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  2. Introduction • Kidney failure is abnormal kidney function in which the kidneys are unable to adequately excrete the body’s metabolic waste from the body or perform their regulatory functions. 3/13/2023 2 Mr. KASONGO
  3. • The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as resulting in fluid, electrolyte and acid-base disturbances. • Renal failure is a systemic disease and is a final common pathway of many different kidney and urinary tract diseases. (Smeltzer 2010) 3/13/2023 3 Mr. KASONGO
  4. Anatomy of the Kidney 3/13/2023 4 Mr. KASONGO
  5. Nephron 3/13/2023 5 Mr. KASONGO
  6. Functions Of The Kidney’s • Urine Formation: Formed in the nephrons through a complex three-step process: Glomerular filtrate, tubular reabsorption, and tubular secretion • Excretion of waste products: eliminates the body’s metabolic waste products (urea, creatinine, phosphates, sulfates) 3/13/2023 6 Mr. KASONGO
  7. • Regulation of electrolytes: volume of electrolytes excreted per day is exactly equal to the volume ingested – Na – allows the kidney to regulate the volume of body fluids, dependent on aldosterone (fosters renal reabsorption of Na) – K – kidneys are responsible for excreting more than 90% of total daily intake • RETENTION OF K IS THE MOST LIFE-THREATENING EFFECT OF RENAL FAILURE 3/13/2023 7 Mr. KASONGO
  8. Renin-Angiotensin System 3/13/2023 8 Mr. KASONGO
  9. • Control of water balance: Normal ingestion of water daily is 1-2L and normally all but 400-500mL is excreted in the urine – Osmolality: degree of dilution or concentration of urine – Specific Gravity: measurement of the kidney’s ability to concentrate urine (weight of particles to the weight of distilled water) – ADH: vasopressin – regulates water excretion and urine concentration in the tubule by varying the amount of water reabsorbed. 3/13/2023 9 Mr. KASONGO
  10. • Control of blood pressure: BP monitored by the vasa recta. – Juxtaglomerular cells, afferent arteriole, distal tubule, efferent arteriole • Renal clearance: ability to clear solutes from plasma – Dependent on rate of filtration across the glomerulus, amount reabsorbed in the tubules, amount secreted into the tubules 3/13/2023 10 Mr. KASONGO
  11. –CREATININE • Regulation of red blood cell production: Erythropoeitin is released in response to decreased oxygen tension in renal blood flow. • This stimulates the productions of RBCs (increases amount of hemoglobin available to carry oxygen) 3/13/2023 11 Mr. KASONGO
  12. • Synthesis of vitamin D to active form: final conversion of vit D into active form to maintain Ca balance • Secretion of prostaglandins: important in maintaining renal blood flow. • They have a vasodilatory effect 3/13/2023 12 Mr. KASONGO
  13. Acute Renal Failure 3/13/2023 13 Mr. KASONGO
  14. Definition • Acute renal failure (ARF) is an abrupt and sudden reduction in renal function resulting in the inability to excrete metabolic wastes and maintain proper fluid & electrolyte balance • It is usually associated with oliguria (urine output <30cc/hr or <400cc/day), although urine output may be normal or increased • BUN & creatinine values are elevated 3/13/2023 14 Mr. KASONGO
  15. Statistics of ARF • Frequency: condition develops in 5% of hospitalized patients and 0.5% patients require dialysis – Elderly are at high risk – Post-op patients • Mortality: the mortality rate estimates vary from 25-90% • Race: no racial predilection is recognized 3/13/2023 15 Mr. KASONGO
  16. Pathophysiology • ARF may occur in 3 clinical settings: • As an adaptive response to severe volume depletion and hypotension, with structurally and functionally intact nephrons (Prerenal) • In response to cytotoxic or ischemic insults to the kidney, with structural and functional damage (Intrinsic or Intrarenal) • Obstruction to the passage of urine (Postrenal) 3/13/2023 16 Mr. KASONGO
  17. Phases of Acute Renal Failure • Clinical progression of reversible RF occurs in four phases: – Initiation phase • Begins with initial insult and ends when oliguria develops – Oliguric phase • Accompanied by rise in serum concentrations of substances usually excreted by kidneys (urea, creatinine, organic acids, intracellular cations [K+ & Mg]) • urinary output <400cc/day 3/13/2023 17 Mr. KASONGO
  18. Diuretic phase • The kidneys begin to recover • Initially produce hypotonie urine due to increase in glomerular filtration rate Recovery phase • Tubular function restored • Diuresis subsides and kidney begins to function normally again 3/13/2023 18 Mr. KASONGO
  19. Aetiology of acute renal failure Prerenal acute renal failure • Is the most common cause of ARF occurring in 60-70% of cases • It is caused by impaired blood flow as a result of intravascular depletion, which leads to decreased effective circulating volume to the kidneys • In patients with prerenal ARF, the parenchymal is undamaged, and the kidneys 3/13/2023 19 Mr. KASONGO
