbcapillaries of the limb

This results in cool extremities of the limb, cramping This results in cool extremities of the limb, cramping pains and possible tissue damagepains and possible tissue damage

Long term complications can be the development Long term complications can be the development of a bulging in the wall of the vein (aneurysm)of a bulging in the wall of the vein (aneurysm) The vessel wall is weakened by the repeated insertion of The vessel wall is weakened by the repeated insertion of

needles over timeneedles over time Can be reduced by careful needling techniqueCan be reduced by careful needling technique

Hemodialysis ~ fistulaHemodialysis ~ fistula

AV GraftAV Graft

This is much like a fistula, except an This is much like a fistula, except an artificial vessel is used to join the artificial vessel is used to join the artery and the veinartery and the vein

Grafts are used when client’s own Grafts are used when client’s own vasculature does not permit a fistulavasculature does not permit a fistula

An AV graft will mature much faster An AV graft will mature much faster than an AV fistula, and it could be than an AV fistula, and it could be ready to use within days after ready to use within days after formationformation

Hemodialysis ~ GraftHemodialysis ~ Graft

Complications of an AV Complications of an AV GraftGraft

AV grafts are at high risk for AV grafts are at high risk for narrowing where the graft is sewn narrowing where the graft is sewn to the veinto the vein As a result clotting or thrombosis may As a result clotting or thrombosis may

occuroccur As a foreign material is being As a foreign material is being

placed in the body, there is a placed in the body, there is a greater risk of infectiongreater risk of infection

Equipment Needed for HDEquipment Needed for HD The HD machine performs the function of The HD machine performs the function of

pumping the patient's blood and the pumping the patient's blood and the dialysate through the dialyzer. dialysate through the dialyzer.

The newest dialysis machines on the market The newest dialysis machines on the market are highly computerized and continuously are highly computerized and continuously monitor an array of safety-critical monitor an array of safety-critical parameters, including blood and dialysate parameters, including blood and dialysate flow rates, blood pressure, heart rate, flow rates, blood pressure, heart rate, conductivity, pH, etc. conductivity, pH, etc.

If any reading is out of normal range, an If any reading is out of normal range, an audible alarm will sound to alert the patient-audible alarm will sound to alert the patient-care technician who is monitoring the care technician who is monitoring the patient. patient.

Equipment – Water Equipment – Water SystemSystem

An extensive water purification system is An extensive water purification system is absolutely critical for HD absolutely critical for HD

Since dialysis patients are exposed to vast Since dialysis patients are exposed to vast quantities of water, which is mixed with the acid quantities of water, which is mixed with the acid bath to form the dialysate, even trace mineral bath to form the dialysate, even trace mineral contaminants or bacterial endotoxins can filter contaminants or bacterial endotoxins can filter into the patient's blood. into the patient's blood.

Because the damaged kidneys are not able to Because the damaged kidneys are not able to perform their intended function of removing perform their intended function of removing impurities, ions that are introduced into the impurities, ions that are introduced into the blood stream via water can build up to blood stream via water can build up to hazardous levels, causing numerous symptoms hazardous levels, causing numerous symptoms including death including death

For this reason, water used in HD is purifiedFor this reason, water used in HD is purified

Equipment – The DialyzerEquipment – The Dialyzer The dialyzer, or artificial kidney, is the piece of The dialyzer, or artificial kidney, is the piece of

equipment that actually filters the blood equipment that actually filters the blood The blood is run through a bundle of very thin The blood is run through a bundle of very thin

capillary-like tubes, and the dialysate is pumped in a capillary-like tubes, and the dialysate is pumped in a chamber bathing the fibers chamber bathing the fibers

The process mimics the physiology of the glomerulus The process mimics the physiology of the glomerulus and the rest of the nephron and the rest of the nephron

Dialyzers come in many different sizes. A larger Dialyzers come in many different sizes. A larger dialyzer will usually translate to an increased dialyzer will usually translate to an increased membrane area, and an increase in the amount of membrane area, and an increase in the amount of undesired solutes removed from the patient's blood. undesired solutes removed from the patient's blood.

The nephrologist will prescribe the dialyzer to be The nephrologist will prescribe the dialyzer to be used depending on the patient used depending on the patient

Dialyzers are not shared between patients in the Dialyzers are not shared between patients in the practice of reuse.practice of reuse.

