1 McMurtrie/Nur 2241/Fall2012 Nursing Care of the with Nursing Care of the with Client Acute Renal Failure Client Acute Renal Failure Christine R. McMurtrie RN, MSN Christine R. McMurtrie RN, MSN Professor, Nursing Professor, Nursing Nursing Institute Nursing Institute Brevard Community College Brevard Community College 433-7538 433-7538 [email protected][email protected]
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Nursing Care of the with Nursing Care of the with Client Acute Renal FailureClient Acute Renal Failure
Christine R. McMurtrie RN, MSNChristine R. McMurtrie RN, MSN Professor, NursingProfessor, Nursing Nursing InstituteNursing Institute Brevard Community CollegeBrevard Community College 433-7538433-7538 [email protected]@brevardcc.edu
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Longitudinal Section of the Longitudinal Section of the KidneyKidney
Age Related ChangesAge Related Changes Loss of glomeruliLoss of glomeruli Decreased glomerular filtration rateDecreased glomerular filtration rate Decreased production of creatinine Decreased production of creatinine
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Effects of renal function Effects of renal function Changes in the ElderlyChanges in the Elderly
Altered ability to concentrate urine Altered ability to concentrate urine and compensate for Na excess or lossand compensate for Na excess or loss
Decreased response to ADHDecreased response to ADH Decreased thirst responseDecreased thirst response Decreased aldosterone levels leading Decreased aldosterone levels leading
to hypokalemiato hypokalemia Altered drug excretion & renal Altered drug excretion & renal
toxicitytoxicity
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Classification of Renal Classification of Renal DiseasesDiseases
CongenitalCongenital Disorders of the glomerulusDisorders of the glomerulus Vascular DisordersVascular Disorders TraumaTrauma NeoplasmsNeoplasms
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ACUTE RENAL FAILUREACUTE RENAL FAILURE Patho: Abrupt (hours to a few days) Patho: Abrupt (hours to a few days)
decrease in renal function sufficient to decrease in renal function sufficient to result in retention of nitrogenous waste result in retention of nitrogenous waste (BUN & creat) in the body(BUN & creat) in the body
Hallmark of ARF is progressive Hallmark of ARF is progressive azotemia caused by accumulation of azotemia caused by accumulation of nitrogenous end products of metabolismnitrogenous end products of metabolism
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Nephron Destruction in Nephron Destruction in Acute Renal FailureAcute Renal Failure
A.A. Normal nephron. Normal nephron. BB Damage from Damage from
renal ischemia renal ischemia results in patchy results in patchy necrosis of the necrosis of the tubule. The lumen tubule. The lumen may also be blocked may also be blocked by casts.by casts.
C.C. Damage from Damage from nephrotoxic agents.nephrotoxic agents.
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EtiologyEtiology Three categories of causationThree categories of causation
Prerenal - Decrease renal blood flowPrerenal - Decrease renal blood flow hypovolemia, CV failure, MI (↓CO)hypovolemia, CV failure, MI (↓CO)
dehydration, shock, trauma with bleedingdehydration, shock, trauma with bleeding Quick response & resolution with Quick response & resolution with
interventionintervention Intrarenal - Produce a renal Intrarenal - Produce a renal
Management: Management: Health Prevention and Promotion Health Prevention and Promotion Determine and treat the causeDetermine and treat the cause Initiate proper therapyInitiate proper therapy
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ARF ProgressionARF Progression Initiating Phase Initiating Phase (onset until s & s)(onset until s & s) Oliguric Phase Oliguric Phase (onset 1-7 d; lasts 10-14 d(onset 1-7 d; lasts 10-14 d Diuretic Phase Diuretic Phase (1-3 weeks)(1-3 weeks) Recovery Phase Recovery Phase (1 wk to 1 yr)(1 wk to 1 yr)
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Initiating Phase (Hrs to Initiating Phase (Hrs to days)days)
Begins at time of insultBegins at time of insult Continues until clinical Continues until clinical
ed, effusionsed, effusions Metabolic acidosis – Kussmaul resp, lethargy, stuporMetabolic acidosis – Kussmaul resp, lethargy, stupor Sodium balance – serum Na nml or below nmlSodium balance – serum Na nml or below nml Potassium excessPotassium excess – – leading cause of deathleading cause of death; see table 475, p. ; see table 475, p.
