This ppt will be helpful for a nursing student.

1. CHRONIC RENAL FAILURE
BSc.Nursing Year II Adult Health Nursing Course – I
CASE STUDY PRESENTATION
Clinical Preceptor: Mam Shamim Chandani
Placement: Patel hospital

2. GROUP MEMBERS
 Azeema Abdul Aziz
 Bakhtawar Khan
 Bilal Ramzan
 Danial Hassan
 Erum Azad
 Farheen Baig

3. OBJECTIVES
 Discuss case scenario of patient along with diagnosis and brief
history
 Highlight related anatomy, physiology, pathophysiology and
causes
 Discuss sign and symptoms of disease and those shown by the
patient
 Integrate lab and other investigations
 Discuss medical and surgical management of the patient
 Explain the procedure of Dialysis and its types
 List down the relevant nursing diagnosis
 Discuss goals for patient/family care
 Discuss the teaching plan as per need of the patient

4. SCENARIO
 55 year old female patient came in for hemodialysis with a
complicated past medical history. She was known case of
DM, HTN.
 She was diagnosed with Renal Failure about 3 years back
and since then she has been on dialysis.
 She is Hypertensive since 22 years.
 DM was diagnosed about 28 years back

5. …CONT’D
SURGERIES
She had breast cancer and right breast
mastectomy was done about 23 years back.
She had cataract and a surgery was done for
both the eyes.

6. FAMILY HISTORY
 Two of her elder sisters had been diagnosed with the Renal
Failure and 1 of them died.
 Diabetes and Hypertension ran in the family.

7. KIDNEYS
 The kidneys are pair of brownish
reddish structures located
retroperitoneally (behind and outside
peritoneal cavity) from 12th thoracic
vertebrae to 5th lumbar vertebrae.
 Protected well by ribs, muscles,
perrenal fat and renal capsule which
surround the kidney.

8. 1. Renal parenchyma
(consist of cortex
and medulla).
2. Renal pelvis
(concave portion of
kidney through
which renal artery
enters and vein
exits).

9. NEPHRONS
 Each kidney contains about one million nephrons, the
functional unit of kidney. Each kidney is capable of
providing adequate renal function if the opposite kidney is
damaged.
 The nephron consists of a glomerulus containing afferent
and efferent arterioles, Bowman’s capsule, proximal tubule,
loop of Henle, distal tubule, and collecting ducts
 Collecting ducts converge into papillae, which empty into
the minor calices, which drain into three major calices that
open directly into the renal pelvis.

11. KIDNEY FUNCTIONS
 Urine formation
 Excretion of waste products
 Regulation of electrolytes
 Regulation of acid base balance
 Control of blood pressure
 Secretion of prostaglandins
 Synthesis of vitamin D to active form

12. PATHOPHYSIOLOGY OF CHRONIC RENAL
FAILURE
Predisposing factors (Hypo perfusion, DM, Recurrent
infections, Urinary tract obstruction
Endothelial injury
Sluggish blood flow
Glomerulosclerosis
Decrease number of nephrons

13. …CONT’D
Structural and functional change of nephrons
Increased intra glomerular pressure
Accelerated sclerosis of remaining nephrons
Proteinuria
Impaired kidney functions and uremia

14. CAUSES
 The most common causes of chronic renal failure are diabetes
mellitus (type 1 or type 2 diabetes) and high blood pressure.
 The most common cause of end-stage renal failure worldwide is IgA
nephropathy (an inflammatory disease of the kidney).
 One of the complications resulting from diabetes or high blood pressure
is the damage to the small blood vessels in the body. The blood vessels
in the kidneys also become damaged, resulting in CKD.
 Other common causes of chronic renal failure include:
 Recurring pyelonephritis (kidney infection)
 Polycystic kidney disease (multiple cysts in the kidneys)
 Putoimmune disorders such as systemic lupus erythematous

15. …CONT’D
 Hardening of the arteries, which can damage blood vessels
in the kidney
 Urinary tract blockages and reflux, due to frequent
infections, stones, or an anatomical abnormality that
happened at birth
 Excessive use of medications that are metabolized through
the kidneys

16. SIGN AND SYMPTOMS
 Some signs of chronic renal failure are more obvious than others.
These are:
 Decreased urination
 Blood in the urine (not a common symptom of chronic renal failure)
 Urine that is cloudy or tea-colored
Other symptoms aren't as obvious, but are a direct result of the
kidneys' inability to eliminate waste and excess fluid from the body:
 Puffy eyes, hands, and feet (Edema)
 High blood pressure

17. …CONT’D
 Fatigue
 Shortness of breath
 Loss of appetite
 Nausea and vomiting (this is a common symptom)
 Thirst
 Bad taste in the mouth or bad breath
 Weight loss
 Generalized, persistent itchy skin
 Muscle twitching or cramping
 A yellowish-brown tint to the skin
 As the kidney failure gets worse and the toxins continue to build
up in the body, seizures and mental confusion can result.

