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NURSING CARE: PHARMACOLOGY AND THE URINARY SYSTEM (RNB: 10504) PART 2 TOPICS: RENAL FAILURE

INSTRUCTIONAL OBJECTIVE
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On completion of this lesson, learners will be able to: describe the causes and pathophysiology of acute and chronic renal failure discuss the clinical manifestations of acute and chronic renal failure describe the phases of reversible acute renal failure and the phases in chronic renal failure discuss tests used for acute and chronic renal failure describe the treatment and nursing care of patient with renal failure

INTRODUCTION
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Renal failure Renal failure is severe impairment or total lack of kidney function, in which there is an inability to excrete metabolic waste products and water.

Renal failure may be acute in onset or chronic Renal failure refers to a significant loss of renal function and when only 10% of renal function remains, the person is considered to have endstage renal disease

ACUTE RENAL FAILURE (ARF)

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Definition: Acute renal failure (ARF) is defined as sudden, rapid, potentially reversible deterioration of renal function.

ACUTE RENAL FAILURE (ARF)

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ARF is a syndrome of varying causation that result in a sudden decline in renal function Often associated with: an increase in BUN and creatinine, oliguria (less than 500 mL/24 hrs) hyperkalaemia sodium retention.

ACUTE RENAL FAILURE (ARF)

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Pathophysiology and etiology (cont) The exact pathogenesis of ARF is unknown. Most common cause of decreased glomerular filtration is a decline in renal blood flow (RBF). Decrease in RBF causes tissue ischemia and eventually cell necrosis or cell death, which produces oxygen free radicals and other enzymes which exacerbate the problem. Cell damage causes sloughing of cells which in turn block renal tubules and cause a back leak of glomerular filtrate.

ACUTE RENAL FAILURE (ARF)

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Causes: Renal failure can develop as a consequence of: prerenal intrarenal postrenal

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Stages of ARF
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1. Onset/initiation phase
Begins when the kidney is injured and last from hour to days

Characterized by an increase BUN and serum creatinine with normal to decrease urine output With prompt treatment, irreversible damage can be achieved during this pre renal failure onset phase.

Stages of ARF
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2. Oliguric stage This phase begins within 48 hours after the initial cellular insult and usually lasts between 814 days Urine output decreases to 400 mL/day or less Serum values for BUN, Creatinine, potassium, and phosphate are increase. Serum calcium and bicarbonate decrease Fluid volume excess develop leading to oedema, hypertension and cardio-pulmonary complication

Stages of ARF
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3. Diuretic phase

This phase usually lasts an additional 7-14 days and characterized by: Urine output exceed 400 ml/day and may rise to 4L/day Despite an increased water content of urine, the excretion of waste products and electrolytes continues to be impaired. Towards the end of the diuretic stage, the kidney begins to excrete BUN, creatinine, potassium, phosphorous and retain calcium and bicarbonatean indication of return of kidney function

Stages of ARF
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4. Recovery stage As renal tissue recovers, serum electrolytes, BUN, creatinine return to normal It may take from several months to over a year If complete recovery does not occur, renal insufficiency or chronic renal failure may develop Renal insufficiency is indicated by loss of approximately 80% of function It is possible to lead a normal life with renal insufficiency unless other illness place an additional burden on the kidney function.

ACUTE RENAL FAILURE (ARF)

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Clinical manifestation Decreased urine output (urine may be pink or reddish in color) Edema (face, arms, legs, feet, eyes) Flank pain/Pelvic pain Poor appetite (nausea, vomiting) Bitter or metallic taste in mouth Dry itchy skin (due to an increased phosphorus level)

ACUTE RENAL FAILURE (ARF)

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Clinical manifestation (cont) Easy bruising (because of uraemia induced platelet dysfunction and coagulopathies). Fatigue due to the accumulation of waste Seizures/LOC due to uremia Shortness of breath- fluid overload Arrhythmias due to electrolyte imbalance, hyperkalemia, or fluid overload Sudden weight gain due to fluid retention

