The Client with Alterations in Urinary Elimination[1]

The Client with Alterations in Urinary Elimination Sherry A. Burrell, RN, MSN Rutgers University Nursing III Lecture Date: 10/24/05 Anatomy: The Renal System   Kidneys Ureters   Enter at oblique angle Peristalsis  Both prevent reflux  Bladder  Capacity 300–500 ml  Urethra   Excretion; outside of body. In Males surrounded by prostate Functions of the Renal System   Elimination of Metabolic Wastes Regulation of RBC Production Regulation of Vitamin D & Calcium Regulation of Blood Pressure Regulation of Electrolyte, Acid-Base & Fluid Balances    Elimination of Waste Products  Urea Nitrogen   By-product of the protein metabolism. Measured clinically via serum BUN  Some amounts normally found in blood; Not a reliable indicator of renal function alone.  Creatinine  A by-product of muscle metabolism.   Normally, almost completely excreted A more reliable as an indicator of renal function than BUN. RBC Production  Erythropoietin is a hormone that prompts bone marrow to produce RBC’s therefore more HgB to carry oxygen to cells.  Secreted in response to decreased amount of oxygen delivered to kidneys (i.e. anemia or hypoxia). Vitamin D & Calcium Regulation  Vitamin D from food sources must be converted into it’s active form by the kidneys. Active Vitamin D increases absorption of calcium by the renal tubules and the intestines. Required to maintain normal calcium balances with the body.   Blood Pressure & Fluid Regulation  RAAS: Maintenance of blood volume & altering peripheral vascular resistance.  Specialized JGA cells in the kidneys respond to decreased renal blood flow and pressures by releasing renin…activating angio. I → lungs → angio. II: Vasoconstriction  Stimulates aldosterone release from the adrenal cortex = Na & H2O retention (distal tubules).  Net Result: ↑ BP & ↑ renal blood flow.   Antidiuretic Hormone (ADH): release from the posterior pituitary = H20 retention (collecting ducts). Electrolyte Balances  Potassium  NL: 3.5 – 5.0 mEq /liter  Sodium  NL: 135-145 mEq / liter Total NL: 8.5 – 10.5 mg/dL Ionized Calcium NL: 4.5- 5.1 mg/dL NL: 1.8 – 2.7 mg /dL NL: 2.5 -4.5 mg/dL *See Thalen (pp. 748-749; table 30-2 & 3)  Calcium    Magnesium   Phosphorous  Acid-Base Balance  Kidneys regulate day-to-day acid-base balances; not as rapid as lungs.   Hydrogen: potent organic acidic Bicarbonate (HCO3-): principle buffer CO2 + H20 ↔ H2CO3 LUNGS Carbonic Acid ↔ H + HCO3 Kidneys Anatomy & Physiology: The Nephron  Functional unit or the “heart” of the kidney One million nephrons per kidney Each can perform all individual functions of the kidney   Components of the Nephron See Thalen pp. 720-722 A Closer Look: Urine Formation   Excretion of waste products and retention of essential electrolytes and water. Three processes involved:  Glomerular Filtration Glomeruli filter blood as it follows through the kidneys; creating filtrate.  Glomerular blood flow and pressures   Tubular Reabsorption  The movement of substances from the filtrate (renal tubules) into plasma (capillaries).  Tubular Secretion  The movement of substances from plasma into renal tubules to be excreted. Factors Affecting Glomerular Filtration  Glomerular Blood Flow:  Plasma Hydrostatic Pressure  Pushing pressure: result of arterial blood pressure; Favors filtration pressure: result of plasma proteins (i.e. albumin); Opposes filtration  Plasma Oncotic / Osmotic Pressures  Pulling  Pressure within the Bowman Capsule:  Capsular Hydrostatic Pressures  Pushing pressures from within the capsule; Opposes filtration Glomerular Filtration Plasma Hydrostatic Pressure 70 mmHg Plasma Oncotic Pressure 32mmHg Forces Favoring Filtration: Plasma Hydrostatic Pressure Forces Opposing Filtration: Plasma Oncotic Pressure Capsule Hydrostatic Pressure 70 mmHg - 32 mmHg 38 mmHg Total Plasma 38 mmHg Capsule Hydrostatic Pressure 14mmHg 38 mmHg - 14 mmHg 24 mmHg NET FILTRATION PRESSURE = 24 mmHg (70 mmHg - 46mmHg (32mmHg + 14mmHG) = 24mmHg) General Renal Failure Symptoms  Subjective   Objective  Metallic taste in mouth Weakness Irritability Fatigue Nausea Anorexia Ammonia (urine) odor to breath Oliguria / anuria Tachycardia Dysrhythmias Hypertension Rapid weight gain              Pruritis Dry, scaly skin Peripheral edema Laboratory Studies  Serum Analysis    BUN (5-20mg/dl) Creatinine (0.6 -1.5 mg/dl) Osmolarity H&H Electrolytes (K+, Na+, Mg+, Ca++ & PO4-) Creatinine Clearance (100-140 