Nursing Interventions for the Client with Renal Failure March 5, 1998, 8:30 - 11:20 am Jennifer M.

Hawley, RN, MSN (Jenny) Class Outline I. II. Brief Review of Renal Physiology Acute Renal Failure A. Causes B. Phases C. Nursing Care: Interventions III. Laboratory Values in Renal Failure A. B. C. D. IV. BUN Creatinine Creatinine Clearance Electrolytes: Sodium, Potassium,

Calcium, & Phosphorus

Chronic Renal Failure A. Causes B. Clinical Manifestations C. Nursing Care: Nursing Diagnoses & Interventions Renal Medications Renal Nutrition

V.

Renal Failure Treatment Options A. Hemodialysis B. Peritoneal Dialysis C. Transplantation

VI.

Renal Failure Case Study

Renal Anatomy & Physiology Review Jennifer M. Hawley, RN, MSN Kidney Size (determined by renal ultrasound) Average size: 10-12 cm Small kidneys vs. Enlarged kidneys (Hydronephrosis) Components of Nephron: Glomerulus Bowmans capsule Proximal convoluted tubule Loop of Henle Distal convoluted tubule Collecting duct Normal renal function depends upon the adequate and interrelated functioning of the CV system, nervous system, endocrine system, and the urinary collecting system. Kidneys receive 25% of cardiac output Sympathetic and parasympathetic nerve innervation ADH and aldosterone Collecting system of calyces, renal pelvis, ureters, and urethra Functions of the Kidney: Excretory functions: removal of waste products from the body regulation of fluids, electrolytes, blood pressure, and pH within the body 3 processes: Filtration, Reabsorption, and Secretion Non-Excretory or Metabolic functions: release of renin in response to renal ischemia to maintain normal BP production of prostaglandins production of erythropoietin Vitamin D conversion to active form calcium and phosphorus regulation insulin degradation excretion of certain medications

Nomal 24-hr urine output: Kidneys filter about 180 liters of fluid/day! GFR (Glomerular Filtration Rate): Normal GFR= 125 cc/minute 99% of filtrate reabsorbed, 1% becomes urine (about 1 cc/minute) Nomal 24-hr urine output= 1440 or 1500 cc/day

ACUTE RENAL FAILURE Jennifer M. Hawley, RN, MSN Acute Renal Failure (ARF) = an abrupt loss of renal function (hours, days) *potentially reversible Three Types of Causes of ARF: a) b) c) Prerenal: caused by decreased renal blood flow Examples: thrombus in renal artery, hypovolemia due to hemorrhage Postrenal: caused by urinary obstruction Examples: Renal calculi (stones), tumors Intrarenal: Most frequent cause, damage to kidney itself Examples: primary renal diseases (acute pyelonephritis), systemic diseases (lupus), ATN (acute tubular necrosis)= destruction of tubular epithelial cells caused by trauma, infection, metabolic conditions, or NEPHROTOXINS

Nephrotoxic Agents
Antibiotics Aminogycosides: Amikacin Gentamicin Kanamycin Others: inflammatory Amphotericin B Cephalosporins Sulfonamides Vancomycin Other Agents Captopril Cimetidine Cisplatin Cocaine Contrast media Cyclosporin Heroin Rifampin Lithium Methotrexate Nitrosoureas (Carmustine) Nonsteroidal antiagents (Ibuprofen, Indocin)

Neomycin Streptomycin Tobramycin Colistin Bacitracin Polymyxin B

Ethylene glycol Phenacetin Gold Quinine Heavy metals (lead) Salicylates (large quantities)

Three Phases of ARF: a) Oliguric Phase: <400 cc urine/day, lasts 8 to 14 days Increased BUN, creatinine, K, low Na Protein, red blood cells, and casts found in urine, low urine SG Nausea, vomiting, lethargy, elevated BP Need for short-term dialysis therapy *The longer this phase lasts, the poorer the prognosis. THE WAIT AND SEE PERIOD