ACUTE RENAL FAILURE (ARF)

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Diagnostic evaluation Urinalysis-reveals proteinuria, hematuria, casts Rising serum creatinine and BUN levels (to evaluate renal function) Renal ultrasonography- for estimate of renal size and to exclude a treatable obstructive urophaty Urine chemistry examination such as Creatinine Clearance Test to determine glomerular filtration rates

ACUTE RENAL FAILURE (ARF)

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Medical management The primary goal of treatment for ARF is to prevent further damage Supportive measures aim to control symptoms and prevent complications which include: Fluid and dietary restriction Restoration of electrolyte imbalance and dialysis. Nephrotoxic drugs and drugs that altered renal blood flow must be avoided. Intrenal and Postrenal failure is treated by relieving the obstruction.

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1. Drug therapy a. Oliguria Treated with diuretics, most often such as: an osmotic diuretic such as mannitol loop diuretic such as furosemide (Lasix)

ACUTE RENAL FAILURE (ARF)

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b. Hyperkalemia is treated most aggressively as it is life threatening. Drugs to lower potassium level include:
A

bolus of 1020ml of 10% calcium gluconate or chloride is given intravenously over two to five minutes calcium should be given as a slow infusion in hyperkalemic patients taking of digoxin (that is, 10ml 10% calcium gluconate in 100ml 5% dextrose over 30minutes). Hypertonic glucose (50 mL of 50% dextrose) with insulin and infused over 1020minutes Calcium polystyrene sulphonate (Calcium resonium) and sodium polystyrene sulphate (Resonium A/ Kayexalate) , given at an oral dose of 15 g thrice daily or rectally.

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Fluid management Fluid intake is usually restricted once the vascular volume and renal perfusion are restored The allowed daily fluid intake is calculated allowing 500mL for insensible loss (respiration, perspiration, bowel looses) and adding the amount excreted as urine ( or loss as vomitus) during the previous 24 hours. E.g. if a client excrete 400 mL of urine in 24 hrs, the client is allowed (500+400=900 mL) for the next 12 hrs.

ACUTE RENAL FAILURE (ARF)

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Nutrition Renal insufficiency and the underlying disease process increase the rate of catabolism and decreased the rate of anabolism Protein are limited to 0.6 g per kg of body weight to minimize the degree of azotemia Carbohydrate are increased to maintain adequate calorie intake and provide proteinsparing effect. Parental nutrition providing amino acids , concentrated carbohydrate and fats if nutritional needs are not being met by oral

ACUTE RENAL FAILURE (ARF)

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Dialysis: A short term intervention when fluids and electrolytes cannot be managed by other means. This may involve the use of any of the following methods: Peritoneal Dialysis Hemodialysis

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ACUTE RENAL FAILURE (ARF)

Nursing assessment Both subjective and objective data are useful when assessing client with ARF Health history: determine the followings Complaints of anorexia, nausea, weight gain, or eodema Recent exposure to a nephrotoxin such as antibiotic (gentamicin ,amikacin) or radiologic procedures using an injected contrast medium Previous blood transfusion reaction Chronic diseases such as diabetes, heart failure or kidney failure
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ACUTE RENAL FAILURE (ARF)

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Physical examination
Vital

signs including temperature Urine output (amount, colour, clarity, specific gravity, presence of blood cells and protein) Weight Skin colour Peripheral pulses Presence of eodema Lungs sound, heart sound and bowel sound

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Nursing diagnosis Excess fluid volume related to sodium and water retention Imbalance nutrition; less than body requirement related to anorexia, dietary restriction and increased catabolism Deficient knowledge of condition, treatment and self care.

Acute renal failure (ARF)

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Nursing intervention 1. Excess fluid volume Maintain hourly intake and output records to help guide (including urine, gastric suction, stools, wound drainage, perspiration (estimate) therapy, especially fluid restriction. Weigh daily. Use standard technique to ensure accuracy.