12021202 Hematologic disorders – pancytopenia *Infection main cause Hematologic disorders – pancytopenia *Infection main cause
of deathof death Calcium deficit and phosphate excessCalcium deficit and phosphate excess Waste product accumulation – creatinine best indicatorWaste product accumulation – creatinine best indicator Neurologic disorders – fatigue, concentration, seizures, Neurologic disorders – fatigue, concentration, seizures,
Recovery (up to 1 yr)Recovery (up to 1 yr) BUN & creat plateau, then decreaseBUN & creat plateau, then decrease May progress to CRFMay progress to CRF Elderly at riskElderly at risk May achieve normal kidney functionMay achieve normal kidney function
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Health Health Promotion/PreventionPromotion/Prevention
Monitor high risk populationsMonitor high risk populations ElderlyElderly TraumaTrauma Surgical procedures; dyes used in dx testsSurgical procedures; dyes used in dx tests Extensive burnsExtensive burns CHFCHF SepsisSepsis OBOB Renal insufficiency due to htn, DMRenal insufficiency due to htn, DM
Monitor nephrotoxic drugs, chemicalsMonitor nephrotoxic drugs, chemicals Prevent prolonged hypotension and Prevent prolonged hypotension and
hypovolemiahypovolemia
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Health PromotionHealth Promotion Medication SEMedication SE OTC DrugsOTC Drugs Chemical and Environmental Chemical and Environmental
ExposureExposure
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Assessment Assessment
Diagnostic StudiesDiagnostic Studies H & P (Differential Dx)H & P (Differential Dx) UAUA Urine osmolalityUrine osmolality Renal ultrasoundRenal ultrasound Renal perfusion scanRenal perfusion scan CT scanCT scan MRIMRI
CV, Resp statusCV, Resp status Lab values/dx test Lab values/dx test
resultsresults
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Planning Outcomes ARFPlanning Outcomes ARF Preservation of renal functionPreservation of renal function Maintanence of fluid and electrolyte Maintanence of fluid and electrolyte
and nutritional balanceand nutritional balance Decreased anxietyDecreased anxiety Adherence to medical regimen and Adherence to medical regimen and
*DO NOT GIVE TO PT WITH PARALYTIC ILEUS*DO NOT GIVE TO PT WITH PARALYTIC ILEUS Dietary restriction K+ to 40 mEq dailyDietary restriction K+ to 40 mEq daily Phosphate and Na restrictionPhosphate and Na restriction Calcium supplements, phosphate binding agentsCalcium supplements, phosphate binding agents Cardiac monitoring, check pulse freq.Cardiac monitoring, check pulse freq.