ml/min)     Combination: Serum/Urine Analysis  Direct measure of glomerular filtration (GFR) See Thalen pp. 738-742 Laboratory Studies Cont.,  Urine Analysis  Spot / Random Urine Collections Urine Analysis (UA)  Color, appearance & casts  Specific gravity (1.010 -1.030)  Protein  WBC’s & RBC’s  Urine Osmolarity  Culture & Sensitivity (C&S)   Twenty-Four Hour Urine Collections  i.e. For creatinine or electrolytes Diagnostic Studies       Kidney-Ureter-Bladder (KUB) Intravenous Pyelogram (IVP) Renal Ultrasound Renal Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Renal Angiography  Interventional radiology procedure Gold standard to diagnosis specific renal disease.  Renal Biopsy  Renal Failure   Is a severe impairment in or a total lack of renal function, which leads to disturbances in all body systems. Classification According To Onset:  Acute Renal Failure (ARF)  Developing within hours to days with little time to adjust to the biochemical changes, but is potentially reversible with treatment.  Chronic Renal Failure (CRF)   Insidious & progressive development over a period of several years; allows for some adjustment to biochemical changes. Irreversible; often necessitates some form of dialysis or transplantation for long-term survival. Acute Renal Failure (ARF)  Sudden loss of kidney function over a period of hour or days.  Characterized by:   A rapid decrease in GFR Retention of metabolic waste  A progressive ↑ in BUN & Creatinine levels.  Associated with:  Classic finding of Oliguria (UO < 400ml/day); but may have normal to increase UO.  Fluid, electrolyte and acid-base imbalances  Usually reversible with prompt treatment Classification of ARF  Acute renal failure is often classified according to location of the initial insult:  Prerenal Before the kidneys; ↓ Blood flow to kidneys  Occurs in about 55-60% of all ARF cases   Intrarenal Within the kidneys; actual damage to the filtering structures of the kidneys.  Occurs in about 35-40% of all ARF cases   Postrenal After the kidneys; obstruction of urinary excretion  Occurs in about 5% of all ARF cases  Prerenal ARF  It occurs when renal blood flow is decreased before reaching the kidney, causing ischemia of nephrons.    ↓ Renal Perfusion = ↓ GFR leading to Oliguria Most common type of ARF Common Causes:    Hypotension (severe and abrupt) Hypovolemia Low Cardiac Output States  Treatment to correct cause, if not corrected it may lead to permanent renal damage. Intrarenal ARF  It occurs when there is actual damage to the renal tissue, resulting in malfunction of the nephrons.  Acute Tubular Necrosis (ATN)  Damage to the renal tubules characterized by varying degrees of cellular damage or death.  Ischemic: Renal trauma, massive hemorrhage or post-surgery  Nephrotoxic: I.V. contrast dyes, heavy metals or antibiotics (i.e. aminoglyclosides)  Treatment: Immediate treatment to increase renal blood flow and minimize damage. Not always reversible; may lead to CRF. Postrenal ARF  Occurs as a result of conditions that block urine flow distal to kidneys, resulting in urine to backing-up into the kidneys.  Caused by a bilateral obstruction of the ureters or a bladder outlet obstruction.     Calculi (stones) Tumors or masses Blood clots Benign prostate hypertrophy (BPH)   ↓ UO: Oliguria or Anuria (UO < 100ml/day). Treatment to correct cause, if not corrected it may lead to permanent renal damage. ARF: The Clinical Course  Involves Four Distinct Phases:   Onset (Initiation) Phase Oliguric Phase   Diuresis Phase Recovery Phase Onset Phase  Time of insult until cell injury ending with the development of oliguria.   ↓ renal blood flow and pressures =↓ GFR Accumulation of metabolic waste products; ↑ Serum creatinine and BUN. Onset is sudden; can last hours to days; toxic causes longer duration Treatment during the onset phase may alleviate irreversible cellular damage.   Oliguric Phase  Characterized by a decreased UO (less than 400ml/day) that does not respond to fluid challenges or diuretics.  Also, call the “maintenance phase” because total support of renal function is required. May last for several days to several weeks; 8-15 days on average. Further impairment of GFR:      Continued ↑ BUN and ↑ Creatinine (serum) Metabolic Acidosis: ↓HCO3- Electrolytes: ↑ K+, ↑ PO4-, ↑ Mg+, ↓ Na+ & ↓Ca++ Diuretic Phase  Begins with the onset of polyuria (2-4 liters / day) and ends when BUN & creatinine levels cease to rise .   