Fluid intake is usually restricted once the vascular volume and renal perfusion are restored The allowed daily fluid intake is calculated allowing 500mL for insensible loss
Assess vital sign at least every 4 hours.. Inspect neck veins for engorgement and extremities, abdomen, sacrum and eyelids for eodema. Manifestation of hyperkalemia, and monitor serum potassium levels. Notify doctor if value above 5.5mg/L

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Acute renal failure (ARF) -Watch for ECG changes- tall, tented T waves:, depressed ST segment, wide QRS complex.

ACUTE RENAL FAILURE (ARF)

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Nursing intervention 1. Excess fluid volume Administer sodium bicarbonate, calcium gluconate or glucose and insulin to shift potassium into the cells as prescribed Administer sodium polystyrene sulfonate (kayexalatel/Resonium A) orally or rectally to correct elevated potassium Watch for cardiac arrhythmia and heart failure from kyperkalemia, electrolyte imbalance or fluid overload

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Nursing intervention 1. Excess fluid volume (cont..) Instruct client about the importance of following the prescribed diet, avoiding foods high in potassium. Provide frequent mouth care and encourage to suck candy to decrease thirst. Fluids are restricted to minimize fluid retention and complication for fluid volume excess. Prepare for dialysis when rapid lowering of potassium is needed or for uncontrolled acidosis

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Nursing intervention

Impaired nutrition Monitor and record food intake including the amount and type of food consumed. Arrange for dietary consultation to provide food in keeping with the prescribed restriction and clients preference including cultural and religious factor. Engage client in planning the daily menus. Allow family members to prepare meals within dietary restriction. Encourage family members to eat with client

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Nursing intervention Impaired nutrition Offer high carbohydrate feedings because carbohydrates have a greater protein-sparing power and provides additional calories. Provide frequent, small amount meal or between meals snack. (these measure promote food intake in the fatigue or anorexic client. Administer antiemetics as ordered. Administer parental nutrition as ordered if client is unable to eat or tolerate enteral feeding

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Deficient knowledge Provide basic information about the disease, diagnostic tests and procedure and treatments. Explain the reason for interventions such as fluid restrictions, turning, deep breathing and leg exercise. Teach client regarding management of fluids, diet, drug therapy activity and signs and symptom that should be reported to physician (dyspnea, eodema, fever)

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Client education and health maintenance Explain that the client may experience residual defects in kidney function for long period after acute illness. Encouraged reporting for routine urinalysis and follow-up examinations Advice avoidance of any medications unless specifically prescribed Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism

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2. CHRONIC RENAL FAILURE (CFR)

CHRONIC RENAL FAILURE (CRF)

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Definition: Chronic renal failure or ESRD is a progressive, irreversible loss of function of renal tissue. It is ongoing deterioration in kidney function that occurs slowly over a period of time

CHRONIC RENAL FAILURE (CRF)

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It occurs in stages, is irreversible, and result in uremia or end stage renal disease. CRF affect all major body systems and requires dialysis or kidney transplant to maintain life. Hypervolemia can occur because of the inability of the kidney to excrete sodium and water, or hypovolemia can occur because of the inability of the kidneys to conserve sodium and water. There are three stages or CRF

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STAGE I: Diminish renal service: Characterized by 40 to 75% of loss of nephron function.

Client usually does not have any symptom because the remaining nephrons are able to carry out the normal functions of the kidney.