  20. • Causes include: – Secondary to renal hypoperfusion which occurs in setting of extracellular fluid loss • Diarrhea • Vomiting • Diuretics – Impaired/inadequate cardiac output – Drugs • NSAIDs – Hypovolemia – Hemorrhage – Renal vasoconstriction 3/13/2023 20 Mr. KASONGO
  21. • Decreased peripheral resistance due to anaphylaxis, neurologic injury and some hypertensive drugs. i.e ACE inhibitors • Decreased renal vascular blood flow due to bilateral renal vein thrombosis, embolism and renal artery thrombosis. 3/13/2023 21 Mr. KASONGO
  22. Intrinsic acute renal failure • Is the result of actual parenchymal damage to the glomeruli or kidney tubules • A physiologic hallmark is failure to maximally concentrate urine • Is divided into 4 categories: • Acute tubular disease • Glomerular disease • Vascular disease • Interstitial disease 3/13/2023 22 Mr. KASONGO
  23. Intrinsic ARF • Acute Tubular Necrosis – most common type of ARF, a more ischemic insult to the kidneys, usually induced by ischemia or toxins – Caused by: • Burns, and crush injuries – myoglobin & hemoglobin are liberated causing renal toxicity or ischemia • Drugs – NSAIDs, ACE inhibitors, aminoglycosides • Infections • Nephrotoxic agents – contrast agent 3/13/2023 23 Mr. KASONGO
  24. • Glomerulonephritis -uncommon cause, most associated with CRF -Caused by: • Can be a primary disorder or can occur secondary to systemic disease • Systemic lupus erythematosus 3/13/2023 24 Mr. KASONGO
  25. Intrinsic ARF • Acute Interstitial Nephritis -Interstitial disturbance that leads to ARF -Caused by: • Allergic reaction to drugs • Vascular Disease -Can occur on microvascular and macrovascular 3/13/2023 25 Mr. KASONGO
  26. – Caused by: • Microvascular -Hemolytic anemia -ARF secondary to small vessel thrombosis or occlusion • Macrovascular -Suspected in elderly -Renal artery stenosis or thrombosis -Atheroembolism secondary to atrial fibrillation and aortic disease 3/13/2023 26 Mr. KASONGO
  27. Postrenal acute renal failure • Is rare and occurs with urinary tract obstruction that affects the kidneys bilaterally • Pressure rises in the kidney tubules, eventually the GFR decreases 3/13/2023 27 Mr. KASONGO
  28. Post renal ARF • Causes include: – Bladder tract obstruction – Prostatic hypertrophy – Catheters – Urethral strictures. – Bladder cancer. – Spinal cord disease. Trauma from the back, pelvis or perineum. • Postrenal causes are typically reversible 3/13/2023 28 Mr. KASONGO
  29. Clinical manifestations • Muscle weakness • Dysrhythmias • Pruritus • Oliguria • Pitting oedema • Hypertension • Pulmonary oedema 3/13/2023 29 Mr. KASONGO
  30. • Metabolic acidosis with kussmal respirations (hyperventilation) and pulmonary oedema • Altered mental state • Anorexia • Nausea • Dry skin • Headache • Seizure 3/13/2023 30 Mr. KASONGO
  31. Investigations • BUN and serum creatinine values • Creatinine clearance which measures the kidney’s ability to clear the blood of creatinine and approximate the glomerular filtration rate • Urinalysis • Renal ultrasound 3/13/2023 31 Mr. KASONGO
  32. • Renal scan • Renal biopsy • Serum electrolyte analysis will show increased levels of potassium due to decreased GFR and increased phosphate concentration • CT scan or MRI retro grade pyelogram • Haemoglobin levels will be lower due to reduced erythropoietin production 3/13/2023 32 Mr. KASONGO
  33. Nursing Care Plan • Fluid volume deficit related to hemorrhage (hypovolemic shock) – Priority to restore fluid balance and circulation • The patient will: – show stable vital signs – have adequate urine output >30cc/hr – have strong peripheral pulses indicating tissue perfusion 3/13/2023 33 Mr. KASONGO
  34. Nursing Care Plan • Interventions – Bleeding reduction, fluid resuscitation, blood product administration, IV therapy – Monitor VS q2h – Monitor weight daily – Skin & tongue turgor – Monitor and document I&O – Monitor CBC, ABG, urinalysis, ECG • Rationales – Early intervention can prevent progression of hypovolemia to hypovolemic shock that may result in renal damage – S&S correlate with the approximate percentage of volume loss • Medullary vasomotor center stimulation via the baroreceptor reflex • ADH – Foley catheter facilitates monitoring of urine output – Shock pt hemodynamically unstable with compromised compensatory mechanisms, volume admin may cause fld overload 3/13/2023 34 Mr. KASONGO
  35. Nursing Care Plan • Electrolyte imbalance related to decreased electrolyte excretion, and metabolic acidosis – Priority to prevent complications of electrolyte imbalance • Within 24h of admission and then continuously, the pt will: – Maintain serum electrolyte levels within acceptable limits – Have normal sinus rhythm 3/13/2023 35 Mr. KASONGO
