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Flashcards in Acute and Chronic Renal Failure Deck (61):
1

Functions of the kidney

1. Excretion of waste products
2. Urine formation
3. Water and salt balance
4. Acid-base balance
5. Hormone secretion
6. Control of blood pressure
7. Erythropoietin production (RBC)
8. Synthesis of vitamin D to active form ( low Ca)

2

Renal failure results in:

– Altered fluid balance
– Electrolyte imbalance
– Acid-base imbalance

3

Causes of kidney failure include:

– Hypertension
– Diabetes

4

Kidney failure may be:

Acute or chronic

5

Acute renal failure (ARF)

• Rapid decrease in kidney function
• Leading to the collection of metabolic wastes in the body
• Potentially reversible condition
Lasts < 3 months

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Etiology/Types of ARF:

– Prerenal failure
– Intrarenal/intrinsic renal failure
– Post renal failure

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Prerenal failure

decreased blood flow to the kidneys - ischemia in the nephrons;prolonged hypoperfusion can lead to tubular necrosis and ARF.

8

Prerenal failure: causes

1. Conditions that cause decreased cardiac output.
2. Shock
3.HF
4. Pulmonary embolism
5.Anaphylaxis
6. Pericardial tamponade
7. Sepsis

9

Intrarenal/intrinsic renal failure

actual tissue damage to the kidney caused by inflammatory or immunologic process or from prolonged hypoperfusion.

10

Intrarenal/intrinsic renal failure:causes

1.Acute interstitial nephritis
2.Exposure to nephrotoxins
3.Acute glomerulonephritis
4.Vasculitis
5.Hepatorenal syndrome
6.ATN
7.Renal artery or vein stenosis/thrombosis

11

Post renal failure

obstruction of the urine collecting system anywhere from calyces to urethral meatus; obstruction of the bladder must be bilateral to cause post renal failure unless only one kidney is functional

12

Post renal failure: causes

1.Urethral or bladder cancer;
2.Renal, ureteral or bladder stones;
3. Atony of bladder
4. Prostatic hyperplasia or cancer;
5. Cervical cancer;
6.Urethral stricture (narrowing)

13

Acute tubular necrosis

• Syndrome of abrupt and progressive decline in tubular and glomerular function
• Most intrarenal failure is from ATN
• Etiology: Nephrotoxic substances

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Potentially Nephrotoxic Substances/ Drugs

– PCN, Vancomycin, NSAIDs
– Radiocontrast dyes
– Heavy metals
– Snake bites
– Pesticides
– Transfusion reaction

15

Phases of ARF

1. Onset
2.Oliguric
3.Diuretic (high output)
4.Recovery

16

Onset phase

until oliguria develops; accumulation of nitrogenous wastes may be noted (BUN, serum creatinine); hours - several days.

17

Oliguric phase

100-400 / 24 hours urine output that does not respond to fluid chalenges or diuretics; 1-3 weeks; SC and BUN up; K, P, Mg up ; Ca down ; Na up but masked by water retention ;bicarbonate deficit - acidosis ;

18

Diuretic phase ( hight output phase)

2-6 weeks after oliguric; sudden onset ; urine flow increased over several days; 10 L /day of dilute urine ; electrolyte losses; BUN down; normal renal tubular function .

19

Recovery phase (convalescent phase)

Recovery may take up to 12 months; pt has lower energy level; residual renal insufficiency may be noted through renal monitoring; renal function may never return to pre illness level; but renal function likely good for healthy life.

20

ARF: management

1.Fluid challenges
2. Diuretics (Lasix)
3. Calcium channel blockers
4. Diet therapy
5. Renal replacement therapy
– Peritoneal dialysis
– Hemodialysis
– Hemofilteration

21

Cardiac glycosides: Digoxin ( Lanoxin)

Increases ventricular contraction, stroke volume, cardiac output; teach pt to take pulse before taking the drug ( below 60 call !); Digoxin toxicity: blurred vision; changes in color vision; sensitive eyes; halos around bright lights; changes in mental status; chest pain or palpitations. Not to take antacid within 2 hours (prevent drug absorption). Listen to apical for 1 full minute.

22

Vitamins and Minerals: Folic acid and Ferrous sulfate (iron)

Replacement needed because of dialysis; Take drug after dialysis; Take iron with meals ( reduce N&V); Take stool softener ( oral iron causes constipation); Iron change the color of the stool.

23

Synthetic erythropoietin: Epoetin alfa (Epogen, Procrit)

Prevents anemia by stimulating RBC growth and maturation in the bone marrow; Side effects: chest pain, difficulty breathing, high BP, rapid weigh gain,( risk for MI infarction); Hemoglobin levels monitored weekly ( blood viscosity increases - high BP - risk for MI ).

24

Phosphate binders: Aluminium hydroxide gel (Amphojel, Nephrox)

High Phosphate levels cause hypocalcemia and osteodystrophy; Drug lowers P levels by binding P present in food; Take with meals ( binding in food) ; Take Digoxin separately but at least 2 hr ; Take stool softener ( constipation) ; Report: muscle weakness, slow or irregular pulse, confusion - hypophosphatemia.