18. COMPLICATIONS
 Anemia
 High blood pressure (hypertension)
 Increased risk of bleeding
 Increased risk of infection
 Fluid overload (called edema)
 Dehydration
 Electrolyte abnormalities (e.g., hyperkalemia, high levels of potassium
in the blood)

19. …CONT’D
 Mineral abnormalities (e.g., hyperkalemia [high levels of
calcium in the blood] or hypophosphatemia [high levels of
phosphorus in the blood])
 Brittle bones
 Malnutrition
 Seizures

20. LAB VALUES
Component Pt Lab Values Normal Serum
Values
Creatinine 9.8mgdl 0.6-1.3mg/dl
BUN 27 8-20
Hemoglobin 10.4 female 10-14,
male 13-17
Hematocrit 33 female 36-48,
male 42-52
RBC Count 3.79 female 4.0-5.0
Potassium 5.5meq/L 3.5-5.3
Calcium 8mg/dl 8.6-10mg/dl
PH 7.24 7.35-7.45
Phosphorus 4.7mg/dl 2.5-4.5

21. MEDICATIONS
Erythropoietin
Indication: hemopoietic agent, prescribed for anemia
in people with CRF. Helps in formation of RBCs by the
Bone Marrow.
Contra-indication: avoid in patients with
hypersensitivity and uncontrolled Hypertension.
Side Effects:
1. High BP
2. Muscle and joint pain
3. Flu-Like Syndrome
4. Rashes and Hives
Precautions:
Avoid excess dossage

22. ALLUPURINOL
Indication: reduces serum and and urinary uricacid concentrations.
Contra-indication: Patients who have developed a severe reaction
to Allopurinol, should not be restarted on the drug.
Side Effects:
1. Diarrhea
2. Nausea
3. Fever and headache
4. Rashes on skin
Precautions:
Avoid excess dossage

23. Ferrous Sulphate- Iron
Indication: Essential body mineral prescribed for Iron
deficiency Anemia. Helps in RBC production in the
body.
Contra-Indication: avoid in pts with high Iron in blood and
Hypersensitivity
Side Effects:
Constipation
Dark-Green colored stool
Diarrhea
Nausea
Stomach Upset
Precautions: Monitor CBC, blood Iron level

24. …CONT’D
Sodium Bicarbonate
Indication: to treat metabolic acidosis, drug intoxications and
replacing bicarbs lost due to severe diarrhea
Contra-Indication: Avoid in pts with allergic to any ingredient in
Na2CO3
 Alkalosis
 low blood level of calcium and Chloride
 Vomitting
Side Effects:
 Frequent urge to urinate
 Headache
 Loss of appetite
 Muscle pain or twiching

25. …CONT’D
 Nervousness and restlessness
 Slow breathing
 Unpleasant taste
 Unusual weakness and tiredness

26. Ferrous Sulphate- Iron
Indication: Treating high blood pressure alone or with other medicines.
It is used in certain patients to decrease the risk of stroke.
Contra-Indication: You are allergic to any ingredient in losartan
• You are pregnant
Side Effects:
• Back pain
• Diarrhea
• Dizziness
• Tiredness
Precautions: Losartan may cause dizziness, light-headedness, or
fainting. These effects may be worse if you take it with alcohol or certain
medicines. Use losartan with caution. Do not drive or perform other possibly
unsafe tasks until you know how you react to it.

27. Vitamin B-12
Indication: Used to prevent and treat the
deficiency of Vit-B-12. to maintain health of
metabolism, blood cells and nerves. Given in:
1. Stomach problems
2. Poor nutrition
3. Cancer
4. HIV Infection
5. Pregnancy
6. Old Age
Contra-Indication:
Avoid in pts with allergy to any component including Cobalt

28. …CONT’D
Side Effects:
1. Abdominal/Stomach Pain
2. Bleeding from gums and nose
3. Blue lips and fingernails
4. Chest pain
5. Cough
6. Pale skin
7. Weight gain
8. Irregular HR
9. Irregular respiration
10.Tinnitus
11.Headache

29. MEDICAL AND SURGICAL MANAGEMENT
People with chronic Kidney failure have 3 treatment
choices
1. Dialysis
2. Renal Transplant
3. Conservative Treatment