Temporary Hemodialysis Temporary Hemodialysis CatheterCatheter

Exit site at Exit site at surface of the surface of the skinskin

Tip located at Tip located at junction of junction of SVC and right SVC and right AtriumAtrium

Inserted in Inserted in the jugular the jugular veinvein

Tunneled Hemodialysis Tunneled Hemodialysis CatheterCatheter

Exit site Exit site

Catheter tunnelCatheter tunnel

Tip located at Tip located at junction of junction of SVC and right SVC and right AtriumAtrium

Inserted in Inserted in the jugular the jugular veinvein

Dacron cuffDacron cuff

Peritoneal DialysisPeritoneal Dialysis

Peritoneal DialysisPeritoneal Dialysis

Peritoneal Dialysis Peritoneal Dialysis CatheterCatheter

What is Peritoneal Dialysis What is Peritoneal Dialysis (PD)?(PD)?

Peritoneal dialysis works by using the body's Peritoneal dialysis works by using the body's peritoneal membrane, which is inside the abdomen, peritoneal membrane, which is inside the abdomen, as a semi-permeable membrane. as a semi-permeable membrane.

A specially formulated dialysis fluid is instilled around A specially formulated dialysis fluid is instilled around the membrane, using an indwelling catheter, then the membrane, using an indwelling catheter, then dialysis can occur, by diffusion dialysis can occur, by diffusion

Excess fluid can also be removed by osmosis, by Excess fluid can also be removed by osmosis, by altering the concentration of glucose in the fluid. altering the concentration of glucose in the fluid.

Dialysis fluid is instilled via a peritoneal dialysis Dialysis fluid is instilled via a peritoneal dialysis catheter, which is placed in the patient's abdomen, catheter, which is placed in the patient's abdomen, running from the peritoneum out to the surface, near running from the peritoneum out to the surface, near the navelthe navel

Peritoneal dialysis is typically done in the patient's Peritoneal dialysis is typically done in the patient's home and workplace, but can be done almost home and workplace, but can be done almost anywhereanywhere

Advantages of PDAdvantages of PD

Can be done at home Can be done at home Relatively easy for the client to learn Relatively easy for the client to learn Easy to travel with, bags of solution Easy to travel with, bags of solution

are easy to take on holidayare easy to take on holiday Fluid balance is usually easier when Fluid balance is usually easier when

the client is on PD than if the client is the client is on PD than if the client is on HDon HD

Disadvantage of PDDisadvantage of PD

Requires a degree of motivation Requires a degree of motivation and attention to cleanliness while and attention to cleanliness while performing PDperforming PD

There are a number of There are a number of complicationscomplications

Complications of PDComplications of PD Peritoneal dialysis requires access to the peritoneum. Peritoneal dialysis requires access to the peritoneum.

As this access breaks normal skin barriers, and as As this access breaks normal skin barriers, and as people with renal failure generally have a slightly people with renal failure generally have a slightly suppressed immune system, infection is a relatively suppressed immune system, infection is a relatively common problem common problem

Long term peritoneal dialysis can cause changes in Long term peritoneal dialysis can cause changes in the peritoneal membrane, causing it to no longer act the peritoneal membrane, causing it to no longer act as a dialysis membrane as well as it used to. as a dialysis membrane as well as it used to.

This loss of function can manifest as a loss of dialysis This loss of function can manifest as a loss of dialysis adequacy, or poorer fluid exchange (also known as adequacy, or poorer fluid exchange (also known as ultrafiltration failure) ultrafiltration failure)

Fluid may leak into surrounding soft tissue, often the Fluid may leak into surrounding soft tissue, often the scrotum in males scrotum in males

Hernias are another problem that can occur due to Hernias are another problem that can occur due to the abdominal fluid loadthe abdominal fluid load

Nursing AssessmentsNursing Assessments Before client is in the unit, look at the nurses Before client is in the unit, look at the nurses

notes from the treatment beforenotes from the treatment before Any problems, will help nurse plan for the upcoming Any problems, will help nurse plan for the upcoming

treatmenttreatment Look at the clientLook at the client

StrengthStrength GaitGait Whether client needs assistanceWhether client needs assistance ColorColor PuffinessPuffiness

Could be caused by excess fluid, too much to drink, more Could be caused by excess fluid, too much to drink, more fluid should be taken off with each treatment, changes in fluid should be taken off with each treatment, changes in voiding pattern (are they voiding less than they did last voiding pattern (are they voiding less than they did last month)month)

Assessments Con’tAssessments Con’t Shortness of breathShortness of breath

Could indicate fluid around the lungsCould indicate fluid around the lungs Ask about SOB at night (does client have to sleep in a Ask about SOB at night (does client have to sleep in a

sitting position?)sitting position?) Ask the client how they are feelingAsk the client how they are feeling