Nursing Care: Same as for chronic renal failure, includes: fluid restriction, monitoring electrolytes (hyperkalemia), management of mental status changes & GI complaints, patient/family education important

b) Diuretic Phase: kidneys begin recovery, lasts one week 1) Early diuretic phase: urine output >400 cc/day Hypotonic urine (unable to concentrate urine, low SG) Large amount of K and Na losses 2) Late diuretic phase: BUN returns to normal Kidneys regain ability to concentrate Nursing Care: Monitor for dehydration, hypokalemia, hyponatremia (early diuretic phase), provide free access to fluids and salt, possible need for IV replacement of urine output, monitor SG, strict I & O, daily weights c) Recovery Phase: lasts 4 to 5 months, vulnerable to further renal insults Nursing Care: Monitor renal function closely, teach pt to avoid potential renal insults (nephrotoxins) Leading Causes of Death in Acute Renal Failure: 1) Hyperkalemia 2) Infection

Laboratory Values in Renal Failure Jennifer M. Hawley, RN, MSN I. BUN (Blood Urea Nitrogen) Urea is a product of protein metabolism. Urea concentration is regulated by the rate at which the kidney excretes urea. However, BUN is affected by other factors, such as muscle mass, excessive protein intake, GI bleeding, or dehydration. Normal range: 10 - 20 mg/dL Creatinine Since creatinine is a product of muscle metabolism, it is excreted by the kidney at a constant rate. Therefore, it is the most reliable index of renal function. Normal range: 0.5 - 1.2 mg/dL (lower in women) Creatinine Clearance Since creatinine is relatively constant, the creatinine clearance is an excellent guide for determining the glomerular filtration rate (GFR).

II.

III.

GFR= the amount of glomerular filtration that occurs within a given period of time Normal GFR= 125 ml/minute with range of 100 - 150 ml/minute (lower in women) Creatinine Clearance = Urine creatinine X Urine volume/24 hrs Serum creatinine Time (min) A 24-hr urine collection is used to calculate the creatinine clearance. IV. Sodium (Na) -determines blood volume -increased Na results from renal tubular damage Normal range: 135 - 145 meq/L Potassium (K) -aids in regulation of osmotic pressure -important in conduction of nerve impulses Normal range: 3.5 - 5.5. meq/L Calcium (Ca) and Phosphorus (PO4) -Calcium necessary for muscle contractions, nerve transmissions, and clotting -Phosphorus related to calcium in an inverse relationship Normal Ca: 9 - 10.5 mg/dL Normal PO4: 3 - 5 mg/dL

V.

VI.

In renal failure, there is decreased calcium and Vitamin D absorption in the GI tract. Therefore, patients with renal failure tend to be hypocalcemic and hyperphosphatemic. This leads to the stimulation of the parathyroid gland to secrete PTH to increase serum Ca. PTH can lead to extraction of Ca from bones and long-term orthopedic complications (renal osteodystrophy) if untreated. CHRONIC RENAL FAILURE

Jennifer M. Hawley, RN, MSN Correlation Between Creatinine Clearance, Serum Creatinine, and Degree of Renal Failure Creatinine Clearance 85 - 150 50 - 84 10 - 49 <10 0 Serum Creatinine 1.0 - 1.4 1.5- 2.0 2.1 - 6.5 >6.5 >12 Degree of RF Normal function Renal Insufficiency Moderate CRF Severe CRF End-stage renal disease

Causes of Chronic Renal Failure: 1) Hypertension 2) Diabetes 3) Long history of analgesic abuse- Phenacetin 4) Chronic urinary tract infections 5) Glomerulonephritis 6) Long history of renal stones 7) Polycystic kidney disease 8) Systemic Lupus Erythematosus (SLE) Clinical Manifestations of Renal Failure: I. Cardiovascular 1) Anemia 2) Pericarditis/ Pericardial Effusion 3) Hypertension 4) Congestive Heart Failure 5) Hyperkalemia 6) Edema II. Pulmonary 1) Pulmonary Edema 2) Dyspnea 3) Pleural Effusion Gastrointestinal 1) Anorexia 2) Nausea/Vomiting 3) Diarrhea or Constipation 4) Mucosal Ulcerations- GI Bleeding Integumentary 1) Pruritus 2) Uremic Frost (rare) 3) Easy Bruising Neuromuscular/Behavioral 1) Headache

III.

IV.

V.

2) 3) 4) 5) 6) 7) VI.