  36. Nursing Care Plan • Interventions – Monitor & document electrolyte levels q8-12h, especially: • K+, P, Ca, Mg – Monitor ABG – Monitor ECG especially: • High tented T waves, prolonged PR interval or widened QRS complex – Limit dietary & drug intake of potassium • Rationales – Kidneys’ ability to regulate electrolyte excretion & reabsorption may result in high K+ & P, low Ca, & high/low Mg levels. – ARF causes metabolic acidosis which may increase the release of K+ from cells in exchange for H+ ions – Electrolyte abN can trigger arrhythmias & cardiac arrest – When kidneys cannot excrete K+, excess intake can increase serum K+ to dangerous levels 3/13/2023 36 Mr. KASONGO
  37. Nursing Care Plan • Knowledge deficit of acute renal failure related to lack of exposure to information on management of complex condition – Priority to provide in depth information on acute renal failure • Upon discharge the patient will: – Be able to identify signs and symptoms to report to nurse or physician – Commitment to comply with treatments, including dialysis, dietary modifications, and activity restrictions 3/13/2023 37 Mr. KASONGO
  38. Nursing Care Plan • Interventions – Provide as appropriate information on the severity of ARF & dialysis • Stages of ARF • Medications including action and adverse effects • S&S • Procedures such as dialysis including schedule and adverse effects • Dietary modifications including limitations of proteins (catabolism), electrolytes and fluids • Rest and activity restrictions • Rationales – The patient and family need assistance, explanation, and support during this time. – Teaching may decrease anxiety and fear, and enhance recovery to patient and family members. – Continued assessment of the patient for complications of ARF and of its precipitating cause is essential. 3/13/2023 38 Mr. KASONGO
  39. Medications for ARF Pharmacologic treatment of ARF has been attempted on an empirical basis, with varying success rates. It is critical to adjust (decrease or discontinue) medication dosages for patient in acute renal failure. Administering the average dose to patient in renal failure can kill a patient. 3/13/2023 39 Mr. KASONGO
  40. Immediate goal is to retain fluid volume deficit through use of blood products and crystalloids • Normal Saline (0.9% Na) - only one that is compatible with blood transfusions – Restores fluid loss – Provides electrolytes resembling those of plasma • Packed RBC – To increase blood volume – To restore blood to kidneys 3/13/2023 40 Mr. KASONGO
  41. •Diuretics –Furosemide (Lasix) only given with severe fluid overload –Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the thick ascending loop of Henle and the distal renal tubule 3/13/2023 41 Mr. KASONGO
  42. –Adult dose: 20-80 mg PO/IV once; repeat 6-8h prn or dose may be increased by 20-40 mg no sooner than 6- 8h after previous dose until desired effect –Nursing Assessments: Watch for hypokalemia, assess BP before and during therapy can cause hypotension 3/13/2023 42 Mr. KASONGO
  43. • Vasodilators – Dopamine • In small doses causes selective dilatation of the renal vasculature, enhancing renal perfusion. • Reduces sodium absorption, thereby decreasing the energy requirement of the tubules. • This enhances urine flow, which, in turn, helps prevent tubular cast obstruction. 3/13/2023 43 Mr. KASONGO
  44. • Adult dose: 2-5 mcg/kg/min • Nursing Assessments: Monitor blood pressure during administration. • Stop infusion if blood pressure drops 30mm Hg • Monitor input and out put 3/13/2023 44 Mr. KASONGO
  45. • Alkalinizer – Sodium Bicarbonate – Increases plasma bicarbonate, which buffers Hydrogen ion concentration; reverses acidosis – Adult Dose: Initial dose IV bolus 1 mEq/kg, then infuse 2-5 mEq/kg over 4- 8 hr depending on CO2, pH • Dilute with equal amounts of NS, 2-5 mEq/kg 3/13/2023 45 Mr. KASONGO
  46. • Nursing assessments: • Assess respirations and pulse rate, rhythm, depth, lung sounds • Monitor input and output, electrolytes, blood pH, HCO3 • Monitor urine pH at the beginning of treatment and monitor for alkalosis as well 3/13/2023 46 Mr. KASONGO
  48. Chronic Renal Failure ESRF 3/13/2023 48 Mr. KASONGO
  49. Definition • Also known as End-Stage Renal Failure (ESRF), is a progressive deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia (retention of urea and other nitrogenous wastes in the blood). • Decreased kidney glomerular filtration rate 3/13/2023 49 Mr. KASONGO
  50. Pathophysiology • As renal function declines, the end products of protein metabolism (which are normally excreted in the urine), accumulate in the blood. • Uremia develops and adversely affects every system in the body. 3/13/2023 50 Mr. KASONGO