Also called the “high-output” phase This phase lasts on average 1 to 3 weeks.  Polyuria may not be as evident with hemodialysis therapy (more pulled off).  Marked ↑ in GFR, but little improvement of tubular function (can’t properly clear wastes). Electrolyte imbalances & volume depletion   Strict I&O, daily weights & electrolyte monitoring are essential !! Recovery Phase  Return to normal activity levels  Major improvement within first 1-2 weeks of the recovery phase. UO and renal function: normal or near normal usually within 1-2 years.    Requires close renal function monitoring Increased vulnerability to additional renal injury during this time.  Remember some do not recover = CRF. Chronic Renal Failure  A progressive and irreversible loss of renal function over a period of months to years  The kidneys can loss up to 80% of all nephrons with relatively few overt changes in functioning of the body. Nephrons are destroyed and replace with scar tissue; remaining nephrons become hypertrophied and eventually fail to function.   Resulting in alterations in all of body’s systems. Precipitating / Risk Factors of CRF  Increased Age   > 60 years-old   Race  Environmental Or Occupational Factors Systemic Disorders    African-Americans, Native Americans & Asian Americans at greater risk Men at slightly greater risk than women  Gender  Diabetes Mellitus* Hypertension* Chronic glomerulonephritis or Pyelonephritis  Frequent obstructions of the urinary tract Sickle cell anemia  Positive Family History   i.e. Polycystic kidney Disease   Smoking Systemic lupus erythematous Stages of CRF  Stage 1  Reduced Renal Reserve  Characterized by a loss of 40-75% of nephron function. asymptomatic; remaining function nephrons able to rid the body of metabolic wastes.  Usually Stages of CRF Cont.,  Stage 2  Renal Insufficiency  Characterized by a 75-90% loss of nephron function. Manifestations:    Clinical ↑ Serum Creatinine and ↑BUN Kidneys loose ability to concentrate urine  Client may report polyuria and nocturia.  Anemia develops Stages of CRF Cont.,  Stage 3  End-Stage Renal Disease (ESRD)  Final Stage: Characterized by < 90% loss of nephron function or < 10% of functioning nephrons remain !! Manifestations:    Clinical ↑ Serum Creatinine & ↑ BUN Electrolyte Imbalances  Uremia Affecting All Body Systems  Requires life-long dialysis or renal transplant to prolong life !! Renal Failure: Clinical Manifestations Cont.,  Retention of Nitrogenous Wastes  Azotemia: ↑ BUN & ↑ Serum Creatinine  Uremia: Signs & symptoms of azotemia  Fluid Volume Excess    ↓ UO leads to ↑ fluid retention JVD, bounding pulse & peripheral edema Hemodynamics: ↑ CVP & ↑ PAOP values Renal Failure: Clinical Manifestations  Metabolic Imbalances:  Electrolyte Imbalances:  Hyperkalemia  Hyperphosphatemia  Hypocalcemia  Hypermagnesia  Hyponatremia (Dilutional)  Acid-Base Imbalances:  Metabolic Acidosis (↓pH & ↓HCO3ˉ) *See Thalen (pp. 748-749; table 30-2 & 3) Renal Failure: Clinical Manifestations  Affects of Renal Failure on the Body’s Systems:  Genitourinary:  Oliguria  Urine    Findings: + Casts, RBC, WBC & Protein Specific gravity decreased & fixed at 1.010 Urine Osmolarity < Serum Osmolarity  Creatinine Clearance: Decreased  Neurologic:  Fatigue, confusion, lethargy, changes in level of consciousness → seizures & coma. Renal Failure: Clinical Manifestations Cont.,  Affects of Renal Failure On The Body’s Systems Cont.,:  Cardiovascular:  Dysrhythmias, HTN, Hyperlipidemia & peripheral edema → HF & Uremic Pericarditis  Respiratory:  Kussmaul respirations, crackles & pulmonary edema → Uremic Pleuritis N/V, stomatitis, metallic taste in mouth and uremic fector → GI Bleeding  Gastrointestinal:  Anorexia, Renal Failure: Clinical Manifestations Cont.,  Affects of Renal Failure On The Body’s Systems Cont.,  Integumentary:  Pruritus, dry skin, brittle nails and hair, ecchymosis, pallor or a yellowish-bronze discoloration of the skin.  When terminal uremic frost (rare today)  Musculoskeletal:  Muscle cramps and weakness → foot drop  Long-Term→ Renal Osteodystrophy: resulting in bone pain, deformities and pathological fractures. Renal Failure: Clinical Manifestations Cont.,  Affects of Renal Failure On The Body’s Systems Cont.,  Hematologic:  Anemia, decreased platelets → prolonged clotting times & decreased leukocytes. Intolerance libido and infertility  Endocrine:  Glucose  Reproductive:  Decreased Renal Failure: Complications   Seizures Coma Heart Failure Pericardial & Pulmonary Effusions      GI Ulcerations & Bleeding Renal Osteodystrophy Secondary Hyperparathyroidism Renal Failure: Conservative Management  Fluid Imbalances  Volume Excess  Fluid  Restriction Daily weights & I&O’s are essential !! 