Acute and Chronic Renal Failure Flashcards
Functions of the kidney
- Excretion of waste products
- Urine formation
- Water and salt balance
- Acid-base balance
- Hormone secretion
- Control of blood pressure
- Erythropoietin production (RBC)
- Synthesis of vitamin D to active form ( low Ca)
Renal failure results in:
– Altered fluid balance
– Electrolyte imbalance
– Acid-base imbalance
Causes of kidney failure include:
– Hypertension
– Diabetes
Kidney failure may be:
Acute or chronic
Acute renal failure (ARF)
• Rapid decrease in kidney function
• Leading to the collection of metabolic wastes in the body
• Potentially reversible condition
Lasts < 3 months
Etiology/Types of ARF:
– Prerenal failure
– Intrarenal/intrinsic renal failure
– Post renal failure
Prerenal failure
decreased blood flow to the kidneys - ischemia in the nephrons;prolonged hypoperfusion can lead to tubular necrosis and ARF.
Prerenal failure: causes
- Conditions that cause decreased cardiac output.
- Shock
- HF
- Pulmonary embolism
- Anaphylaxis
- Pericardial tamponade
- Sepsis
Intrarenal/intrinsic renal failure
actual tissue damage to the kidney caused by inflammatory or immunologic process or from prolonged hypoperfusion.
Intrarenal/intrinsic renal failure:causes
- Acute interstitial nephritis
- Exposure to nephrotoxins
- Acute glomerulonephritis
- Vasculitis
- Hepatorenal syndrome
- ATN
- Renal artery or vein stenosis/thrombosis
Post renal failure
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
Post renal failure: causes
- Urethral or bladder cancer;
- Renal, ureteral or bladder stones;
- Atony of bladder
- Prostatic hyperplasia or cancer;
- Cervical cancer;
- Urethral stricture (narrowing)
Acute tubular necrosis
- Syndrome of abrupt and progressive decline in tubular and glomerular function
- Most intrarenal failure is from ATN
- Etiology: Nephrotoxic substances
Potentially Nephrotoxic Substances/ Drugs
– PCN, Vancomycin, NSAIDs – Radiocontrast dyes – Heavy metals – Snake bites – Pesticides – Transfusion reaction
Phases of ARF
- Onset
- Oliguric
- Diuretic (high output)
- Recovery
Onset phase
until oliguria develops; accumulation of nitrogenous wastes may be noted (BUN, serum creatinine); hours - several days.
Oliguric phase
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 ;
Diuretic phase ( hight output phase)
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 .
Recovery phase (convalescent phase)
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.
ARF: management
1.Fluid challenges
2. Diuretics (Lasix)
3. Calcium channel blockers
4. Diet therapy
5. Renal replacement therapy
– Peritoneal dialysis
– Hemodialysis
– Hemofilteration
Cardiac glycosides: Digoxin ( Lanoxin)
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.
Vitamins and Minerals: Folic acid and Ferrous sulfate (iron)
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.
Synthetic erythropoietin: Epoetin alfa (Epogen, Procrit)
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 ).
Phosphate binders: Aluminium hydroxide gel (Amphojel, Nephrox)
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.
Fluid challenges
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
Calcium channel blockers
- 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
Nursing interventions: monitor
Monitor/maintain F&E balance Monitor for: – Signs of ARF and its complications – Alteration in fluid volume Promote optimal nutritional status
Nursing interventions: prevent and provide
Prevent: – Complications from impaired mobility – Fever/infection Provide: – Care for the client receiving dialysis – Client teaching and discharge teaching
ARF: nursing diagnosis
- Excess Fluid Volume
- Potential for Pulmonary Edema
- Potential for Electrolyte Imbalances
Chronic renal failure CRF
- 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
CRF: Etiology
Two main causes of ESRD
– Diabetes Mellitus (43.4%)
– HTN (25.5%)
CRF: Etiology
Infection and genetic kidney disease – Glomerulonephritis (8.4%) • Diseases that contribute to CRF – Pyelonephritis – Urinary tract obstruction – Renal cell carcinoma
CRF: S/S
- sallow yellow discoloration ; pruritus + uremic frost
- CNS depression , peripheral neuropathy
- high BP- CHF- ASHD- pericarditis
- anorexia, N&V
- GI bleeding, peptic ulcer disease
- Constipation
- Hyper - glycemia; - lipidemia;
- Depression
- Anemia
- Hypeparathyroid
- Amenorrhea, infertility, impotence
- Gout
- GFR less than 10 %
- Renal osteodystrophy
Progression of Kidney Disease
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
Amenorrhea
absence of menstruation
ASHD
arteriosclerotic heart disease
CRF: laboratory profile
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
Dietary restrictions
Protein, Fluid, K, Na, P.
Uremia
Prerenal azotemia is an abnormally high level of nitrogen waste products in the blood.
Foods high in P:
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.
Foods low in P:
1/2 cup of milk products limit; ricotta cheese, non dairy whipped topping, cream cheese, butter.
Foods high in K:
oranges, prunes, bananas, mangos, cantaloupe
Foods low in K:
apples, berries, grapes, watermelon, pineapple
CRF: nursing interventions
Assess for: • Signs of Uremia • Changes in mental function • Orient client to person, place, and time • Monitor serum electrolytes
Promote ultimate GI function:
- Assess and provide care for stomatitis
• Monitor for N/V/anorexia; administer antiemetics as ordered
• Assess for signs of GI bleeding
CRF: interventions
• 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
Uremic frost
a pale frostlike deposit of white crystals on the skin caused by kidney failure and uremia.
Nursing diagnosis
– Imbalanced nutrition – Excess fluid volume – Decreased cardiac output – Risk for infection – Fatigue – Anxiety
Additional nursing diagnoses
– Diarrhea – Constipation – Impaired oral mucus membrane – Social isolation – Sexual dysfunction – Disturbed thought process – Deficient knowledge
Creatinine
Protein and muscle breakdown 0.5-1.2
BUN
Renal excretion of urea nitrogen 10-20
Anuria
Less than 100 ml in 24 hr
Dysuria
Painful urination
Frequency
Need to void often; small amounts
Hesitancy
Trouble initiating urine flow , sensation present
Urgency
sudden onset to void ; NOW
Nocturia
waking in the night to empty bladder; e: don’t give Lasix at nigh !
Oliguria
100-400 ml in 24 hr/ decreased urine output
Polyuria
> 2000 ml in 24 hr; increased urine output
Uremia
symptoms of renal failure
ESKD: most common causes
- Hypertension
2. Diabetes mellitus