Rapid blood loss replacementRapid blood loss replacement Toxicology for nephrotoxic drugsToxicology for nephrotoxic drugs
Mannitol, furosemide (SE: Tinnitus and hearing Mannitol, furosemide (SE: Tinnitus and hearing impairment with IV furosemide)impairment with IV furosemide)
Potassium replacementPotassium replacement Dopamine (low dose)Dopamine (low dose) I & 0, daily wt, renal function studies, labsI & 0, daily wt, renal function studies, labs Prevention of uremic syndrome (fig.47-5, p. 1206)Prevention of uremic syndrome (fig.47-5, p. 1206)
Sx:Sx: early -nausea, anorexia, vomitingearly -nausea, anorexia, vomiting late - stupor, convulsions, coma, bleeding late - stupor, convulsions, coma, bleeding
*can cause hyperkalemia*can cause hyperkalemia I & O, daily wtI & O, daily wt *Fluid & Salt restriction (I = O + 600 mL)*Fluid & Salt restriction (I = O + 600 mL) Elevate legs, teds, scdsElevate legs, teds, scds DialysisDialysis
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Imbalanced Nutrition: LBR Imbalanced Nutrition: LBR R/T altered metabolic state R/T altered metabolic state
and dietary restrictionsand dietary restrictions Adequate calories to prevent Adequate calories to prevent
catabolismcatabolism 30-35 kcal/kg body wt30-35 kcal/kg body wt CHON -0.6 g/kg, increased if catabolicCHON -0.6 g/kg, increased if catabolic 30-40% total cal from fat (fat emulsions)30-40% total cal from fat (fat emulsions)
Enteral nutrition or TPN if indicated Enteral nutrition or TPN if indicated (essential amino acids)(essential amino acids)
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Risk for Infection R/T Risk for Infection R/T leukopenia, invasive lines, leukopenia, invasive lines,
uremic toxinsuremic toxins Strict aseptic techniqueStrict aseptic technique Crowd and exposure controlCrowd and exposure control Monitor local and systemic S & SMonitor local and systemic S & S Nephrotoxic drugs as last resortNephrotoxic drugs as last resort
of kidney tissue by disease which is of kidney tissue by disease which is fatal unless treated by dialysis or fatal unless treated by dialysis or transplanttransplant
Defined as kidney damage or GFR < Defined as kidney damage or GFR < 60 mL/min for > = 3 months60 mL/min for > = 3 months
Urinary tract obstructionUrinary tract obstruction Exposure to nephrotoxic agentsExposure to nephrotoxic agents DehydrationDehydration Multiple myelomaMultiple myeloma
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Classification Systems - Classification Systems - STAGES CRF (5) – Table 47-STAGES CRF (5) – Table 47-
6, p. 12056, p. 1205 Stage 1: Stage 1:
Asymptomatic, functions intactAsymptomatic, functions intact BUN, creat nmlBUN, creat nml GFR > = 90GFR > = 90
Dx and Tx comorbid conditionsDx and Tx comorbid conditions CVD risk reductionCVD risk reduction
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Stage 2Stage 2 Mild Decrease GFR with kidney Mild Decrease GFR with kidney
damagedamage GFR 60-89GFR 60-89 Estimation of progressionEstimation of progression
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Stage 3Stage 3
Moderate decrease in GFR 30-59Moderate decrease in GFR 30-59 Evaluation and treatment of Evaluation and treatment of
complicationscomplications
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Stage 4Stage 4 Severe decrease GRF 15-29Severe decrease GRF 15-29 Preparation for renal replacement Preparation for renal replacement
therapytherapy
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Stage 5Stage 5 Kidney Failure GFR < 15 Kidney Failure GFR < 15 Dialysis or renal replacement (if Dialysis or renal replacement (if
uremia present)uremia present)
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Biochemical Biochemical ConsequencesConsequences
Waste Product AccumulationWaste Product Accumulation Altered CHO metabolismAltered CHO metabolism Elevated triglyceridesElevated triglycerides Occ HypermagnesiumemiaOcc Hypermagnesiumemia Bleeding tendenciesBleeding tendencies InfectionInfection Increased cancer incidenceIncreased cancer incidence