  51. • The greater the buildup of waste products, the more severe the symptoms. • Regardless of the etiology of renal injury, with progressive destruction of nephrons, the kidney has an innate ability to maintain glomerular filtration rate (GFR) by hyperfiltration and compensatory hypertrophy of the remaining healthy nephrons. 3/13/2023 51 Mr. KASONGO
  52. • This nephron adaptability allows for continued normal clearance of plasma solutes such that substances such as urea and creatinine start to show significant increases in plasma levels only after total glomerular filtrateion rate (GRF) has decreased to 50%, when the renal reserve has been exhausted. • The plasma creatinine value will double with a 50% reduction in GFR. 3/13/2023 52 Mr. KASONGO
  53. Stages of Chronic Renal Disease • 3 stages in nephron function • Stage 1: Reduced Renal Reserve Characterized by a 40%-75% loss of nephron funtion. The patient is usually asymptomatic because the remaining nephrons are able to carry out normal function of the kidney 3/13/2023 53 Mr. KASONGO
  54. Stage 2 of Renal Disease • Stage 2: Renal Insufficiency Occurs when 75%-90% of nephron function is lost. At this point, the serum creatinine and BUN rise, the kidney loses its ability to concentrate urine and anemia develops. The patient may report polyuria and nocturia 3/13/2023 54 Mr. KASONGO
  55. Stage 3 of Renal Disease • Stage 3: End-Stage Renal Disease The final stage, occurs when there is less than 10% of nephron function remaining. All normal regulatory, excretory, and hormonal functions of the kidneys are severely impaired. 3/13/2023 55 Mr. KASONGO
  56. ESRD is evidenced by elevated creatinine and BUN levels as well as electrolyte imbalances. Dialysis is usually indicated at this point. 3/13/2023 Mr. KASONGO 56
  57. Glomular Filtration Rate • GFR: a Kidney function test in which results can be determined from amount of ultrafiltrate formed by plasma flowing through the glomeruli of the kidney. • As glomular filtration decreases, the serum creatinine and BUN levels increase. 3/13/2023 57 Mr. KASONGO
  58. Causes Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidney disease in the United States. High Blood Pressure (hypertension), if not controlled, can damage the kidneys over time. 3/13/2023 58 Mr. KASONGO
  59. Glomerulonephritis is the inflammation and damage of the filtration system of the kidney and can cause kidney failure. Post infectious conditions and Lupus are among the many causes of glomerulonephritis. 3/13/2023 Mr. KASONGO 59
  60. More Causes Polycystic Kidney Disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiple cysts Use of analgesics such as acetaminophen (Tylenol) and ibuprophen regularly over long durations of time can cause analgesic nephropathy, another cause of kidney disease. Certain other medications can also damage the kidneys. 3/13/2023 60 Mr. KASONGO
  61. Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a condition called ischemic nephropathy, which is another cause of progressive kidney damage. Obstruction of the flow of urine such as by stones, an enlarged prostate, strictures (narrowings), or cancers may also cause kidney disease 3/13/2023 Mr. KASONGO 61
  62. Clinical Manifestation • Patients with CRF stage 3 or lower (GFR >30 mL/min) generally are asymptomatic and do not experience clinically evident disturbances in water or electrolyte balance or endocrine/metabolic disturbances. • Generally, these disturbances clinically manifest with CRF stages 4 and 5 (GFR <30 mL/min). 3/13/2023 62 Mr. KASONGO
  63. Clinical Manifestations • Hyperkalemia usually develops when GFR falls to less than 20-25 mL/min because of the decreased ability of the kidneys to excrete potassium. • Metabolic acidosis because the kidney cannot excrete increased loads of acid. 3/13/2023 63 Mr. KASONGO
  64. Clinical Manifestations • Extracellular volume expansion and total-body volume overload results from failure of sodium and free water excretion. • Anemia principally develops from decreased renal synthesis of erythropoietin, the hormone responsible for bone marrow stimulation for red blood cell (RBC). 3/13/2023 64 Mr. KASONGO
  65. • Calcium and Phosphorus imbalance occurs because of a disorder in metabolism. • They have a reciprocal relationship in the body; as one rises, the other decreases. 3/13/2023 Mr. KASONGO 65
  66. • weakness, fatigue, confusion, disorientation, tremors, seizures, restlessness of legs, burning of soles of feet, behavioral changes. • Ammonia odour to breath, metallic taste, mouth ulcerations and bleeding, anorexia, N&V, hiccups, constipation or diarrhea, bleeding from GI tract. 3/13/2023 Mr. KASONGO 66