30. …CONT’D
Dietary Modifications
 Aim:
Elimination of symptoms and prevention of further
deterioration
 Initiated:
When patient becomes azotemic
 What we do?
Manage diet, fluid, electrolytes and calcium phosphate balance

31. DIETARY MODIFICATIONS
 1.Dietary regulation of
protein
 a)Improves acidosis,
azotemia and nausea
 b)Reduces the excretory
load of the kidney
 Thereby decreases
intraglomerular pressure
and secondary injury to
nephrons
 2.Nutritional
supplements, if needed
 a)Multivitamin
supplements
 b) Patients with early renal
insufficiency, supplement
diet with CaCO3 along
with limited intake of
phosphate containing
foods

32. TAKE CARE OF “BEANS”
Practical clinical approach to the management of
patients with chronic renal failure
 Blood pressure should be maintained in a target
range lower than 130/80 mm Hg
 Hemoglobin levels should be maintained at 10-12
g/dL
 Hyperlipidemia should be treated with a “statin”
lipid lowering medication
 Smoking cessation should also be encouraged

33. DIALYSIS (DIA- THROUGH, LYSIS –
LOOSENING)
 *When the access should be created??
Serum creatinine> 4.0g/dL
GFR falls to <20 mL/min

34. INDICATIONS
 The decision to initiate dialysis renal failure depends on several
factors, divided into acute or chronic indications.
 In the patient with acute kidney injury -vowel acronym of “AEIOU”
is followed
 1.Acidemia from metabolic acidosis
 2.Electrolyte abnormality, such as severe hyperkalemia,
 3.Intoxication, that is acute poisoning with a dialyzable
substance.
 4.Overload of fluid
 5.Uremia complications, such as pericarditis, encephalopathy,
or gastrointestinal bleeding.

35. …CONT’D
Chronic indications for dialysis:
1. Symptomatic renal failure
2. Low glomerular filtration rate (GFR) In
diabetics, dialysis is started earlier
<15cc/min
3. Difficulty in medically controlling fluid
overload, serum potassium, and/or serum
phosphorus when the GFR is very low

36. DIALYSIS
Haemodialysis
Peritoneal dialysis
Haemodialysis is the removal of nitrogenous and
toxic products of metabolism from the blood by
means of a haemodialyzer system
Exchange occurs between the patient’s plasma
and dialysate (electrolyte composition of which
mimics that of extracellular fluid) across a semi
permeable membrane that allows uremic toxins to
diffuse out of the plasma while retaining the
formed components and protein composition of
blood

37. COMPONENTS OF DIALYSIS UNIT
1. Dialyzer
2. Dialysate production unit
3. Roller blood pump
4. Heparin infusion pump
5. Devices to monitor the
conductivity,temperature,flow rate

38. SET UP

39. …CONT’D
The frequency and duration of dialysis treatment are related to
1. Body size
2. Residual renal function
3. Protein intake
4. Tolerance to fluid removal
 The typical patient undergoes hemodialysis 3 times/week with each
treatment lasting approximately 3-4 hours on standard dialysis units and
slightly less time on high efficiency/high flux dialysis units

41. …CONT’D
1. In hemodialysis, the patient's blood is pumped through the blood
compartment of a dialyzer, exposing it to a partially permeable
membrane.
2. Blood flows through the fibers, dialysis solution flows around the outside
of the fibers, and water and wastes move between these two solutions.
3. The cleansed blood is then returned via the circuit back to the body.
4. Ultrafiltration occurs by increasing the hydrostatic pressure across the
dialyzer membrane.
5. This usually is done by applying a negative pressure to the dialysate
compartment of the dialyzer.
6. This pressure gradient causes water and dissolved solutes to move from
blood to dialysate, and allows the removal of several liters of excess fluid
during a typical 3- to 5-hour treatment

42. PERITONEAL DIALYSIS
1. Access is achieved via a catheter through the abdominal wall into the peritoneum
2. 1-2 liters of dialysate is placed in the peritoneal cavity and is allowed to remain for
varying intervals of time
3. Substances diffuse across the semipermeable peritoneal membrane to dialysate

43. RENAL TRANSPLANTATION
 Treatment of choice for patients with irreversible
kidney failure
 However the use of transplantation is limited by
organ availability
 INDICATIONS:
1. ESRD
2. Glomerulonephritis
3. Pyelonephritis
4. Congenital abnormalities
5. Nephrotic syndrome

44. DEMOGRAPHIC DATA
Name: Khursheed
MR #: 214-44-44
Age: 55 years
Marital Status: Unmarried
Religion: Islam
Culture/Language: Urdu
Education: BSc
Diagnosis and Surgery: Chronic Renal Failure and
Dialysis
Allergies: None

45. HEALTH PERCEPTION HEALTH
MANAGEMENT PATTERN
• General state of health: Client stated that (sehat nahi tou kuch nahi)
• No medications were taken at home.
• Immunization Status: Full
• Family was aware regarding disease process
• Pt. was aged, weak, neat and clean and was lying on the bed.
• Pt. was treated previously for HTN, DM, cataract surgery and
mastectomy.
• Nursing Diagnosis: Body image disturbance r/t loss of body part as
evidenced by patient’s verbalization.