24 hour UO + 500-600ml   Also, treatment for hyponatremia Loop: i.e. Furosemide (Lasix) Osmotic: i.e. Mannitol (Osmitrol)   Diuretics   Both promotes diuresis and increases renal blood flow. Renal Failure: Conservative Management Cont.,  Electrolyte Imbalances  Hyperkalemia  I.V. Glucose accompanied by regular insulin  Forces K+ out of serum and into cells Creates temporary alkalemia moving H+ out of cells and allowing K+ to shift into cells.  I.V. Sodium Bicarbonate   I.V. Calcium Gluconate  Supportive: reduces myocardial irritability= decreasing risk of dysrhythmias Cation exchanging resin; oral, rectal or down NG tube; resin binds with K+ in bowel, promoting elimination in stool.  Polystyrene Sulfonate (Kayexalate)  Renal Failure: Conservative Management Cont.,  Electrolyte Imbalances Cont.,  Hyperphosphatemia  Phosphate  Binders: Bind to phosphate in bowel & promote excretion in stool; Given with meals.   i.e. Renagel or Calcium Acetate (Phos-Lo). Avoid long-term use of aluminum & magnesium based binders = toxicity !!  Hypocalcemia Supplements of Ca++  Synthetic Active Vitamin D i.e. calcitrol (Rocaltrol)  Renal Failure: Conservative Management Cont.,  Acid-Base Imbalances (↓pH & ↓HCO3ˉ)  Metabolic Acidosis  I.V. Sodium Bicarbonate  Hypertensive Management    ACE Inhibitors Angiotensin II Receptor Blockers (ARB’s) Calcium Channel Blockers RBC transfusions Epogen: Stimulates RBC production  Anemia   Renal Failure: Conservative Management Cont.,  Prevention of Complications / Symptom Management:  Antiseizure Antiulcer Antiemetics Antibiotics; ensure renal dosing     Antipruritics Renal Failure: Conservative Management Cont.,  Pharmacologic Considerations:    Potentiation of Effects Prone To Drug Toxicity Renal Dosing for Nephrotoxic Agents  Antibiotics (i.e. Gentamycin or Vancomycin)  Avoid NSAIDs, Demerol & Morphine for pain management.  Use Dilaudid or Percocet instead. Renal Failure Conservative Management Cont.,  Nutrition- Renal Diet  Caloric requirements met with a high carbohydrate diet. Blood glucose control Dietary Restrictions Protein (0.8 grams/kg/day)  Potassium  Sodium  Phosphorus Total parental nutrition: Watch volume !! Dietician Consult helpful with management  “Low”     Nursing Diagnoses: Renal Failure  Fluid volume excess related to inability of kidneys to produce urine. Altered renal perfusion related to damaged nephrons secondary to acute or chronic renal failure. Nutrition Altered: less than body requirements related to renal failure or dietary restrictions. Skin Integrity, high-risk for impairment related to poor cellular nutrition.    Nursing Diagnoses: Renal Failure Cont.,  Infection, high-risk for impairment related to lowered resistance  Potential for infection related to suppressed immune responses associated with azotemia. Anxiety, related to unknown outcomes of disease processes of renal failure Potential for altered family processes related to health crisis in family member. Knowledge deficit related to renal failure and/or its treatments    Renal Failure: Nursing Interventions  Monitoring   Vital Signs Fluid Balances  I&O’s, Daily Weights & Assess For Edema CBC; WBC & Urinalysis / Culture & Sensitivity Electrolytes & Acid-Base Balances   Laboratory Results   Be alert for signs/symptoms of imbalances !!  Signs and Symptoms of Infection Renal Failure: Nursing Interventions Cont.,  Maintain     Diet Restrictions / Supplements Fluids Restrictions Bedrest / Semi-Fowler’s Quiet Environment  Prevent Infection  Avoid unnecessary use of Foley catheters Aseptic technique with invasive line care Pulmonary Care Skin & Mouth Care    Renal Failure: Nursing Interventions Cont.,  Other Considerations     Handle client with care Bleeding Precautions Administer medications as ordered Provide support to client & significant others Renal Failure: Nursing Education  Explain: Renal Failure (and its etiology)  Dietary Restrictions / Supplements  Fluid Restriction  Medications (side effects too)  Signs & Symptoms:   Worsening renal function; signs and symptoms of infection & hyperkalemia i.e. Rapid weight gains (>2 lbs /day) or recurrent nausea / vomiting  When to Notify Physician:  Renal Failure: Nursing