  67. • Crackles, thick tenacious sputum, depressed cough reflex, pleuritic pain, shortness of breath, engorged neck veins, tachypnea, uremic pneumonitis, “uremic lung 3/13/2023 Mr. KASONGO 67
  68. Nursing Care Plan  Excess fluid volume related to decreased urine output, and retention of sodium and water Goal is maintenance of ideal body weight without access fluid • Nursing Interventions  Assess fluid Status  Daily weight  I & O  Skin turgour & edema  Distention of neck veins  BP, P, R  Limit fluid intake to prescribed volume  Explain to pt and family rationale for restriction of food  Provide or encourage frequent oral care  Rationale  Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions  Fluid restriction will determine on the basis of weight, urine output, and response of therapy  Understanding promotes pt and family cooperation with fluid restrictions  Oral hygiene minimizes dryness of oral mucous membranes  Expected Outcomes  Demonstrates no rapid weight changes  Maintains dietary and fluid restrictions  Exhibits normal skin turgour without edema  Normal vitals  Reports no difficulty breathing or shortness of breath  Reports decrease dryness of oral mucous membranes. 3/13/2023 68 Mr. KASONGO
  69. Nursing Care Plan  Hyperkalemia, pericarditis, pericardial effusion and temponade, hypertension, anemia, bone disease • Goal: Patient experiences and absence of complications  Nursing Interventions  Hyperkalemia  Monitor serum K levels and notify physician if greater than 5.5 mEq/L.  Assess patient for muscle weakness, diarrhea, ECG changes( tall tented Twaves, widened QRS). • Rationale  Hyperkalemia causes potentially life-threatening changes to the body  Cardiovascular S & S are characteristic of hyperkalemia  Expected Outcomes  Pt has normal K level  Experiences no muscle weakness or diarrhea,  Exhibits normal ECG pattern  Vital signs are within normal limits 3/13/2023 69 Mr. KASONGO
  70. • Pericarditis, Pericardial effusion, tamponade  Assess for fever, chills, chest pain and pericardial friction rub (signs of pericarditis).  If pt has pericarditis, ax q 4 hrs • Extreme hypotension • Weak of absent peripheral pulses, altered level of consciousness, bulging neck veins. • Rationale  About 30-50% of CRF pts develop pericarditis due to uremia; fever ,chest pain, and pericardial friction rub are classic signs  Pericardial effusion is common following pericarditis. Signs of effsusion: paradoxical pulse (> 10 mm drop in BPduring inspiration) and signs of shock d/t compression of the heart by a lg effusion.  Cardiac tamponade exists when the pt is severely compromised hemodynamically  Outcomes  Has strong and equal peripheral pulse  Absence of paradoxical pulse  Absence of pericardial effusion, or tamponade 3/13/2023 70 Mr. KASONGO
  71. • Hypertension  Monitor and record blood pressure  Administer antihypertensives as prescribes  Encourage compliance with dietary and fluid restriction therapy  Teach pt report signs of fluid overload, vision changes, headaches, edema, seizures • Rationale  Antihypertensives play a key role in tx of hypertension associated with CRF.  Adherence to diet and fluid restrictions prevents excess fluid and sodium accumulation  These are indications of inadequate control of hypertension, and need to alter therapy  Outcomes  BP is within normal limits  No headaches, visual problems or seizures  No edema  Demonstrates compliance with dietary and fluid restrictions 3/13/2023 71 Mr. KASONGO
  72. • Anemia  Monitor RBC count, Hg, and HCT levels  Administer prescribes meds: iron and folic acid  Avoid drawing unnecessary blood specimens  Teach pt to prevent bleeding; avoid vigorous nose blowing  Administer blood component therapy • Rationale  Provides Ax of degree of anemia  RBCs need iron and folic acid to be produced.  Anemia is worsened by drawing numerous specimens  Blood component therapy may be needed if pt has symptoms  Outcomes  Pt has normal colour without pallor  Hematology values are within acceptable limits  Experiences not bleeding form any site. 3/13/2023 72 Mr. KASONGO
  73. • Bone Disease  Administer the following meds as prescribed: phosphate binders, calcium supplements, vit D supplements  Monitor serum lab values ( calcium, phosphorus, aluminum)  Assist pt with exercise program  Rationale  CRF causes numerous physiologic changes affecting calcium, phosphorus and vit D metabolism.  Hyperphophatemia, hypocalcemia, and excess aluminum accumulation are common  Bone demineraliztion decreases with immobility.  Outcomes  Serum calcium, phosphorus, and aluminum levels are within acceptable ranges.  Has no bone demineralization  Discuss importance of maintaining activity level and exercise program. 3/13/2023 73 Mr. KASONGO