46. ACTIVITY EXERCISE PATTERN
 Reparatory rate: 20 breaths/min, Regular and
normal breaths, no use of accessory muscles,
breath sounds were normal and no cyanosis
observed. Breathing spontaneously on room air.
 No specific exercise at home
 No cough, mucus whitish and watery with no odor.
 No chest tubes were inserted.
 No accessory devices were used by the patient

47. CIRCULATION
 Temperature was 37OC, BP was 124/64 mmHg & Pulse rate was 130
b/m, regular and +2.
 Homen's Sign was negative.
 Capillary refill was rapid within 2 seconds.
 Extremities were Pale and Warm with no Edema.
 No EKG and other monitors were attached and no Pace makers were
in placed.

48. COGNITIVE PERCEPTUAL PATTERN
 Patient was conscious with GCS of 15/15 and was oriented to time,
place and person.
 Memory: Recent: Active
 Speech: Clear
 Was able to share her feelings
 Pain score was zero

49. NUTRITION METABOLIC PATTERN
 Patient's Weight was 63 Kg and Height
 Skin was intact, lesions(1-2cm) and stage:1( Dryness) present on iliac region and on
back of the neck and turgor was loose due to aging.
 Oral cavity Pink and Normal
 Patient was fed orally.
 Diet: regular diet and fluid restriction
 Weight loss in last six months: Approx. 6-7 kg.
 Na: 136 and K: 5.5
Nursing Diagnosis:
 Impaired tissue integrity r/t to decreased blood and nutrients’ flow to tissue s/c to
limited activity.

50. ELIMINATION PATTERN
 Abdomen: Soft, Distended, Bowel sounds present
 Bladder: Soft, Urine clear
 Bowel function normal
 No stomach cramping

51. SLEEP REST PATTERN
 According to the family, patient used to sleep for1– 2 hours in the afternoon and 8
hours at night.
 Patient usual sleep pattern was normal
 Feel rested and relaxed when awaked
 Quality of sleep was good
 No use of sleeping aids

52. SELF PERCEPTION SELF CONCEPT PATTERN
Patient was
conscious and
satisfied with life

53. COPING STRESS TOLERANCE PATTERN
 Patient was calm and relax
 No use of any kinds of drugs.
 Support system: Brother and Mother
 Recitation of holy Quran when got
stressed and playing with her nephews

54. ROLE RELATIONSHIP PATTERN
 Pt. was a member of extended family
 Communication pattern (decision
making) was done by elder brother
 Financially the family was stable
 Satisfied with family and her work

55. SEXUALITY/REPRODUCTION PATTERN
Unmarried
Age of menopause: 48 years.
Mastectomy 23 years back

56. VALUE/BELIEF PATTERN
 She used to pray regularly
 Was satisfied with life and considered
everything as a blessing.
 Spiritually: Very strong

57. NCP’S

58. EDEMA
ASSESSMENT:-
 OBJECTIVE DATA:
Patient manifested:
Edema,
HTN,
Weight gain,
Pulmonary congestion (SOB),
JVP,
Oliguria

59. DIAGNOSIS:
 Fluid volume excess rate decrease GFR and sodium restriction as
menifested by edema, pulmonary congestion.

60. GOALS:
 SHORT TERM GOALS:
After 4-8 hours of nursing interventions, patient will
demonstrate behaving to monitor fluid status and reduce
recurrance of fluid retention.
 LONG TERM GOALS:
After 3-4 days of nursing interventions, patient will
menifest stabilize fluid volume, i.e balance F/O, V/S, stable
weight with no edema.

61. INTERVENTIONS:
 Monitor and record vital signs.
 Asses palpitation.
 Note intake and output of fluid from all
sources/ routes.
 Restrict sodium intake.
 Compare current weight with previous
weight i.e (at the time of admission).