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STAGE II: Renal insufficiency Occurs when 75% to 90% of nephron function is loss

At this point serum creatinine and BUN rise (due to metabolic waste accumulation) the kidney loss its ability to concentrate urine and aneamia develops Client may report polyuria and nocturia

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STAGE II: Renal insufficiency Occurs when 75% to 90% of nephron function is loss At this point serum creatinine and BUN rise (due to metabolic waste accumulation) the kidney loss its ability to concentrate urine and aneamia develops Client may report polyuria and nocturia

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STAGE III: End-stage renal disease (ESRD) Occurs when there is less than 10% nephron functioning remaining All of the normal regulatory, excretory and hormonal functions of the kidney are severely impaired. Characterized by elevated level of creatinine and BUN as well as electrolytes imbalance due to excessive accumulation of metabolic wastes. Dialysis or other replacement therapy is required.

CHRONIC RENAL FAILURE (CRF)

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STAGE III: End-stage renal disease (ESRD) Occurs when there is less than 10% nephron functioning remaining All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired. Characterized by elevated level of creatinine and BUN as well as electrolytes imbalance due to excessive accumulation of metabolic wastes. Dialysis or other replacement therapy is required.

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Pathophysiology

As renal function decline, the end products of protein metabolism accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more severe the symptom The rate of decline in renal function and progression of CRF is related to the underlying disorder, the urinary excretion of proteins, and the presence of hypertension. The disease tends to progress more rapidly in client who excrete significant amount of protein or have elevated blood pressure than in those without.

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Causes of CRF Most common cause of end-stage renal failure worldwide is IgA nephropathy (an inflammatory disease of the kidney). Other common causes of chronic renal failure include: recurring pyelonephritis (kidney infection) polycystic kidney disease (multiple cysts in the kidneys)

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Other common causes of chronic renal failure (cont..) autoimmune disorders such as systemic lupus erythematosus Chronic glomerulonephritis Uncontrolled hypertension Nephrotoxic agents (drugs/toxins).

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Urinary

Oliguria from renal insufficiency. Azotemia (nitrogenous waste present in the blood). Blood Anemia from decrease RBC production. Decreased platelet activity causing bleeding tendency. Hyperkalemia most life-threatening effects Cardiovascul Hypervolemia and tachycardia. ar Hypertension and dysrhythmias from hyperkalemia.

Clinical manifestation by body system

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Respiratory Dyspnea, pulmonary eodema. Hyperventilation from metabolic acidosis. Eventually kussmaul respiration. GI Urea in the blood is converted to ammonia by the mouth, causing uremic halitosis. Hiccups, anorexia, and nausea from eodema within a GI tract Dry skin with pruritus from uremic frost(excretion of urea through the skin with an odor of urine Pallor with anemia

Clinical manifestation by body system

Skin

Clinical manifestation by body system

Nervous
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Sensory

Reproductive Musculoskeletal Immune

Lethargy, headaches, confusion, impaired concentration with disorientation, depression, decreased level of consciousness, sleep disturbances, uremic encephalopathy resulting in seizures and coma Peripheral neuropathy with numbness and tingling of extremities with complaints of prickly , crawling feelings in the feet and legs, especially at night Decrease in libido, decrease sperm count Amenorrhea, impotence, delayed puberty Joint pain and muscle cramping Bone demineralization from hypocalcemia Greater chance of infections from immune suppression. Decrease in antibody.

CHRONIC RENAL FAILURE (CRF)

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Diagnostic evaluation Urinalysis: Measure urine specific gravity usually fixed at 1.010 Detect abnormal urine component Urine culture Twenty-four hour urine tests: Creatinine and urea (BUN) in the blood Estimated GFR (eGFR): Electrolyte levels and acid-base balance Ultrasound Biopsy

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Complications

Hyperkalemia due to decrease excretion, metabolic acidosis, catabolism and excessive intake (diet, medications, fluids) Pericaditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis. Hypertension due to sodium and water retention and malfunction of the reninangiotensin-aldosterone system

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Anemia due to decreased erythropoietin production, and decreased RBC life-span, bleeding in the GI tract from irritating toxins and ulcer formation, and blood loss during hemodialysis Bone disease and vascular calcifications due to retention of phosphorus, low serum calcium level, abnormal Vit D metabolism, and elevated aluminum level.