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Biochemical Biochemical ConsequencesConsequences
Sodium & WaterSodium & Water Sodium can still be reabsorbedSodium can still be reabsorbed Renal tubules lose ability to concentrate Renal tubules lose ability to concentrate
urine by reabsorbing water (sp gr 1.010)urine by reabsorbing water (sp gr 1.010) Should produce polyurea if GFR high Should produce polyurea if GFR high
enoughenough May become rapidly fluid overloaded or May become rapidly fluid overloaded or
depleteddepleted Eventually oliguria and anuria (UO < 400 Eventually oliguria and anuria (UO < 400
Potassium * most serious electrolyte Potassium * most serious electrolyte disturbancedisturbance GFR low, nephron loss increases, less GFR low, nephron loss increases, less
potassium is excreted, develop potassium is excreted, develop hyperkalemiahyperkalemia
Acid/Base BalanceAcid/Base Balance Loose ability to regenerate bicarbonate Loose ability to regenerate bicarbonate
and excrete hydrogen ions so develop and excrete hydrogen ions so develop metabolic acidosismetabolic acidosis
GI: anorexia, N & V, GI bleed, peptic ulcers, GI: anorexia, N & V, GI bleed, peptic ulcers, constipation, diarrhea, metal taste in mouthconstipation, diarrhea, metal taste in mouth
GU: Nocturia, polyurea, sp gr 1.010, GU: Nocturia, polyurea, sp gr 1.010, oliguria, anuria, impotenceoliguria, anuria, impotence
Musc./Sk.: Myopathy, bone pain, renal Musc./Sk.: Myopathy, bone pain, renal osteodystrophyosteodystrophy
Heme: Normochromic, normocytic anemia, Heme: Normochromic, normocytic anemia, depressed platelet production due to uremic depressed platelet production due to uremic toxins, easy bruising and bleeding, Altered toxins, easy bruising and bleeding, Altered WBC production and functionWBC production and function
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Uremia in Chronic Renal Uremia in Chronic Renal FailureFailure
Control htn (diuretics, beta blockers, ace Control htn (diuretics, beta blockers, ace inhibitors) and anemia (Epogen, Procrit)inhibitors) and anemia (Epogen, Procrit)
Control hyperkalemia (Kayexalate)Control hyperkalemia (Kayexalate) Control hyperphosphatemia with oral calcium Control hyperphosphatemia with oral calcium
based phosphate binders to sequester ingested based phosphate binders to sequester ingested phosphate in the gut (Tums, PhosLo, Renagel)phosphate in the gut (Tums, PhosLo, Renagel)
Vit D supplements, (Calcitrol, Calcifediol, Vit D supplements, (Calcitrol, Calcifediol, Rocaltrol)Rocaltrol)
Established for pre-ESRD, hemodialysis, Established for pre-ESRD, hemodialysis, & PD & PD
Goals: Decrease build-up of urea Goals: Decrease build-up of urea and nitrogenous wastesand nitrogenous wastes Delay progression of renal diseaseDelay progression of renal disease prevent wasting and malnutritionprevent wasting and malnutrition
restriction of protein to prevent restriction of protein to prevent accumulation of nitrogenous wastesaccumulation of nitrogenous wastes
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Diet in CRF – Diet in CRF – Table 47-8, p. Table 47-8, p. 12121212
Comparison of diets for ESRD, PD, Comparison of diets for ESRD, PD, HD, ESRDHD, ESRD
ESRDESRD CHON (0.6-1 g/kg/d)CHON (0.6-1 g/kg/d) Unrestricted for fluidUnrestricted for fluid Individualized for K, Na, PhosphorusIndividualized for K, Na, Phosphorus If Phosphorus restriction (avoid organ If Phosphorus restriction (avoid organ
CHON – 1.2-1.3 g/kg (nml diet .8 g/kg)CHON – 1.2-1.3 g/kg (nml diet .8 g/kg) No added salt in diet (2-4 gm)No added salt in diet (2-4 gm) Phosphorus restriction same as HD <= Phosphorus restriction same as HD <=
17 g17 g Fluid unrestricted if wt & B/P controlledFluid unrestricted if wt & B/P controlled
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Diet in CRFDiet in CRF HDHD