  74. Diet • Protein restriction b/c urea, uric acid and organic acids- the breakdown product of dietary and tissue proteins- accumulate rapidly in the blood when there is impaired renal clearance. • The allowed protein must be of high biologic value (diary products, eggs, meats). These proteins are those that are complete proteins and supply the essential amino acids necessary for cell growth and repair; also maintenance of fluid balance, healing and skin integrity, and maintenance 3/13/2023 74 Mr. KASONGO
  75. • Fluid restrictions: fluid allowance is usually 500-600 ml more than the previous day’s 24 hr output. • Calories are supplied by carbs and fats to prevent wasting and malnutrition • Vitamin supplementation because a protein restricted diet does provide the necessary amounts of vitamins and the pt on dialysis may lose water soluble vitamins from the blood during treatment. 3/13/2023 Mr. KASONGO 75
  76. Medications for CRF • Diuretics Furosemide (Lasix) only given with severe fluid overload • Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the thick ascending loop of Henle and the distal renal tubule 3/13/2023 76 Mr. KASONGO
  77. –Adult dose: 20-80 mg PO/IV once; repeat 6-8h prn or dose may be increased by 20-40 mg no sooner than 6-8h after previous dose until desired effect –Nursing Assessments: Watch for hypokalemia, assess BP before and during therapy can cause hypotension 3/13/2023 Mr. KASONGO 77
  78. Medications for CRF continued • Phosphate-lowering agents –Calcium acetate (Calphron) –Combines with dietary phosphorus to form insoluble calcium phosphate, which is excreted in feces. –Adult dose: 1-2 g PO bid-tid with each meal; increase to bring serum phosphate value to 6 mg/dL as long as hypercalcemia does not develop; 3/13/2023 78 Mr. KASONGO
  79. • Calcium carbonate (Caltrate) • Successfully normalizes phosphate concentrations • Neutralizes gastric acidity, increase serum Ca - Adult dose: 1-2 g PO divided bid- tid; with meals as a phosphorous binder; between meals as a calcium supplement 3/13/2023 Mr. KASONGO 79
  80. Phosphate-lowering agents – Calcitriol (Rocaltrol) • Increases intestinal absorption of calcium for treatment of hypocalcemia and increases renal tubular resorption of phosphate – Adult dose for hypocalcemia during chronic dialysis: • 0.25 mcg/day or every other day, may require 0.5-1 mcg/day PO – Sevelamer (Renagel) • Indicated for the reduction of serum phosphorous in patients with ESRD. – Adult dose: Initial: 800-1600 mg PO tid with meals Maintenance: Increase or decrease by 400-800 mg per meal q2wk to maintain serum phosphorous at 6 mg/dL or less 3/13/2023 80 Mr. KASONGO
  81. Phosphate-lowering agents – Doxercalciferol (Hectorol) • To lower parathyroid hormone levels in patients undergoing chronic kidney dialysis. Increases serum Ca – Adult dose: 10 mcg PO 3 times/wk at dialysis; increase dose by 2.5 mcg/8 wk if iPTH is not lowered by 50% and fails to reach the target range; not to exceed 20 mcg/3 times/wk Alternatively, 4 mcg IV 3 times/wk; may adjust dose by 1-2 mcg/8 wk to maintain iPTH levels – Nursing Assessment for all phosphate lowering agents: Monitor BUN, creatinine, chloride, electrolytes, urine pH, urinary calcium, mg, phosphate, urinalysis urinary Ca should be 9-10mg/dl, assess for hypocalcemia: headache, N/V, confusion 3/13/2023 81 Mr. KASONGO
  82. Medications • Anemia – Epoetin alfa (Epogen, Procrit) • Stimulates RBC production – Adult dose: 50 -150 U/kg IV/SC 3 times per week, then adjust dose by 25 U/kg/dose to maintain appropriate Hct; maintenance 12.5-25 U/kg, titrate to target Hct, – Nursing Assessment: Monitor renal studies: urinalysis, protein, blood, BUN, creatinine; I&O. Monitor blood studies, Hgb, Hct, RBC, WBC, INR, PTT 3/13/2023 82 Mr. KASONGO
  83. Medications – Darbepoetin (Aranesp) • Stimulates erythropoiesis – Adult dose: 0.45 ug/kg IV/SC as a single injection, titrate not to exceed a target Hgb of 12 g/dl – Has a longer half-life than epoetin alfa – Nursing Assessments: Assess blood studies, renal studies; assess BP, check for rising BP as Hct rises 3/13/2023 83 Mr. KASONGO
  84. Medications • Iron Salts – To treat anemia – Ferrous sulfate (Feosol, Feratab, Slow FE) • Replaces iron stores need for RBC development – Adult dose: 100-200mg tid – Iron sucrose (Venofer) • Used to treat iron deficiency dute to chronic hemodialysis – Adult dose: IV 5ml (100mg of elemental iron) given during dialysis, most will need 1000mg of elemental iron over 10 dialysis • Nursing Assessments: Monitor blood studies, Hct, Hgb, total Fe, monthly. Assess bowel elimination for constipation 3/13/2023 84 Mr. KASONGO
  85. Dialysis 3/13/2023 85 Mr. KASONGO
  86. What is Dialysis? • Dialysis is a type of renal replacement therapy which is used to provide artificial replacement for lost kidney function due to acute or chronic kidney failure • It is a life support treatment, it does not cure acute or chronic renal failure 3/13/2023 86 Mr. KASONGO