Education Cont.,  Demonstrate how to check daily weights and to assess for edema. Stress the Importance of:    Keeping follow-up appointments Importance of good hygiene Maintaining an activity-rest balance Maintaining a normal weight Smoking Cessation Avoiding OTC medications i.e. NSAIDs     Renal Failure: Nursing Education Cont.,  Demonstrate how to check daily weights. Stress the Importance of:       Keeping follow-up appointments Importance of good hygiene Maintaining an activity-rest balance Smoking cessation Maintaining a normal weight The Client with Alterations in Urinary Elimination Sherry A. Burrell, RN, MSN Rutgers University Nursing III Lecture Dates: 10/28/05 Renal Dialysis  Process of movement of fluid and particles from one fluid compartment to another across a semipermeable membrane.    Removes excess fluid and metabolic waste products from the body when the kidneys are unable to do so. Can be done in-home, in-hospital or incenter The need for dialysis maybe acute or chronic in nature. Renal Dialysis Cont.,   In 2001, 287,494 Americans with ESRD received dialysis. (ASN.org, 2005) Dialysis therapies are expensive; Medicare covers 80% of cost of dialysis.  In 1997, the total cost of treatment for ESRD in the U.S. was 15 billion dollars. Hemodialysis Continuous renal replacement therapies (CRRT) Peritoneal dialysis (various forms)  Types of Dialysis Therapies:    General Principles of Dialysis  Diffusion  Toxins and waste products are moved from an area higher concentration in the client’s blood to an area of lower concentration the dialysate solution. Excess water is moved from a higher concentration in the client’s blood to a lower concentration in the dialysate solution.  Osmosis  General Principles of Dialysis Cont.,  Ultrafiltration   Removal of excess water by creating a pressure gradient between the positive hydrostatic pressure of the client’s blood and the negative hydrostatic pressure (suctioning force) applied to the dialysate solution. More efficient water removal than osmosis Indications For Acute Dialysis   Hyperkalemia Fluid Overload    Impending pulmonary edema Pericarditis Drug overdose or poisoning Acidosis Severe mental confusion   Indications For Chronic Dialysis  End-Stage Renal Disease (ESRD)       Hyperkalemia Nausea / Vomiting Anorexia Mental confusion Increasing lethargy Fluid overload despite medical therapies Pericardial friction rub indicates an urgent need for dialysis  Mnemonic “AEIOU”     Acid-base Imbalances Electrolyte Disturbances Intoxication Overload, Fluid Uremic Symptoms  Hemodialysis   Most common method of dialysis Maybe used for short-term therapy (days to weeks) in acutely ill or lifelong therapy as in ESRD.  Life-Long Therapy 3 times a week for 3-4 hours each session  Prevents death, but does not cure renal disease   Dialysis machine removes “dirty” blood, cleanses it and then returns it to the body. Hemodialysis: Requirements   Vascular Access Dialysis Machine  Dialyzer  Tube-like apparatus containing a semipermeable membrane.  Dialysate Solution A solution containing all important electrolytes in ideal cellular concentrations.  Can be adjusted based on client needs.  The Process of Hemodialysis  Blood is removed from the arterial end and pumped through the dialysis machine (extracorporeal circuit) to the dialyzer at 200400 ml/min (rapid flow).  Heparin added to blood to prevent clotting with in the dialysis machine.  The dialyzer receives arterial blood flow along one side of the semipermeable membrane, with the dialysis solution flowing along the other side, usually in the opposite (countercurrent) direction.  Osmosis, Diffusion & Ultrafiltration Occur  The filtered blood then is returned through venous access to the client. Vascular Access  Short-Term Devices   Venous Catheters Arteriovenous (A-V) Shunts  Long-Term Devices  Arteriovenous (A-V) Fistulas Arteriovenous (A-V) Grafts  Venous Catheters   Preferred method for temporary access Often used for acute dialysis Often double lumen, cuffed subclavian catheters   i.e. Hickman or Quinton  Complications:   Infection Inadequate Flow Thrombosis  Arteriovenous (A-V) Shunts   Temporary access; rarely used today. External shunt created by connecting a peripheral artery and vein with a Ushaped silicone tubing.  Complications:      External Occlusion Infection Skin erosion Dislodgement Thrombosis Arteriovenous (A-V) Fistulas  Preferred method for chronic dialysis  Decreased rate of infection, inexpensive and tend to last longer.    