Weitere ähnliche Inhalte Ähnlich wie Crf wtih fluid overload mx pathway summary (20) Crf wtih fluid overload mx pathway summary1. CHRONIC RENAL FAILURE WITH FLUID OVERLOAD – PATHWAY Treatment Orders:
1. Diuresis with IV frusemide:
Investigations: 120-240 mg/8hrly (if serum Cr > 400 μmol/L)
• FBC--anaemia 80-120 mg/8hrly (if serum Cr < 400μmol/L)
• PT/PTT, GXM—for dialysis, transfusion If no response, step up to maximum OR infusion at 30 mg/hr
• U/E/Cr/HCO3/Glucose—renal fxn, DM Urinary catheter if no urine output > 6hrs
• HbA1c if diabetic--DM
• Ca/Phosphate/Magnesium—renal osteodystrophy 2. Exclude cardiac event
• Fasting iPTH—endocrine compx Check baseline ECG
• LFT If pt has IHD, do CK/CKMB/Trop T
Repeat ECG x3
• Fasting lipids--hyperlipidaemia
• ECG/CXR )
3. Consider acute dialysis/filtration (if hypoxic, severe fluid overload, acidosis, or
• ABG on room air—metab acidosis ) exclude AMI hyperkalaemia)
• CK/CKMB ) PT/PTT, GXM
• UFEME, Urine c/s If for dialysis, trace Hep/HIV status.
If results > 6mths, order HBsAg, Anti-HCV, HIV
Day 2: 4. (Day 3) If anaemia workup negative, consider erythropoietin therapy – refer
• If Hb<11 g/dL: pharmacist and inform on cost
Fe/TIBC
Ferritin 5. (Day 5) Review CXR: if clear, consider switching to oral frusemide. If well on oral
B12 / folate frusemide, consider discharge
Stool OB x3
• If Hb<6 g/dL 6. Discharge plan:
Consider OGD, transfusion, thal workup etc Fluid restriction
Nutritional restriction (decreased protein, potassium, phosphate, calories (if DM))
Nutrition: When to seek medical help: skin turgor, pitting oedema, weakness, fatigue,
• Low salt muscle cramps, N/V
• Low protein 0.8g/kg/day Skin care
• Low phosphate Identify primary physician, appointments, home care etc.
• Low potassium
• DM 1500/1800/2000 kcal Referral Plan (Day 2 onwards):
• If Cr > 400 μmol/L
Fluids: Assess ADL (toilet needs, dressing, feeding)
• 500ml/day (if serum Cr > 400 μmol/L) If can’t do any one ADL, refer MSW
• 800ml/day (if serum Cr < 400μmol/L) If can do all, refer renal coordinator, vascular surgeon
• If Cr < 400 μmol/L, refer renal coordinator, MSW, vascular surgeon as required
• Others: pharmacist, physiotherapist, psychologist etc.
Assessment:
• Vital signs
• Height/weight
• Urine dipstick
• Pruritus
• Oedema – sites and severity
• Compliance with fluid restriction
• I/O charting
• IV plug
• O2 therapy
• Urinary catheter if required