  87. • Healthy kidneys remove waste products (potassium, acid, urea) from the blood and they also remove excess fluid in the form of urine • Dialysis has to duplicate both of these functions Dialysis – waste removal Ultrafiltration – fluid removal 3/13/2023 Mr. KASONGO 87
  88. Principle of Dialysis • Dialysis works on the principle of diffusion of solutes along a concentration gradient across a semipermiable membrane • Blood passes on one side of the semipermeable membrane, and a dialysis fluid is passed on the other side • By altering the composition of the dialysis fluid, the concentrations of the undesired solutes (potassium, urea) in the fluid are low, but the desired solutes (sodium) are at their natural concentration found in healthy blood 3/13/2023 88 Mr. KASONGO
  89. 2 Main Types of Dialysis • Hemodialysis • Peritoneal Dialysis 3/13/2023 89 Mr. KASONGO
  90. Hemodialysis Adapted from National Institute of Diabetes and Digestive and Kidney Diseases. National Institute of Diabetes and Digestive and Kidney Diseases. End-stage renal disease: choosing a treatment that's right for you. Available at: Accessed May 10, 2000. 3/13/2023 90 Mr. KASONGO
  91. What is Hemodialysis (HD)? • Client’s blood is passed through a system of tubing (dialysis circuit) via a machine to a semipermeable membrane (dialyzer) which has the dialysis fluid running on the other side • The cleansed blood is then returned via the circuit back to the body 3/13/2023 91 Mr. KASONGO
  92. • The dialysis process is very efficient (much higher than in the natural kidneys), which allows treatments to take place intermittently (usually 3 times a week), but fairly large volumes of fluid must be removed in a single treatment which can be very demanding on a client 3/13/2023 Mr. KASONGO 92
  93. Side Effects of HD • The side effects are proportionate to the amount of fluid being removed • Decreased blood pressure • Fatigue, Chest pains, Leg cramps • Headaches, Electrolyte imbalance • Nausea and vomiting • Reaction to the dialyzer • Air embolism 3/13/2023 93 Mr. KASONGO
  94. Complications of HD • Infection The risk of infection depends on the type of access used • Bleeding may also occur at the access site • Blood clotting was a serious problem in the past, but the incidence of this has decreased with the routine use of anticoagulants (Heparin is the most 3/13/2023 94 Mr. KASONGO
  95. Rare Complication of HD • On the rare occasion, a client may have a severe anaphylactic reaction Sneezing Wheezing Back pain Chest pain Sudden death • This can be caused by the sterilant in the dialyzer or the material in the membrane itself 3/13/2023 95 Mr. KASONGO
  96. Equipment Needed for HD • The HD machine performs the function of pumping the patient's blood and the dialysate through the dialyzer. • The newest dialysis machines on the market are highly computerized and continuously monitor an array of safety-critical parameters, including blood and dialysate flow rates, blood pressure, heart rate, conductivity, pH, etc. • If any reading is out of normal range, an audible alarm will sound to alert the patient- care technician who is monitoring the patient. 3/13/2023 96 Mr. KASONGO
  97. Equipment – Water System • An extensive water purification system is absolutely critical for HD • Since dialysis patients are exposed to vast quantities of water, which is mixed with the acid bath to form the dialysate, even trace mineral contaminants or bacterial endotoxins can filter into the patient's blood. • Because the damaged kidneys are not able to perform their intended function of removing impurities, ions that are introduced into the blood stream via water can build up to hazardous levels, causing numerous symptoms including death • For this reason, water used in HD is purified 3/13/2023 97 Mr. KASONGO
  98. Equipment – The Dialyzer • The dialyzer, or artificial kidney, is the piece of equipment that actually filters the blood • The blood is run through a bundle of very thin capillary-like tubes, and the dialysate is pumped in a chamber bathing the fibers • The process mimics the physiology of the glomerulus and the rest of the nephron • Dialyzers come in many different sizes. A larger dialyzer will usually translate to an increased membrane area, and an increase in the amount of undesired solutes removed from the patient's blood. • The nephrologist will prescribe the dialyzer to be used depending on the patient • Dialyzers are not shared between patients in the practice of reuse. 3/13/2023 98 Mr. KASONGO
  99. Peritoneal Dialysis 3/13/2023 99 Mr. KASONGO