Client’s vessels (peripheral artery & vein) anastomosed end-to-end, end-to-side, or side-to-side. Requires 4-6 weeks to mature Complications  Vascular Steal Syndrome Hand pale and cold  Extremely Painful   Thrombosis Arteriovenous (A-V) Grafts     Used in chronic renal failure when vessels inadequate to create a fistula. Ready to use in about 2 weeks Gore-Tex graft implanted to connect a peripheral artery and vein. Complications    Vascular steal syndrome Infection Thrombosis Hemodialysis: Nursing Considerations    Strict aseptic technique during dialysis Universal precautions Continuous monitoring of vital signs  Watch for hypotension from rapid fluid shifts!!   Monitor Laboratory Results  i.e. CBC, BUN, Creatinine & PTT levels Bleeding Infection Daily weights and I & O’s Observe for signs & symptoms of    Monitor Fluid balance  Hemodialysis: Nursing Considerations Cont.,  Chronic Access Devices  Assessment Auscultate for bruit & palpate for thrill  Neurovascular Checks  Monitor for s/sx of infection  No blood pressure or venipuncture to the extremity with A-V access.   Education Care of device  No constrictive clothing, avoid sleeping on arm with access  Signs and symptoms of infection  Hemodialysis: Pharmacologic Considerations  Some medications are removed during hemodialysis.    Caution with medication administration prior to dialysis Daily Medications usually administered after dialysis or at night Medication doses often need to be adjusted with the initiation of dialysis  Protein bound medications or some drug metabolites are not removed  Tend to remain in system longer; prone to toxicity. Complications of Hemodialysis    Hypotension Dysrhythmias Chest Pain Muscle Cramping Exsanguination    Air embolism Sleep Disorders   Hyperlipidemia (esp. triglycerides) Complications of Hemodialysis Cont.,  Dialysis Disequilibrium Syndrome  Acute disorder occurring during or shortly after hemodialysis procedure.  Results from the faster removal of urea from plasma than brain & cerebrospinal fluid causing water from plasma to be shifted into the brain= cerebral edema.  S/Sx: HA, N/V, muscle cramps, restlessness, decreased level of consciousness and seizures Complications of Hemodialysis Cont.,  Dialysis Encephalopathy Occurs in clients on chronic hemodialysis  Results from aluminum toxicity   i.e. aluminum containing antacids or dialysate bath  S/Sx: dementia, muscle uncoordination, speech disturbances, personality changes and later seizures Continuous Renal Replacement Therapies (CRRT)    Completed only on critical care units Indicated for the acute treatment of drug overdose, fluid overload and acute or chronic renal failure client’s who are too hemodynamically unstable for traditional hemodialysis. Procedure is similar to hemodialysis:   Requires vascular access to circulation A hollow fiber filter (semipermeable membrane); hemofilter often used. Extracorporeal circuit   One Type of CRRT is Continuous Arteriovenous Hemofiltration (CAVH) Continuous Arteriovenous Hemofiltration (CAVH)  Arterial blood pressure used to circulate blood through the extracorporeal circuit.  Requires a MAP < 70 mm Hg    Rate of fluid removal much slower than hemodialysis; about 5 - 20 ml / minute Therapy lasts 12 hours or longer Gentle fluid removal by convection  Convection: No concentration gradient, filters fluid only, but solutes are removed because they are pulled or “dragged” along with the fluid.  Can clear more drugs, wastes and fluid than traditional hemodialysis.  CAVH: Procedural Considerations  Blood removed via arterial access  Arterial blood pressure used to propel blood through the extracorporeal circuit Heparin added to arterial flow once leaves the body to prevent clotting Blood filtered through semipermeable membrane (hemofilter); Convection Occurs.    Filtered blood returned to the body via venous access.  