The client is usually the best source of informationThe client is usually the best source of information Clients are in 3 times a week, dialysis nurses really get Clients are in 3 times a week, dialysis nurses really get

to know their clientsto know their clients Evaluate accessEvaluate access

Bruising, swollen, tenderBruising, swollen, tender Bruit – listen with the stethoscope for a swishing sound Bruit – listen with the stethoscope for a swishing sound

of the blood, listen all the way up the armof the blood, listen all the way up the arm Thrill – felt with the fingers, tells the nurse if the blood is Thrill – felt with the fingers, tells the nurse if the blood is

flowing in the fistula (client’s are told to feel for this at flowing in the fistula (client’s are told to feel for this at home when a fistula is first initiated)home when a fistula is first initiated)

Assessments During Assessments During TreatmentTreatment

Ask client how he/she feelsAsk client how he/she feels Dizziness, diaphoretic, Dizziness, diaphoretic,

The machines automatically take BP and HR every 30 The machines automatically take BP and HR every 30 minutesminutes Can program the machines to take it at whatever Can program the machines to take it at whatever

interval is necessary (every min, 10 min, 15 min)interval is necessary (every min, 10 min, 15 min) Try to recognize a problem before it starts (ex. Try to recognize a problem before it starts (ex.

Hypovolemic shock)Hypovolemic shock) Assess access siteAssess access site

Watch trend of BPWatch trend of BP It usually gradually decreases throughout the course It usually gradually decreases throughout the course

of the treatment, but look for sudden or drastic dropsof the treatment, but look for sudden or drastic drops Assess access siteAssess access site

Bleeding, swelling, tendernessBleeding, swelling, tenderness

Nursing InterventionsNursing Interventions

If client comes in with shortness of If client comes in with shortness of breath, offer Obreath, offer O22 which can be kept on which can be kept on for the full treatment if necessaryfor the full treatment if necessary

ComfortComfort Client’s are sitting in the same chair for up Client’s are sitting in the same chair for up

to four hoursto four hours Offer extra pillows, some clients have Offer extra pillows, some clients have

special back pillow they leave in the unitspecial back pillow they leave in the unit Ensure TV and audio is working properlyEnsure TV and audio is working properly

Nursing Interventions Nursing Interventions Con’tCon’t

If the blood pressure is dropping too quickly:If the blood pressure is dropping too quickly: Slow or stop fluid removal for a time periodSlow or stop fluid removal for a time period The machines are constantly being adjusted The machines are constantly being adjusted

throughout the course of the treatment throughout the course of the treatment depending on the BPdepending on the BP

If the BP drops suddenly 200-300cc of normal If the BP drops suddenly 200-300cc of normal saline can be given to balance fluid levelssaline can be given to balance fluid levels

Usually, more fluid will be taken off at the Usually, more fluid will be taken off at the beginning of the treatment, this will allow the beginning of the treatment, this will allow the client to feel better at the endclient to feel better at the end

If the client is elderly, fluid removal starts slowly If the client is elderly, fluid removal starts slowly to ease them into the treatmentto ease them into the treatment

Responsibilities of Nursing Responsibilities of Nursing StaffStaffPrior to DialysisPrior to Dialysis

Ensure client is ready to sit for up Ensure client is ready to sit for up to four hoursto four hours Encourage client to use washroom Encourage client to use washroom

before arriving to the unitbefore arriving to the unit Try to avoid laxatives if possible Try to avoid laxatives if possible

before treatmentbefore treatment Ensure client has eaten meal prior Ensure client has eaten meal prior

to treatmentto treatment

Responsibilities of Nursing Responsibilities of Nursing StaffStaffAfter DialysisAfter Dialysis

A dialysis nurse will give unit leader or primary A dialysis nurse will give unit leader or primary nurse a verbal report of treatmentnurse a verbal report of treatment Any complications during treatmentAny complications during treatment Check BP standing and sittingCheck BP standing and sitting Assess access siteAssess access site

Encourage client to restEncourage client to rest Avoid treatments or physio for a couple of hours if Avoid treatments or physio for a couple of hours if

possiblepossible Watch fluid intakeWatch fluid intake

Be aware if client is on fluid restrictionBe aware if client is on fluid restriction Check thrill and bruitCheck thrill and bruit Do not take a BP on access armDo not take a BP on access arm Do not take blood from access armDo not take blood from access arm

Does everyone understand Does everyone understand how important we are?how important we are?

Kidneys Urine Kidneys Urine