renal failure critically ill[1]

8/6/2019 Renal Failure Critically Ill[1]

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Care of the patient with renal

failure

Christina Ballejos-Campos

Renal Failure

� severe impairment or total lack of kidney

function

� little or no excretion of metabolic wasteproducts and water

� Acute

± Sudden and reversible� Chronic

± Slow and irreversible

Acute Renal Failure

� Abrupt decline in glomerular filtration rate

leading to:

± reduction of urine output (less than400

mL/day)

± build up of nitrogenous waste products

± inability to maintain acid-base and electrolyte

balance

Causes of Acute Renal Failure

1. Prerenal renal failure: ± 70%

± anything that decreases blood flow to the

kidneys

ETIOLOGY

� Intravascular volume depletion (hypovolemia)

� Impaired cardiac output

� Systemic vasodilation

� Hypoperfusion, hypotension

2. Acute Intrarenal Renal Failure

± 25% of ARF

± damage directly to the renal tissues

ETIOLOGY� *Acute Tubular Necrosis - type of ARF

± Ischemia, nephrotoxin, pigment

� Contrast dye

� Drugs

� Infection or immunologic

3. Acute Postrenal Renal Failure

± obstruction of urine flow that causes retrograde flow backinto the kidneys

Etiology

Obstruction

Stenosis, calculi

FunctionalPregnancy

Spinal cord injury

Acute Renal Failure Review(3 forms by location)

� A. Prerenal ²disrupted blood flow

� B. Intrarenal ²damaged renal tissue

� C. Postrenal ²disrupted urine flow

ARF Phases

� 1. Onset

± Time from when the insult occurs until cell

injury.

� May last hours to days

� May have reduced urine output or it may be

normal

� With prompt treatment may have noresidual damage

Phases of ARF

� 2. Oliguric/Anuric

� Less than 400 ml urine/24hours

± Within 1- 7 days of insult ± Total support of renal function is needed

± Lasts 5 to 16 days ( or may lead to CRF)

± GFR creatinine, BUN

Phases of ARF

� 3. Diuretic ± High output failure

± increased glomerular filtration rate and

increased urine output.

� Lasts for 7-14 days� Kidneys clearing fluid but not solutes so that the

urine osmolality is either fixed or low

� Up to 5L/day

± May become volume depleted because of the

large urine output

Phases of ARF

� 4. Recovery

± Slow return to normal renal function

� 3 -12 months (may take years)

� 62% of patients will recover normal renal

function

� 33% of patients will have some renal

insufficiency controlled by diet and fluidvolume restrictions

� 5% of patients will need long term dialysis

Complications of Acute Renal

Failure� Hyperkalemia

� Metabolic Acidosis

� Hypervolemia

� Infection

� Anemia

� Congestive Heart Failure

Diagnostic tests for Acute Renal

Failure� US� CT scan

� Angiography

� UA

� Serum ± BUN, Creatinine

� Elevations in serum creatinine indicate damageto at least 50% of the nephrons

± Electrolytes

� Hyperkalemia, etc. ± ABG

� Metabolic acidosis

� Urine Creatinine

± Urine creatinine clearance is reduced thus less

creatinine appears in the urine 27

Nursing DX

Fluid volume excess r/t impaired renalperfusion and fluid retention

� Altered nutrition: less than bodyrequirements r/t altered metabolic stateand dietary restrictions

� Impaired skin integrity r/t sites for vascular

access for peritoneal or hemodialysis� Risk for injury r/t increased K+ levels and

potential for cardiac arrhythmias

Nursing Management of Acute

Renal Failure� Prevent

� Fluid volume restriction:

± Past 24 hour urine output + 600 mL (insensible loss)

� Dialysis (discussed later)

� Electrolyte Balance

� Medications

Especially ?

What about diuretics?

Nutrition

� Decrease protein catabolism

� BUT they need enough calories because?

� What other restrictions?