Fluid and solutes wastes are collected in a drainage bag; measure & discard Continuous Arteriovenous Hemofiltration (CAVH) Cont.,  Nursing Considerations   Continuous monitoring of vital signs Monitor Laboratory Results  i.e. CBC, BUN, Creatinine & PTT  Observe for signs & symptoms of Bleeding  Infection   Monitor Fluid balance  Daily weights and I & O’s  Assess extremity distal to arterial & venous access  Neurovascular checks CRRT Complications:  Fluid & Electrolyte Imbalances Hypotension Infection    Bleeding   Access Dislodgement Heparin Peritoneal Dialysis  Indications for peritoneal dialysis:      Acute or Chronic Renal failure Young Children & Older Adults Severe Cardiovascular Disease Diabetes Mellitus Client with bleeding disorders and can not tolerate systemic use of heparin. Osmosis, Diffusion & Ultrafiltration   Principles of Peritoneal Dialysis  Ultrafiltration: pressure gradient established by high dextrose content of dialysate solution. Peritoneal Dialysis Cont.,  Contraindications   Recent abdominal surgery Previous abdominal surgery resulting in scaring and adhesions Significant pulmonary disease Peritonitis Client that requires rapid fluid removal.    Peritoneal Dialysis Cont.,  The peritoneum, a serous membrane that covers the abdominal organs functions as the semipermeable membrane to the capillaries below.  A catheter is inserted into the abdomen for access. (i.e. Tenckhoff catheter) Exchanges: Dialysate instilled (over 5-10 min) at body temperature into the peritoneal cavity; left in (dwell time) usually is between 1- 8 hours. Fluid later drained over 10-30 min by gravity  Peritoneal Dialysis Cont.,  Peritoneal drainage should be clear or straw-colored.   Fluid maybe blood-tinged or pink the first treatment after new catheter insertion Turn client side-to-side to facilitate drainage  Dialysate composition, amount of dialysate used & dwell time as per MD. Main Types of Peritoneal Dialysis  Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling Peritoneal Dialysis (CCPD)  Continuous Ambulatory Peritoneal Dialysis (CAPD)  Completed in the home; As per MD’s orders  Exchanges preformed 4-5 times a day, 7 days a week; dwell time from 4-8 hours. More consistent, less electrolyte imbalances Frees client physically & mentally from dialysis centers More opportunity for infection Must be able to complete exchanges at more frequent intervals; less freedom for work and social engagements outside the home.  Advantages    Disadvantages   Continuous Cycling Peritoneal Dialysis (CCPD)  Completed in the home; As per MD’s orders  Peritoneal automated cycler machine 4-5 exchanges completed during sleep, with one prolonged dwell time during the day. Free from exchanges during the day allowing work and social activities outside the home. Reduced risk of infection in comparison to CAPD Frees client from attending dialysis centers Prolonged daytime dwell time Requires a peritoneal cycler machine Less night-time mobility  Advantages:     Disadvantages:    Peritoneal Dialysis  Nursing Considerations  Teaching Self-Care the importance of proper hand washing  Explain and Demonstrate Basic aseptic technique  PD procedure  Tenckhoff catheter exit site care  Daily Weights   Stress  A home health care consult is necessary!! Complications: Peritoneal Dialysis Peritonitis  Bleeding  Abdominal Wall Hernias  Hyperlipidemia (esp. triglycerides)  Anorexia  Low-Back Pain  Catheter Malfunction    Leakage Occlusion Dialysis: Dietary Considerations   “High” Protein Diet (1.0-1.5 g/kg/day) Dietary Restrictions  Sodium, Potassium & Phosphate   Likely to continue; may be less severe Use of phosphate binders likely to continue  Fluid Restrictions  24 Hour UO + 500-600 ml  Dietary Supplements   Calcium Active Vitamin D i.e. calcitrol (Rocaltrol) Long-Term Dialysis: Psychosocial Considerations  Client’s and their significant others constantly vulnerable to medical, social and emotional crisis.  In-center and in-hospital dialysis schedule according to the convenience of others.  May affect work, schooling or leisure activities  In-home dialysis may increase a client’s dependence. Sick Role  Often leads to caregiver strain   Family roles and responsibilities change  Creating tension, feelings of guilt or inadequacy Long-Term Dialysis: Psychosocial Considerations Cont.,  Financial burdens of treatment, medications and transportation  Changes in sexual function  i.e. decreasing libido and impotence   Body image disturbances Fear, depression and anger are common and permissible    Suicide rates increased in dialysis clients Some act-out depression with non-compliance Fear is common related to medications, infection and contracting HBV and/or HIV Kidney Transplantation  The treatment of choice of ESRD     The average cost of maintaining a successful kidney transplant is 1/3 the cost of dialysis. Medicare will cover 80% of the cost of transplant surgery As of October 1, 2005 there are 63,301 individuals wait-listed to receive a kidney transplant (www.unos.org). Lack of donors is a major problem!!  