CHON – 1.1-1.4 g/kgCHON – 1.1-1.4 g/kg Sl less than PDSl less than PD
Individualized Phosphorus restrictionIndividualized Phosphorus restriction Sodium – based on body wt & B/PSodium – based on body wt & B/P Fluid = 0utput previous 24 hr + Fluid = 0utput previous 24 hr +
insensible lossinsensible loss(600 mL) (600 mL)
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Electrolyte Imbalances in Electrolyte Imbalances in the Pt with Renal Fxthe Pt with Renal Fx
Hyperkalemia - impaired excretion of KHyperkalemia - impaired excretion of K Sx: Irritability, nausea, diarrhea, abd cramps, Sx: Irritability, nausea, diarrhea, abd cramps,
dysrhythmias, ECG changesdysrhythmias, ECG changes Hyponatremia - water retention (sodium Hyponatremia - water retention (sodium
leaves vascular compartment and moves to leaves vascular compartment and moves to interstitial space) interstitial space) Sx: Nausea, vomiting, headache, CNS involvement Sx: Nausea, vomiting, headache, CNS involvement
causing lethargy, confusion, seizures, & comacausing lethargy, confusion, seizures, & coma Hyperphosphatemia - decreased excretion of Hyperphosphatemia - decreased excretion of
phosphate in urinephosphate in urine Sx: Hyperreflexia, paraesthesias, tetany (same sx Sx: Hyperreflexia, paraesthesias, tetany (same sx
as hypocalcemia)as hypocalcemia)
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Dietary Goals:Dietary Goals: Encourage foods low in K and NaEncourage foods low in K and Na
avoid salt substitutes and processed avoid salt substitutes and processed foodsfoods
2-4 g/d K and sodium restriction2-4 g/d K and sodium restriction 1 g NaCl = 400 mg Na1 g NaCl = 400 mg Na
Avoid foods high in phosphorusAvoid foods high in phosphorus Restrict P to 1 G/dRestrict P to 1 G/d nuts, anchovies, organ meat, bran, nuts, anchovies, organ meat, bran,
are restricted)are restricted) Vitamin D (lose ability to produce Vit Vitamin D (lose ability to produce Vit
D)D) Give Vit DGive Vit D
RocaltrolRocaltrol CalcijexCalcijex
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AnemiaAnemia Fe supplements (FeTinic)Fe supplements (FeTinic)
Tarry stools, constipation, GI irritationTarry stools, constipation, GI irritation Do not take at same time as phosphate Do not take at same time as phosphate
bindersbinders Folic acid – RBC formation and dialysisFolic acid – RBC formation and dialysis Epogen (EPO), Procrit Epogen (EPO), Procrit
(adverse effects= htn, increased blood (adverse effects= htn, increased blood viscosity, iron deficiency)viscosity, iron deficiency)
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DyslipidemiaDyslipidemia Goal to keep LDL’s less than Goal to keep LDL’s less than
100mg/dl and triglycerides below 100mg/dl and triglycerides below 200 mg/dl200 mg/dl StatinsStatins fobratesfobrates
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Drug Excretion & Drug Excretion & NephrotoxicityNephrotoxicity
Drugs Excreted by KidneysDrugs Excreted by Kidneys DigoxinDigoxin Narcotic AnalgesicsNarcotic Analgesics
Meperidine (converted to normeperidine)Meperidine (converted to normeperidine) OxycodoneOxycodone MSMS
Renal TransplantationRenal Transplantation Review indications for Review indications for
transplantation, patient preparation, transplantation, patient preparation, patient education, postoperative patient education, postoperative care, immunosuppression, rejection, care, immunosuppression, rejection, and management following and management following transplantationtransplantation
Pre-opPre-op Supportive Care for both donor & recipientSupportive Care for both donor & recipient H & PH & P Continue dialysisContinue dialysis Immunosuppressive therapy to prevent Immunosuppressive therapy to prevent
rejection (can occur hours to years after rejection (can occur hours to years after transplantation)transplantation) Azathioprine (Imuran)Azathioprine (Imuran) PrednisonePrednisone Cyclosporine (Sandimmune)Cyclosporine (Sandimmune)
