Acute and Chronic Renal Failure

Question 1

Functions of the kidney

Answer 1

1. Excretion of waste products
2. Urine formation
3. Water and salt balance
4. Acid-base balance
5. Hormone secretion
6. Control of blood pressure
7. Erythropoietin production (RBC)
8. Synthesis of vitamin D to active form ( low Ca)

Question 2

Renal failure results in:

Answer 2

– Altered fluid balance
– Electrolyte imbalance
– Acid-base imbalance

Question 3

Causes of kidney failure include:

Answer 3

– Hypertension

– Diabetes

Question 4

Kidney failure may be:

Answer 4

Acute or chronic

Question 5

Acute renal failure (ARF)

Answer 5

• Rapid decrease in kidney function
• Leading to the collection of metabolic wastes in the body
• Potentially reversible condition
Lasts < 3 months

Question 6

Etiology/Types of ARF:

Answer 6

– Prerenal failure
– Intrarenal/intrinsic renal failure
– Post renal failure

Question 7

Prerenal failure

Answer 7

decreased blood flow to the kidneys - ischemia in the nephrons;prolonged hypoperfusion can lead to tubular necrosis and ARF.

Question 8

Prerenal failure: causes

Answer 8

1. Conditions that cause decreased cardiac output.
2. Shock
3. HF
4. Pulmonary embolism
5. Anaphylaxis
6. Pericardial tamponade
7. Sepsis

Question 9

Intrarenal/intrinsic renal failure

Answer 9

actual tissue damage to the kidney caused by inflammatory or immunologic process or from prolonged hypoperfusion.

Question 10

Intrarenal/intrinsic renal failure:causes

Answer 10

1. Acute interstitial nephritis
2. Exposure to nephrotoxins
3. Acute glomerulonephritis
4. Vasculitis
5. Hepatorenal syndrome
6. ATN
7. Renal artery or vein stenosis/thrombosis

Question 11

Post renal failure

Answer 11

obstruction of the urine collecting system anywhere from calyces to urethral meatus; obstruction of the bladder must be bilateral to cause post renal failure unless only one kidney is functional

Question 12

Post renal failure: causes

Answer 12

1. Urethral or bladder cancer;
2. Renal, ureteral or bladder stones;
3. Atony of bladder
4. Prostatic hyperplasia or cancer;
5. Cervical cancer;
6. Urethral stricture (narrowing)

Question 13

Acute tubular necrosis

Answer 13

• Syndrome of abrupt and progressive decline in tubular and glomerular function
• Most intrarenal failure is from ATN
• Etiology: Nephrotoxic substances

Question 14

Potentially Nephrotoxic Substances/ Drugs

Answer 14

– PCN, Vancomycin, NSAIDs
– Radiocontrast dyes
– Heavy metals 
– Snake bites 
– Pesticides
– Transfusion reaction

Question 15

Phases of ARF

Answer 15

1. Onset
2. Oliguric
3. Diuretic (high output)
4. Recovery

Question 16

Onset phase

Answer 16

until oliguria develops; accumulation of nitrogenous wastes may be noted (BUN, serum creatinine); hours - several days.

Question 17

Oliguric phase

Answer 17

100-400 / 24 hours urine output that does not respond to fluid chalenges or diuretics; 1-3 weeks; SC and BUN up; K, P, Mg up ; Ca down ; Na up but masked by water retention ;bicarbonate deficit - acidosis ;

Question 18

Diuretic phase ( hight output phase)

Answer 18

2-6 weeks after oliguric; sudden onset ; urine flow increased over several days; 10 L /day of dilute urine ; electrolyte losses; BUN down; normal renal tubular function .

Question 19

Recovery phase (convalescent phase)

Answer 19

Recovery may take up to 12 months; pt has lower energy level; residual renal insufficiency may be noted through renal monitoring; renal function may never return to pre illness level; but renal function likely good for healthy life.