62. EVALUATION:
 Patient shall have demonstrate behaviour to
monitor fluid status

63. LOSS OF APETITE
ASSESSMENT:
 SUBJECTIVE DATA:
“Khana bilkul bhi accha nahin lagta mujhay”
 OBJECTIVE DATA:
Weight loss
Anemia
Anorexia
Temperature: 36.3
Heart rate: 87
Respiration rate: 20
Blood pressure: 100/70

64. DIAGNOSIS
 Altered nutrition less than body
requirement, anorexia, malnutrition.

65. GOALS
 SHORT TERM GOALS:
After 4-5 hours of nursing interventions, client will
verbalize understanding of causative factors of
nursing intervention to promote optimum nutrition
 LONG TERM GOALS:
After 1-2 days of nursing intervention, client will be
able to demonstrate positive behavior to regain and
maintain appropriate nutritional intake.

66. EVALUATION:
 Client demonstrate behaviors and
lifestyle changes to maintain appropriate
nutritional intake.

67. DECREASED URINATION
ASSESSMENT
 SUBJECTIVE DATA:
“Peshaap bohot kam aata hai.”
 OBJECTIVE DATA:
increased lab value
Bun, cv, uric acid level, anuria, oliguria, urinary
retention

68. DIAGNOSIS:
 Impaired urinary elimination rate, impaired
excretion of nitrogenous products secondary
to renal failure.

69. GOALS:
 SHORT TERM GOALS:
After 2-3 hours of nursing intervention patient will
verbalize understanding of condition.
 LONG TERM GOALS:
After 1-2 days of nursing intervention, patient will
participate in measures to correct/ composite for
detects.

70. INTERVENTIONS
 Asses general condition of patient.
 Review laboratory tests
 Determine client pattern of elimination
 Palpate bladder
 Investigate pain

71. EVALUATION:
 Patient demonstrate participation in her
recommended progress.
 Patient demonstrate behaviours to prevent
complications

72. TEACHING PLAN: CHRONIC RENAL FAILURE
Assessment Objectives Content Strategy/
Time
Evaluation
Subjective Data:
Small amount or low
output of urine.
By the end of
the teaching
session,
learners will be
able to:
 Define chronic
Renal Failure.
Chronic Kidney Failure occurs
when disease or disorder
damages the kidney so that they
fail to remove water and waste
from the body ,as a result; loss of
kidney function occurs.
o Lecture
Assessing the
patient’s
knowledge at the
end of the
session.
Objective Data:
 Increase lab values.
o creatinine =1.6
o Bun= 17
 Describe
various
causes/
factors of
chronic renal
failure.
 Diabetes Mellitus(type 1 or type
2 diabetes)
 High blood pressure.
 Inflammatory, immunological or
hereditary disease of the
kidneys.
 charts
5 minutes

73. CONTINUE….
Assessment Objectives Content Strategy/time Evaluation
o Na= 137
o Cl= 107
o Hb= 10.4
o Hct= 36.9
o And uric acid
level.
 Pt feels oliguria.
 Pt feels
hesitation
 Urinary
retention.
 Explain the
symptoms and few
complication
Symptoms:
Fatigue, general ill feeling,
small amount of urine or no
urine, headache, nausea,
vomiting, weight loss, easy
bruising or bleeding,
increased or decreased urine
output etc.
Complications:
Hypertension, increased risk
of bleeding, increased risk of
infection, dehydration,
electrolyte abnormalities,
acidosis occurs etc.
•Discussion and
explanation with
patient’s family
members.
10 minutes
 The family
members
verbalized all
the symptom.

74. CONTINUE….
Assessment Objectives Content Strategy/time Evaluation
 Discuss few
preventive
measures to treat
the disease.
 Smoke:
Avoid smoking i.e. increase risk
of cardiovascular disease
including heart attack or stroke.
 Diet:
• Eat a balanced diet that
includes plenty of fresh fruits,
vegetables and whole grains.
• Limit the amount of salt in diet.
• Avoid eating foods high in
saturated fats includes meat
pills, hard cheese, cakes and
biscuits etc.
Pamphlet
10 minutes
Family was
satisfied with
the teaching.

75. CONTINUE….
Assessment Objectives Content Strategy/time Evaluation
• May need phosphorus restriction
i.e. restrict protein, restrict milk
and milk products.
• Eat some foods that are high in
unsaturated fats i.e. nuts and
seeds, avocados, oily fish, olive
oil etc. It helps to decrease the
level of cholesterol.
 Exercise:
Regular exercise should help lower
your blood pressure and reducing
risk of developing CKD,

76. CONTINUE….
Assessment Objectives Content Strategy/
time
Evaluation
Such exercise is recommended i.e.
(cycling or fast walking) every week.
Pain Killers:
Chronic kidney failure (CKF) can be
caused by the improper use of (NSAIDS)
such as Aspirin or Ibuprofen. Drugs can
be related to:
• Active Vitamin D supplements.
•Cholesterol lowering medications etc.