  100. What is Peritoneal Dialysis (PD)? • Peritoneal dialysis works by using the body's peritoneal membrane, which is inside the abdomen, as a semi- permeable membrane. • A specially formulated dialysis fluid is instilled around the membrane, using an indwelling catheter, then dialysis can occur, by diffusion 3/13/2023 100 Mr. KASONGO
  101. • Excess fluid can also be removed by osmosis, by altering the concentration of glucose in the fluid. • Dialysis fluid is instilled via a peritoneal dialysis catheter, which is placed in the patient's abdomen, running from the peritoneum out to the surface, near the navel • Peritoneal dialysis is typically done in the patient's home and workplace, but can be done almost anywhere 3/13/2023 Mr. KASONGO 101
  102. Advantages of PD • Can be done at home • Relatively easy for the client to learn • Easy to travel with, bags of solution are easy to take on holiday • Fluid balance is usually easier when the client is on PD than if the client is on HD 3/13/2023 102 Mr. KASONGO
  103. Disadvantage of PD • Requires a degree of motivation and attention to cleanliness while performing PD • There are a number of complications 3/13/2023 103 Mr. KASONGO
  104. Complications of PD • Peritoneal dialysis requires access to the peritoneum. • As this access breaks normal skin barriers, and as people with renal failure generally have a slightly suppressed immune system, infection is a relatively common problem • Long term peritoneal dialysis can cause changes in the peritoneal membrane, causing it to no longer act as a dialysis membrane as well as it used to. 3/13/2023 104 Mr. KASONGO
  105. • This loss of function can manifest as a loss of dialysis adequacy, or poorer fluid exchange (also known as ultra filtration failure) • Fluid may leak into surrounding soft tissue, often the scrotum in males • Hernias are another problem that can occur due to the abdominal fluid load 3/13/2023 105 Mr. KASONGO
  106. Nursing Assessments • Before client is in the unit, look at the nurses notes from the treatment before Any problems, will help nurse plan for the upcoming treatment • Look at the client Strength Gait Whether client needs assistance Color Puffiness 3/13/2023 106 Mr. KASONGO
  107. • Could be caused by excess fluid, too much to drink, more fluid should be taken off with each treatment, changes in voiding pattern (are they voiding less than they did last month) 3/13/2023 Mr. KASONGO 107
  108. Assessments Con’t • Shortness of breath  Could indicate fluid around the lungs  Ask about SOB at night (does client have to sleep in a sitting position?) • Ask the client how they are feeling  The client is usually the best source of information  Clients are in 3 times a week, dialysis nurses really get to know their clients • Evaluate access  Bruising, swollen, tender  Bruit – listen with the stethoscope for a swishing sound of the blood, listen all the way up the arm  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 home when a fistula is first initiated) 3/13/2023 108 Mr. KASONGO
  109. Nursing Interventions • If client comes in with shortness of breath, offer O2 which can be kept on for the full treatment if necessary • Comfort Client’s are sitting in the same chair for up to four hours Offer extra pillows, some clients have special back pillow they leave in the unit Ensure TV and audio is working properly 3/13/2023 109 Mr. KASONGO
  110. Nursing Interventions Con’t • If the blood pressure is dropping too quickly: Slow or stop fluid removal for a time period The machines are constantly being adjusted throughout the course of the treatment depending on the BP If the BP drops suddenly 200-300cc of normal saline can be given to balance fluid levels 3/13/2023 110 Mr. KASONGO
  111. • Usually, more fluid will be taken off at the beginning of the treatment, this will allow the client to feel better at the end • If the client is elderly, fluid removal starts slowly to ease them into the treatment 3/13/2023 Mr. KASONGO 111
  112. Responsibilities of Nursing Staff Prior to Dialysis • Ensure client is ready to sit for up to four hours Encourage client to use washroom before arriving to the unit Try to avoid laxatives if possible before treatment • Ensure client has eaten meal prior to treatment 3/13/2023 112 Mr. KASONGO
  113. Responsibilities of Nursing Staff After Dialysis • A dialysis nurse will a verbal report of treatment Any complications during treatment Check BP standing and sitting Assess access site • Encourage client to rest Avoid treatments or physio for a couple of hours if possible • Watch fluid intake Be aware if client is on fluid restriction • Check thrill and bruit • Do not take a BP on access arm • Do not take blood from access arm 3/13/2023 113 Mr. KASONGO
  114. Questions? Thank you for listening. 3/13/2023 114 Mr. KASONGO