Question 20

ARF: management

Answer 20

1.Fluid challenges
2. Diuretics (Lasix)
3. Calcium channel blockers
4. Diet therapy
5. Renal replacement therapy
– Peritoneal dialysis
– Hemodialysis
– Hemofilteration

Question 21

Cardiac glycosides: Digoxin ( Lanoxin)

Answer 21

Increases ventricular contraction, stroke volume, cardiac output; teach pt to take pulse before taking the drug ( below 60 call !); Digoxin toxicity: blurred vision; changes in color vision; sensitive eyes; halos around bright lights; changes in mental status; chest pain or palpitations. Not to take antacid within 2 hours (prevent drug absorption). Listen to apical for 1 full minute.

Question 22

Vitamins and Minerals: Folic acid and Ferrous sulfate (iron)

Answer 22

Replacement needed because of dialysis; Take drug after dialysis; Take iron with meals ( reduce N&V); Take stool softener ( oral iron causes constipation); Iron change the color of the stool.

Question 23

Synthetic erythropoietin: Epoetin alfa (Epogen, Procrit)

Answer 23

Prevents anemia by stimulating RBC growth and maturation in the bone marrow; Side effects: chest pain, difficulty breathing, high BP, rapid weigh gain,( risk for MI infarction); Hemoglobin levels monitored weekly ( blood viscosity increases - high BP - risk for MI ).

Question 24

Phosphate binders: Aluminium hydroxide gel (Amphojel, Nephrox)

Answer 24

High Phosphate levels cause hypocalcemia and osteodystrophy; Drug lowers P levels by binding P present in food; Take with meals ( binding in food) ; Take Digoxin separately but at least 2 hr ; Take stool softener ( constipation) ; Report: muscle weakness, slow or irregular pulse, confusion - hypophosphatemia.

Question 25

Fluid challenges

Answer 25

500mL- 1L of NS over 1 hour – Patient may respond to the fluid challenge by producing urine soon after the initial bolus – Lasix may be prescribed along with fluid bolus – If oliguric renal failure is diagnosed fluid bolus and diuretics are discontinued

Question 26

Calcium channel blockers

Answer 26

- Used to treat ARF resulting from nephrotoxic ATN - Prevent the movement of calcium into kidney cells - Maintain kidney cell integrity and improve the GFR rate - Thereby improving renal blood flow

Question 27

Nursing interventions: monitor

Answer 27

``` Monitor/maintain F&E balance Monitor for: – Signs of ARF and its complications – Alteration in fluid volume Promote optimal nutritional status ```

Question 28

Nursing interventions: prevent and provide

Answer 28

``` Prevent: – Complications from impaired mobility – Fever/infection Provide: – Care for the client receiving dialysis – Client teaching and discharge teaching ```

Question 29

ARF: nursing diagnosis

Answer 29

- Excess Fluid Volume - Potential for Pulmonary Edema - Potential for Electrolyte Imbalances

Question 30

Chronic renal failure CRF

Answer 30

- Progressive irreversible kidney damage - Damage continues until nephrons are replaced by scar tissue - Kidney function does not recover - Complication : End-stage renal disease: When kidney function is too poor to sustain life

Question 31

CRF: Etiology

Answer 31

Two main causes of ESRD – Diabetes Mellitus (43.4%) – HTN (25.5%)

Question 32

CRF: Etiology

Answer 32

``` Infection and genetic kidney disease – Glomerulonephritis (8.4%) • Diseases that contribute to CRF – Pyelonephritis – Urinary tract obstruction – Renal cell carcinoma ```

Question 33

CRF: S/S

Answer 33

1. sallow yellow discoloration ; pruritus + uremic frost 2. CNS depression , peripheral neuropathy 3. high BP- CHF- ASHD- pericarditis 4. anorexia, N&V 5. GI bleeding, peptic ulcer disease 6. Constipation 7. Hyper - glycemia; - lipidemia; 8. Depression 9. Anemia 10. Hypeparathyroid 11. Amenorrhea, infertility, impotence 12. Gout 13. GFR less than 10 % 14. Renal osteodystrophy

Question 34

Progression of Kidney Disease

Answer 34

Kidneys fail in organized fashion involving five stages based on estimated glomerular filtration rate (GFR) . > 90 - Kidney damage : normal or increased GFR < 15 or dialysis : kidney failure

Question 35

Amenorrhea

Answer 35

absence of menstruation

Question 36

ASHD

Answer 36

arteriosclerotic heart disease

Question 37

CRF: laboratory profile

Answer 37