25

Fluid challenges

500mL- 1L of NS over 1 hour
– Patient may respond to the fluid challenge by producing urine soon after the initial bolus
– Lasix may be prescribed along with fluid bolus
– If oliguric renal failure is diagnosed fluid bolus and diuretics are
discontinued

26

Calcium channel blockers

- Used to treat ARF resulting from nephrotoxic ATN
- Prevent the movement of calcium into kidney cells
- Maintain kidney cell integrity and improve the GFR rate
- Thereby improving renal blood flow

27

Nursing interventions: monitor

Monitor/maintain F&E balance
Monitor for:
– Signs of ARF and its complications
– Alteration in fluid volume
Promote optimal nutritional status

28

Nursing interventions: prevent and provide

Prevent:
– Complications from impaired mobility
– Fever/infection
Provide:
– Care for the client receiving dialysis
– Client teaching and discharge teaching

29

ARF: nursing diagnosis

- Excess Fluid Volume
- Potential for Pulmonary Edema
- Potential for Electrolyte Imbalances

30

Chronic renal failure CRF

- Progressive irreversible kidney damage
- Damage continues until nephrons are replaced by scar tissue
- Kidney function does not recover
- Complication : End-stage renal disease: When kidney function is too poor to sustain life

31

CRF: Etiology

Two main causes of ESRD
– Diabetes Mellitus (43.4%)
– HTN (25.5%)

32

CRF: Etiology

Infection and genetic kidney disease
– Glomerulonephritis (8.4%)
• Diseases that contribute to CRF
– Pyelonephritis
– Urinary tract obstruction
– Renal cell carcinoma

33

CRF: S/S

1. sallow yellow discoloration ; pruritus + uremic frost
2. CNS depression , peripheral neuropathy
3. high BP- CHF- ASHD- pericarditis
4. anorexia, N&V
5. GI bleeding, peptic ulcer disease
6. Constipation
7. Hyper - glycemia; - lipidemia;
8. Depression
9. Anemia
10. Hypeparathyroid
11. Amenorrhea, infertility, impotence
12. Gout
13. GFR less than 10 %
14. Renal osteodystrophy

34

Progression of Kidney Disease

Kidneys fail in organized fashion involving five stages based on estimated glomerular filtration rate (GFR) .
> 90 - Kidney damage : normal or increased GFR
< 15 or dialysis : kidney failure

35

Amenorrhea

absence of menstruation

36

ASHD

arteriosclerotic heart disease

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CRF: laboratory profile

Serum creatinine (0.5-1.2) - 15-30
BUN (10-20) - 180-200
Increased Na, K, P, Mg; Low Ca;
Metabolic acidosis
H&H decreased

38

Dietary restrictions

Protein, Fluid, K, Na, P.

39

Uremia

Prerenal azotemia is an abnormally high level of nitrogen waste products in the blood.

40

Foods high in P:

milk, yogurt, cheese, dried beans, meat, poultry, fish and seafood;
** The phosphorus content is the same for all types of milk – skim, low fat,
and whole! Patients need to take a phosphate binder if and when they eat any
high-phosphorus foods.

41

Foods low in P:

1/2 cup of milk products limit; ricotta cheese, non dairy whipped topping, cream cheese, butter.

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Foods high in K:

oranges, prunes, bananas, mangos, cantaloupe

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Foods low in K:

apples, berries, grapes, watermelon, pineapple

44

CRF: nursing interventions

Assess for:
• Signs of Uremia
• Changes in mental function
• Orient client to person, place, and time
• Monitor serum electrolytes

45

Promote ultimate GI function:

- Assess and provide care for stomatitis
• Monitor for N/V/anorexia; administer antiemetics as ordered
• Assess for signs of GI bleeding

46

CRF: interventions

• Monitor prevent alteration in F/E balance
• Assess for:
– Hyperphosphatemia
– Uremic frost
• Assess/provide care for pruritus (itching)
• Promote maintenance of skin integrity
• Monitor for bleeding complications
– Prevent injury to client
• Promote/maintain maximal cardiovascular function
• Provide care for client receiving hemodialysis

47

Uremic frost

a pale frostlike deposit of white crystals on the skin caused by kidney failure and uremia.

48

Nursing diagnosis

– Imbalanced nutrition
– Excess fluid volume
– Decreased cardiac output
– Risk for infection
– Fatigue
– Anxiety

49

Additional nursing diagnoses

– Diarrhea
– Constipation
– Impaired oral mucus membrane
– Social isolation
– Sexual dysfunction
– Disturbed thought process
– Deficient knowledge

50

Creatinine

Protein and muscle breakdown 0.5-1.2

51

BUN

Renal excretion of urea nitrogen 10-20

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Anuria

Less than 100 ml in 24 hr

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Dysuria

Painful urination

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Frequency

Need to void often; small amounts

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Hesitancy

Trouble initiating urine flow , sensation present

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Urgency

sudden onset to void ; NOW

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Nocturia

waking in the night to empty bladder; e: don't give Lasix at nigh !

58

Oliguria

100-400 ml in 24 hr/ decreased urine output

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Polyuria

> 2000 ml in 24 hr; increased urine output

60

Uremia

symptoms of renal failure

61

ESKD: most common causes

1. Hypertension
2. Diabetes mellitus