Nursing Interventions for the Client with Renal Failure

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					                  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.     Brief Review of Renal Physiology

II.    Acute Renal Failure

       A. Causes
       B. Phases
       C. Nursing Care: Interventions

III.   Laboratory Values in Renal Failure

       A.   BUN
       B.   Creatinine
       C.   Creatinine Clearance
       D.   Electrolytes: Sodium, Potassium,     Calcium, & Phosphorus

IV.    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
 Bowman’s 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)      Prerenal: caused by decreased renal blood flow
        Examples: thrombus in renal artery, hypovolemia due to hemorrhage
b)      Postrenal: caused by urinary obstruction
        Examples: Renal calculi (stones), tumors
c)      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                                   Other Agents
Aminogycosides:                               Captopril                 Heroin        Rifampin
Amikacin                Neomycin              Cimetidine                Lithium
Gentamicin              Streptomycin          Cisplatin                 Methotrexate
Kanamycin               Tobramycin            Cocaine                   Nitrosoureas (Carmustine)
Others:                                       Contrast media            Nonsteroidal
anti-inflammatory
Amphotericin B          Colistin              Cyclosporin           agents (Ibuprofen, Indocin)
Cephalosporins          Bacitracin            Ethylene glycol     Phenacetin
Sulfonamides            Polymyxin B           Gold                Quinine
Vancomycin                                    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

II.    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)

III.   Creatinine Clearance
       Since creatinine is relatively constant, the creatinine clearance is an excellent
       guide for determining the glomerular filtration rate (GFR).

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

V.     Potassium (K)
       -aids in regulation of osmotic pressure
       -important in conduction of nerve impulses
       Normal range: 3.5 - 5.5. meq/L

VI.    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

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            Serum Creatinine             Degree of RF
85 - 150                          1.0 - 1.4                   Normal function
50 - 84                           1.5- 2.0                    Renal Insufficiency
10 - 49                           2.1 - 6.5                   Moderate CRF
<10                               >6.5                        Severe CRF
     0                            >12                         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

III.       Gastrointestinal
           1) Anorexia
           2) Nausea/Vomiting
           3) Diarrhea or Constipation
           4) Mucosal Ulcerations- GI Bleeding

IV.        Integumentary
           1) Pruritus
           2) Uremic Frost (rare)
           3) Easy Bruising

V.         Neuromuscular/Behavioral
           1) Headache
        2)   Daytime drowsiness/insomnia
        3)   Confusion/ disorientation
        4)   Asterixis
        5)   Muscle weakness and cramping
        6)   Peripheral Neuropathy
        7)   Body image/ Self-Concept disturbances

VI.     Endocrine/ Metabolic
        1) Calcium/Phosphorus Imbalance- Renal osteodystrophy
        2) Metabolic Acidosis

VII.    Psychosocial
        1) Denial
        2) Depression/ Grief
        3) Dependency

VIII.   Sexual
        1) Impotence
        2) Amenorrhea
        3) Decreased sexual desire

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) Shohl’s 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/family’s 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 blood’s 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 patient’s 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 patient’s 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 today’s 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.
Thomas’s 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 patient’s predisposing factors for CRF?

2) What are Mr. Thomas’s 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. Thomas’s 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?


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