Two main types of human donors   Living (related or non-related) Cadaver Kidney Transplantation Cont.,  Regulatory Agencies:  United Network for Organ Sharing (UNOS) Gift of Life Program Coalition on Donation (Southern NJ)  Regional Support Agencies:    Legislation:     Uniform Anatomical Gift Act (1968) End Stage Renal Disease Act (1972) The National Organ Transplant Act (1984) Organ Donation Leave Act (1999) Preoperative Considerations  Informed Consent  Dialyzed within 24 hours of procedure to ensure best metabolic state as possible. Donor Compatibility   ABO (blood type) & cross-match antigens and HLA (human leukocyte antigens).  Lower urinary tract studies to ensure proper functioning prior to transplant.  Screening for infection; must be infection free to proceed. Preoperative Considerations Cont.,  Psychosocial Considerations:   Some welcome transplant as freedom Some anxious about the procedure, possible rejection or the need to return to dialysis or dietary restrictions. Intraoperative Considerations  The donor kidney is placed in the iliac fossa, anterior to iliac crest.  The native kidney is usually left in for hormones unless cancer or prone to chronic infection. Postoperative Considerations  Standard Postoperative Care  Monitor Vital Signs  Daily Weight and I&O’s  Strict aspesis with invasive lines and catheters    Provide Pain Control Prevent Infection Early Ambulation  Pulmonary Toileting  Incisional Care    Administer medications as ordered Advance diet with return of bowel sounds; encourage protein for healing Postoperative Considerations Cont.,  Immunosuppressive Therapy  The survival of the kidney depends on blocking the body’s immune response. Neoral (cyclosporine)  Prograf (tracrolimus)  CellCept (mycophenolate)  Rapamune (Sirolimus)    Doses gradually decreased over a period over several weeks, but will need to be on immunosuppressants for life !! Complications: nephrotoxicity, decreased platelets and leukocytes and malignancies. Postoperative Considerations Cont.,  Immunosuppressive Therapy Cont.,  Corticosteroids i.e. Oral: Prednisone / I.V. Solu-Medrol  Doses gradually decreased, but require a lifelong maintenance dose !!  Many Long-Term Adverse Effects:       Glucose Intolerance; Monitor Closely !! Weight Gain GI Ulcerations Osteoporosis Increased Susceptibility to Infections  Dietary Considerations:   Glucose Intolerance: No concentrated sweets Weight Gain: Reduced caloric intake Kidney Transplantation: Complications  Cardiovascular Disease  Most common overall cause of mortality; occurs most often in the later stages of transplantation 3-5x more likely to have CV disease than normal population. Common cause of mortality within the first year of transplantation.   Infection   Sources: urine, lung, operative site, catheters or drains. S/Sx: shaking chills, fever, tachycardia, tachypnea, changes in WBC’s counts  Kidney Transplantation: Complications Cont.,  Graft Rejection  Three Types Hyperacute:  Occurs within 24 hours of transplantation; usually within minutes.  This type of rejection is rare due to advances in compatibility screening.  Acute:  Usually occurs in 6 weeks to 3 months, but can occur for up to 2 years after transplant.  Chronic:  Occurs slowly over months to years; often occurs more than 1 year of transplantation.  Kidney Transplantation: Complications Cont.,  Graft Rejection Cont.,  Acute Rejection:  Signs/Symptoms: Lethargy, fever, edema, weight gain, oliguria, HTN, tenderness & swelling of the graft site.  An elevation in serum creatinine > 20%   Management:  Increased doses of Corticosteroids and other immunosuppressant agents Kidney Transplantation: Complications Cont.,  Graft Rejection Cont.,  Chronic Rejection:  Signs/Symptoms   (mimic CRF): Fatigue Gradual increase in serum BUN and creatinine  Electrolyte imbalances. Conservative therapies until dialysis required or a another transplant can be performed.  Management:  Kidney Transplantation: Nursing Considerations Cont.,  Promoting Organ Donation:     Stress to client the importance of sharing wishes to be an organ donor with significant others. Provide information to the client and/or significant others; clarify any misconceptions. Provide support and understanding the client and / or significant other during the decision making process. Lead by example; become an organ donor.