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RejectionRejection Mechanism of action of Mechanism of action of
T cytotoxic lymphocyte T cytotoxic lymphocyte activation and attack of activation and attack of renal transplanted renal transplanted tissue. The tissue. The transplanted kidney is transplanted kidney is recognized as foreign recognized as foreign and activates the and activates the immune system. T immune system. T helper cells are helper cells are activated to produce IL-activated to produce IL-2, and T cytotoxic 2, and T cytotoxic lymphocytes are lymphocytes are sensitized. After these sensitized. After these T cytotoxic cells T cytotoxic cells proliferate, they attack proliferate, they attack the transplanted kidneythe transplanted kidney
gums, bruising, petechiae, joint pain, gums, bruising, petechiae, joint pain, hematuria, black or tarry stools), pul hematuria, black or tarry stools), pul function (cyclophosphamines can cause function (cyclophosphamines can cause pul fibrosis)pul fibrosis)
Monitor renal and liver function studiesMonitor renal and liver function studies Administer meds with food to avoid GI Administer meds with food to avoid GI
effectseffects Give antacidsGive antacids Encourage po fluidsEncourage po fluids Monitor I & O, hand-washing, prevent Monitor I & O, hand-washing, prevent
TherapyTherapy Avoid large crowds and exposure to infectionAvoid large crowds and exposure to infection Report fever, chills, sore throat, fatigue, Report fever, chills, sore throat, fatigue,
malaisemalaise Use contraceptives to prevent birth defectsUse contraceptives to prevent birth defects Avoid aspirin, ibuprofen to prevent bleedingAvoid aspirin, ibuprofen to prevent bleeding Females may stop having periods while on Females may stop having periods while on
cyclophosphamide; menses resumes after cyclophosphamide; menses resumes after drug is discontinueddrug is discontinued
If on cyclophosphamide, report coughing or If on cyclophosphamide, report coughing or difficulty breathingdifficulty breathing
hourly, maintain closed system; foley out hourly, maintain closed system; foley out after 2-3 days (monitor voiding)after 2-3 days (monitor voiding)
Fluid replacement cc/ccFluid replacement cc/cc VS, arterial pressure, PWP (Diuresis can VS, arterial pressure, PWP (Diuresis can
occur immediately after transplantation)occur immediately after transplantation) DiureticsDiuretics Monitor lytes and urinary function testsMonitor lytes and urinary function tests
Hemorrhage (Swelling of operative site, Hemorrhage (Swelling of operative site, increased abd girth, shock, changes in VS, increased abd girth, shock, changes in VS, LOCLOC
Failure of the ureteral anastomosis Failure of the ureteral anastomosis (leakage of urine into peritoneal cavity – (leakage of urine into peritoneal cavity – abd swelling, tenderness, decreased uoabd swelling, tenderness, decreased uo
Infection from immunosupporession Infection from immunosupporession (change in LOC, cloudy or malodorous (change in LOC, cloudy or malodorous urine, purulent incisional drainage)urine, purulent incisional drainage)
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Discharge TeachingDischarge Teaching Emotional support – allow controlEmotional support – allow control MedicationsMedications Monitor VS and daily wtMonitor VS and daily wt Sx of rejection to be reported immediately:Sx of rejection to be reported immediately:
Swelling and tenderness of graft site, fever, Swelling and tenderness of graft site, fever, joint aching, weight gain, decreased urinary joint aching, weight gain, decreased urinary outputoutput
Dietary Dietary Restricted carbohydrate and increased CHONRestricted carbohydrate and increased CHON Sodium restrictionSodium restriction
Report cushingoid effects: Report cushingoid effects: Wt gainWt gain Fat redistributionFat redistribution HyperglycemiaHyperglycemia Sodium and water retentionSodium and water retention