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Medical treatment Treatment of chronic kidney disease aims to: promote elimination of wastes, maintenance of fluid balance management of the systemic effects of the disease

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Treatments include: IV glucose and insulin, calcium carbonate, calcium acetate, or sodium polystyrene sulfonate (rectally or orally) to treat hyperkalemia Calcium, active Vit D, and phosphate binders (calcium carbonate or calcium acetate) to treat hypocalcemia Fluid restriction and diuretics to treat hypervolemia Diuretics, beta-blockers, calcium channel blockers and ACE inhibitors for hypertension

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Treatments include (cont): Iron supplements, folic acid, and synthetic erythropoietin (administered intravenously or subcutaneously 3 times a week) given to treat anemia High carbohydrate, low protein diet to prevent excess urea. Maintenance dialysis or kidney transplantation when symptoms no longer be controlled with conservative management.

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Dialysis When kidney failure can no longer be managed conservatively, dialysis is required to sustain life.

Goals of dialysis

Remove end product of protein metabolism from blood Maintain safe concentration of serum electrolytes Correct acidosis and replenish bodys bicarbonate buffer system Remove excess fluid from the blood.

Nursing care of client with CRF

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Assessment Obtained history of chronic disorders and underlying health status Assess degree of renal impairment and involvement of other body system by obtaining a review of systems and reviewing laboratory result. Perform thorough examination, including vital sign, cardiovascular, pulmonary, GI, neurologic, dermatologic, and musculoskeletal systems

Nursing care of client with CRF

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Assessment Asses psychological response to disease process including availability of resources and support service. Explore clients understanding about chronic kidney disease, its treatment and self-care measures.

Nursing care of client with CRF

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Nursing diagnosis Excess fluid volume related to disease process Imbalanced nutrition less than body requirement related to dietary restrictions, GI distress, anorexia Risk for impaired skin integrity related to altered metabolic state leading to pruritus from uremic frost Ineffective individual coping related to uncertainty of long term compliance of the treatment regimen

Nursing care of client with CRF

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Refer
Bathe

ARF nursing intervention

2. Impaired skin integrity

skin frequently to remove uremic frost Encourage the use of emollients and lotions on the skin (but discourage OTC drugs without discussing with healthcare provider) Administer antihistamines, as ordered for the temporary relief of itching Assist the client to change position every 2 hours Keep nails short and trimmed to prevent excoriation

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3. Ineffective individual coping Explore the clients coping strategies, and identify factors that interfere with adjustment to renal disease Explain routines and procedure, and provide practical advice on the management for every problem. Be accepting to clients thoughts and feelings. Do not tell client false reassurance or tell client not to worry

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3. Ineffective individual coping (cont) Encourage client to discuss feelings about longterm lifestyle changes Include the client and family in rehabilitation and discharge planning to ensure compliance. Topics for this sessions include: diet, rest, medications, fluid restrictions, intake and output, activities, dialysis, required blood test, and frequent follow ups Encourage strengthening of social support system and coping mechanism to lesson anxiety

Nursing care of client with CRF

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1. To promote adherence to the therapeutic program, teach the followings: Weigh self every morning to avoid fluid overload Drink limited amount of fluids only when thirsty Measure allotted fluids, and save some for ice cubes, sucking on ice is thirst quenching Use candy or chewing gum to moisten mouth

Nursing care of client with CRF

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2. Report to any healthcare provider any of the followings symptom Worsening sign and symptom of renal failure (nausea, vomiting, change in usual urine output (if any), ammonia odor on breath Signs and symptom of hyperkalemia (muscle weakness, diarrhea, abdominal cramps) Sign and symptom of access problems (clotted fistula, or infection)

Evaluation: expected outcome

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The client understand the importance of the prescribed (restricted)fluid amount Blood pressure stable, no excessive weight gain and participate in dietary plan The skin integrity is maintained Client verbalizes feelings and complies with treatment.

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