Daytime drowsiness/insomnia Confusion/ disorientation Asterixis Muscle weakness and cramping Peripheral Neuropathy Body image/ Self-Concept disturbances

Endocrine/ Metabolic 1) Calcium/Phosphorus Imbalance- Renal osteodystrophy 2) Metabolic Acidosis Psychosocial 1) Denial 2) Depression/ Grief 3) Dependency Sexual 1) Impotence 2) Amenorrhea 3) Decreased sexual desire

VII.

VIII.

Renal Medications a) Multivitamin, Iron supplements (ferrous fumurate), Folic acid b) Epogen - to prevent anemia c) Tums (Calcium carbonate) or Basalgel- phosphate binders, can cause constipation d) Shohls solution- bicarbonate replacement, used for chronic metabolic acidosis e) Rocalcitrol- Vitamin D supplement f) Stool softeners g) Sorbitol- artificial sweetener used as a laxative h) Kayexalate- resin that binds K in GI tract, causes diarrhea BEWARE OF MEDICATIONS that contain MAGNESIUM and PHOSPHORUS! RF patients cannot excrete these substances. Examples: Milk of Magnesia, Mylanta, Fleets Enema Renal Nutrition Typical renal diet: restricted protein, potassium, and sodium Less restricted diet for PD patients, lose protein through PD Beware of salt substitutes, frequently contain KCl Frequently require fluid restrictions - 1 liter/day More liberal diet for PD pts

Selected Nursing Diagnoses & Interventions for Clients with ESRD

Fluid volume excess related to inability of kidneys to excrete fluid Reinforce necessity of fluid and sodium restrictions in diet Daily weights Strict I & O Assess for edema, SOB, increased resp rate, pulse, & BP, crackles in lungs Check for JVD and pericardial friction rub Risk for injury: Fracture related to Ca-PO4 imbalances Administer phosphate binders, calcium supplements, and Vitamin D as prescribed Teach pt importance of taking these meds at home *Phosphate binders need to be taken with meals Monitor serum calcium & phosphorus levels Assess for bone pain and limited mobility Encourage activity and range of motion exercises as tolerated Activity Intolerance related to anemia Teach pt to plan activities to avoid fatigue with frequent rest periods Monitor Hct and Hemoglobin levels Administer iron supplements between meals and Epogen as prescribed Altered nutrition: less than body requirements related to restricted diet, N/V, anorexia Provide small frequent meals Administer anti-emetics as ordered Provide mouth care and hard candy or gum to improve taste Monitor weight and labs (BUN, creatinine) to assess for effective dialysis Sensory and perceptual alterations related to uremia Assess mental status. Watch for confusion, irritability, behavioral changes, decreased attention. Educate pt/family on relationship of uremia to mental status changes Provide calm, non-stimulating environment Provide short teaching sessions Safety measures as appropriate Reorient pt as necessary. Provide supportive environment. Risk for infection related to uremic effects on immune system Maintain aseptic technique for procedures Assess for signs of infection (fever, chills, redness, edema, or drainage of site) Instruct pt to avoid people with infections Knowledge deficit related to lack of information about diet, meds, dialysis, self-monitoring Teach pt/family about dietary restrictions and rationale for these. Dietary consult helpful. Instruct pt/family about meds and administration times. Provide information about dialysis treatment options, procedures, etc Assess pt/familys understanding of above and reinforce as necessary

RENAL FAILURE TREATMENT OPTIONS Jennifer M. Hawley, RN, MSN Basic Goals of Dialysis Therapy: A) to remove the end products of protein metabolism, such as urea and creatinine, from the blood B) to maintain a safe concentration of serum electrolytes C) to correct acidosis and replenish the bloods bicarbonate buffer system D) to remove excess fluid from the blood 2 Types of Dialysis: A) Hemodialysis - external membrane within dialysis machine used to filter blood via a patients vascular access Types of Permanent Vascular Accesses: 1) Scribner or Thomas-Femoral Shunt= external plastic tubing that connects an artery to a vein 2) Arteriovenous (AV) Fistula= internal connection between an artery and a vein, uses patients own blood vessels 3) Gore-tex Graft= synthetic material used to connect an artery and a vein internally With both AV fistulas and grafts, the blood flow between artery and vein creates a thrill (palpable) and a bruit (audible by a stethoscope). Care of Vascular Accesses: a) No BP, blood drawing, or IV in extremity with access *Important to post sign to inform staff b) Assess for patency by checking for thrill and bruit c) Maintain adequate BP to ensure patency d) No heavy lifting or restrictive clothing on extremity with vascular access e) Assess for signs/symptoms of infection Most common complications of vascular accesses: 1) Infection of access 2) Septicemia 3) Clotting of access Temporary Vascular Access - Permcath or Udall catheter: -external Y-shaped catheter placed in subclavian or femoral vein for short-term hemodialysis (weeks)