Nutrition

� Daily calories

± 30-35 kcal/kg of body weight

Protein

1.2 -1.3 g/kg

increased (30-40% of diet)

Na restriction (prevent overhydration)

K restriction

Prevent and Manage Complications

of Acute Renal Failure� Hyperkalemia ±leading cause of death in oliguric phase

± Electrolyte and EK G monitoring

± Treat with IV Glucose & Insulin

± Ion Exchange R esin

� MetabolicA

cidosis ± ABG

± Sodium bicarb

� Hypervolemia

± Fluid Challenge, I & O

± Diuretics ± Inotropic Agents & Pressure Monitoring

� Infection ± leading cause of death

� Anemia

� Congestive Heart Failure42

Treatment of Acute Prerenal

Renal Failure

� Crystalloids & colloids (*may be given with loop and

osmotic diuretics if kidney functioning)

� If fluid overload (CHF)

± use *diuretics & inotropes

� With sepsis

± increase fluids & vasoconstrictors

Treatment for Acute Intrarenal Renal

Failure

� Dialysis

� Treat complications of renal failure Hypotension or Hypertension

Electrolyte imbalances

Treatment of Acute Postrenal Renal

Failure� R emove obstruction

± Ureteral stent

± ESWL (lithotripsy)

± Prostatectomy

± Suprapubic catheter

Chronic Renal Failure

� Progressive reduction of functioning renal

tissue ± Remaining Kidney Can No Longer Maintain Internal Environment

� Insidiously or Acutely Post Renal Failure

� Hypertension & diabetes most common

causes

4 Stages of Chronic Renal Failure

1. Diminished renal reserve (silent)

2. Renal insufficiency

3. Frank renal failure

4. Uremia (End stage renal disease ±ESRD)

Stages of Chronic Renal Failure

1. Diminished Renal

Reserve

Normal BUN & Cr.

Absence of

symptoms

2. Renal Insufficiency

Depressed

Hypertension Edema

Pruritis

Polyuria

Nocturia

Low specific gravity

GFR ¼ of normal

� Frank Renal Failure

Azotemia

Metabolic acidosis Hyperkalemia

Hyponatremia

Hyperphosphatemia

Hypocalcemia

Severe anemia

3. Frank Renal Failure

Lethargy

Headaches Visual disturbances

Low Urine output N & V

� 4. Uremia (ESRD)

N & V, diarrhea GI bleeding

Mental disturbances

Convulsions

BUN, creatinine dangerously high

U.O. less than 20 ml/hr.7

� Uremia,cont.

Uremic frost

Swollen tongue

Electrolyte imbalances Hypertension

Coma, Death 8

Complications of Chronic Renal

Failure

Metabolic Imbalances

BUN, creatinine

Altered CHO metabolism

Impaired glucose use and insulinresistance (and insulin is excreted bykidneys)

Elevated triglycerides

High insulin increases hepatic

release of triglycerides Increased VLDL, normal or low LDL

and low HDL

Hemopoietic Complications

Anemia� Normocytic normochromic anemia d/t

erythropoietin

� Destruction of RBC

� Lack of intake

� Bleeding tendencies� impaired platelet aggregation and impaired release of

platelet factor 3

� Infection

± altered immune response

± changes in WBC functioning ± protein malnutrition, hyperglycemia, and external trauma

of needle insertions into shunts, etc.

� Cancer

Cardiovascular Complications

� Hypertension from retained Na and increased ECF

� CHF

Respiratory Complications

� Kussmaul respiration (blow of CO2)

� Dyspnea

� Uremic lung ± depressed cough reflex with thick sputum

GI Disturbances

� Excessive Urea irritates the mucosal lining the GI system

� Mucosal ulcerations d/t ammonia

� Uremic fetor ± urine odor breath

� Stomatitis, Anorexia, n/v, all contribute to weight loss

Nervous System Complications

�Generalized CNS depression

�lethargy, apathy, ability to concentrate,

fatigue and altered mental ability

�altered mental status clears with dialysis and

often a sign that dialysis is due

�Seizures and coma if BUN becomes very high

Skin Disorders

�skin yellowish

� from retained urinary chromogens that

normally give urine it¶s yellow color

�Pruritis� calcium-phospate deposits on the skin

� ³Uremic frost´ (urea crystals)

� When BUN levels are extremely high

�Hair and nails tend to be dry and brittle

Neurological� Generalized CNS depression (lethargy, apathy, ability to concentrate, fatigue and alteredmental ability.