``` Serum creatinine (0.5-1.2) - 15-30 BUN (10-20) - 180-200 Increased Na, K, P, Mg; Low Ca; Metabolic acidosis H&H decreased ```

Question 38

Dietary restrictions

Answer 38

Protein, Fluid, K, Na, P.

Question 39

Uremia

Answer 39

Prerenal azotemia is an abnormally high level of nitrogen waste products in the blood.

Question 40

Foods high in P:

Answer 40

milk, yogurt, cheese, dried beans, meat, poultry, fish and seafood; ** The phosphorus content is the same for all types of milk – skim, low fat, and whole! Patients need to take a phosphate binder if and when they eat any high-phosphorus foods.

Question 41

Foods low in P:

Answer 41

1/2 cup of milk products limit; ricotta cheese, non dairy whipped topping, cream cheese, butter.

Question 42

Foods high in K:

Answer 42

oranges, prunes, bananas, mangos, cantaloupe

Question 43

Foods low in K:

Answer 43

apples, berries, grapes, watermelon, pineapple

Question 44

CRF: nursing interventions

Answer 44

``` Assess for: • Signs of Uremia • Changes in mental function • Orient client to person, place, and time • Monitor serum electrolytes ```

Question 45

Promote ultimate GI function:

Answer 45

- Assess and provide care for stomatitis • Monitor for N/V/anorexia; administer antiemetics as ordered • Assess for signs of GI bleeding

Question 46

CRF: interventions

Answer 46

• Monitor prevent alteration in F/E balance • Assess for: – Hyperphosphatemia – Uremic frost • Assess/provide care for pruritus (itching) • Promote maintenance of skin integrity • Monitor for bleeding complications – Prevent injury to client • Promote/maintain maximal cardiovascular function • Provide care for client receiving hemodialysis

Question 47

Uremic frost

Answer 47

a pale frostlike deposit of white crystals on the skin caused by kidney failure and uremia.

Question 48

Nursing diagnosis

Answer 48

``` – Imbalanced nutrition – Excess fluid volume – Decreased cardiac output – Risk for infection – Fatigue – Anxiety ```

Question 49

Additional nursing diagnoses

Answer 49

``` – Diarrhea – Constipation – Impaired oral mucus membrane – Social isolation – Sexual dysfunction – Disturbed thought process – Deficient knowledge ```

Question 50

Creatinine

Answer 50

Protein and muscle breakdown 0.5-1.2

Question 51

BUN

Answer 51

Renal excretion of urea nitrogen 10-20

Question 52

Anuria

Answer 52

Less than 100 ml in 24 hr

Question 53

Dysuria

Answer 53

Painful urination

Question 54

Frequency

Answer 54

Need to void often; small amounts

Question 55

Hesitancy

Answer 55

Trouble initiating urine flow , sensation present

Question 56

Urgency

Answer 56

sudden onset to void ; NOW

Question 57

Nocturia

Answer 57

waking in the night to empty bladder; e: don't give Lasix at nigh !

Question 58

Oliguria

Answer 58

100-400 ml in 24 hr/ decreased urine output

Question 59

Polyuria

Answer 59

> 2000 ml in 24 hr; increased urine output

Question 60

Uremia

Answer 60

symptoms of renal failure

Question 61

ESKD: most common causes

Answer 61

1. Hypertension | 2. Diabetes mellitus