B) Peritoneal Dialysis - instilling fluid into the peritoneal cavity, allowing time for dialysis via this internal membrane, and removing the dialysate fluid 2 Types of Peritoneal Dialysis (PD) a) Continuous Ambulatory P.D. (CAPD) = four to five exchanges daily of dialysate into the peritoneal cavity so that dialysis is constant, done by gravity drainage b) Continuous Cycle P.D. (CCPD) = machine used to perform P.D. for about 8 hours a day, usually at night Peritoneal Dialysis Catheter = Tenckhoff catheter Care of Tenckhoff catheter- Dressing change every day per agency protocol, assess site for signs of infection Most common complications of P.D : a) peritonititis- Treatment: antibiotics in dialysate b) leakage of catheter- Treatment: rest catheter Another Option: Renal Transplantation - living related donor (LRD) or cadaveric transplant - increased success rate: 1-year graft survival is 97% in LRD cases and 90% in cadaver cases Complications of transplantation: 1) Graft rejection- Signs/ symptoms include fever, decreased urine output, edema, weight gain, increased BP, and/or pain or tenderness over kidney site 2) Infection- urinary tract infections, viral, fungal, and parasitic infections Medications of transplant therapy: a) Steroids- Prednisone or Medrol b) Imuran (Azathioprine) c) Cyclosporine- Major side effect is nephrotoxicity d) OKT-3 - monoclonal antibodies that inhibit T cell proliferation (T cells are primarily responsible for transplant rejection)

Chronic Renal Failure Case Study Mr. Thomas, a 65-year-old retired millworker with a long history of diabetes and hypertension, arrives on your unit from the Emergency Room. From the ER report, you learn that Mr. Thomas has chronic renal insufficiency and has been followed in the clinic for several years with increasing BUN and creatinine levels. When Mr. Thomas arrives on your floor, he is lethargic and when aroused, has difficulty with knowing where he is and todays date. His statements are frequently inappropriate, and he states, I feel sick to my stomach. When his family is questioned, they say that they were concerned so they brought Mr. Thomas to the ER. Assessment reveals the following data: T-36.7, P-124 reg, R- 28 and slightly labored, BP- 200/120, 4+ pitting edema in lower extremities up to mid-thigh bilaterally, lungs with coarse rales 2/3 way up bilaterally. Weight is 185 lbs. Family member states that Mr. Thomass usual weight is around 177 lbs. Labs: BUN- 50, Creatinine- 6.8 (last value was 3.2 in the clinic 3 months ago), Glucose- 324, K-6.2, Ca- 8.5, PO4- 5.4 1) What are the patients predisposing factors for CRF? 2) What are Mr. Thomass signs and symptoms of renal failure? 3) What are important nursing assessments that should be done daily and every shft? 4) What nursing diagnoses can you identify for Mr. Thomas? 5) What are Mr. Thomass immediate medical and nursing care needs? What medications can you anticipate that you may need to give to this patient? Mr. Thomas remains in the hospital for 3 days. He has received 2 hemodialysis treatments thus far. His mental status has improved. His BUN and creatinine values have stabilized. His BP is now 160/90 on BP medications. His appetite has improved, and nausea and vomiting occurs only in the morning now. Mr. Thomas has a Permcath catheter in place for dialysis. His potassium is stable at 4.6. The patient and his family receive information about long term dialysis options. Peritoneal dialysis is selected by the patient and family because Mr. Thomas wants to be involved in his own care, and his son will be able to help with P.D. at home. Also, his diabetes can be controlled by putting insulin in his dialysis bags. A Tenckhoff catheter will be placed in two days. Discharge is tentatively scheduled for two days after surgery. Mr. Thomas will be going home on a renal failure diet and will be on multiple medications. 6) What are the teaching needs for Mr. Thomas and his family?
renal98.doc