� Altered mental status clears with dialysis, andoften this is a sign that dialysis is due.

� Seizures and coma if BUN becomes very high

� Peripheral neuropathy

± Restless Leg Syndrome or pt feels like thereare bugs crawling in their legs.

Psychological changes

�Fatigue, lethargy

�Personality and behavioral changes

�Grief

Nursing Diagnoses

Renal Failure� Fluid Volume Deficit/Fluid Volume Excess

� Altered Nutrition: Less Than Body

Requirements

� Risk Of Impaired Skin Integrity Related to

Poor Nutrition/Edema And Pruritus

� AnxietyR

elated to Unknown Outcome of Disease

Medical Goals of

ChronicR

enal Failure� Preservation of Renal Function

� Delay of Need for Dialysis or Transplant

� Improvement of Body Chemistry� Alleviation of Extrarenal Effects

Management for CRF ±

Conservative

� Correct ECF (overload or deficit)

� Nutrition

� Adjust drug dosages ± Digoxin

± Aminoglycosides

± NEVER meperidine

± Avoid NSAIDS

� Medications

� Hyperkalemia

±Diet

± IV glucose and Insulin, SodiumBicarb

± Kayexalate if good GI function

� Hypertension

±Na and fluid restriction

±Antihypertensives

Loop diuretic, beta antagonist, ACEinhibitor

� Phosphate intake limited (<1000 mg/day)

� Calcium based phosphate binders

- Calcium Carbonate (Tums) and

Calcium acetate (PhosLo).- Given with food***

� NON calcium phosphorous binder

- sevelamer (Renegal)

� Lower phosphate before treating low calciumand giving Vit D

� Watch for hypercalcemia

� May need Vitamin D ± calcitrol

� Anemia ± erythropoietin (Epogen)

� May take 2- 3 wks

� Increases HTN

± Oral iron supplements and Folic acid

� (1 mg or more) are given daily

� NOT same time as phosphate binders

Nutrition

� Protein restriction (high biologic protein) ± some renal function & not on dialysis

� a low protein (.6-.8g/kg/day), low phosphorus diet

± on hemodialysis

� protein intake increased to 1.2-1.3g/kg/day ± on peritoneal dialysis

� protein intake at least 1.2g/kg/day

� High calorie intake will prevent proteincatabolism ± High CHO (100g) and fats

� Fluid restriction- same as with ARF 600 mLover yesterday¶s losses

High Biological Value (HBV)

Protein

� sources that are easily assimilated into

body tissue

± EGGS

± fish

± beef

± poultry

� Na restriction

± depends on degree of renal failure (2-4 g)

± avoid foods known to be high in Na

� K+ restriction

± depends on degree of renal failure and

whether on dialysis.

± (see table 45-8 on pg. 1224).

Treatment for Renal Failure

Hemodialysis

Peritoneal Dialysis

Continuous Renal ReplacementTherapy (CRRT)

Kidney Transplantation

Dialysis

� Process used to remove fluid and waste

products when kidneys fail

� Types ± 1. Hemodialysis (HD)

± 2. Peritoneal (PD)

± 3. Continuous renal replacement therapy

(CRRT)

General Principles of Dialysis

� 1. Diffusion-

± movement of solutes from an area of higher

concentration to an area of lesser concentration.

� 2. Osmosis- ± movement of fluid from an area of lesser to an area of

greater concentration of solutes.

� 3. Ultrafiltration-

± water and fluid removal from an area of increasedpressure to an area of decreased pressure

1. Hemodialysis

� Blood shunted from thebody through tubinginto a dialysis machinewhich cleans the blood

using a ³Dialyzer´ or ³Artificial Kidney´.

� Solutes and wasteproducts removed bythe principles of

osmosis, diffusion andultrafiltration

� Performed 2-3 x/wk for 3- 4 hrs

HEMODIALYSIS MACHINE

Requires Vascular Accessa) AV Shunt

b) AV Fistula

c) AV Graft

d) Vascath

Access to Patient¶s blood stream

� a) Shunt

± external device connecting

radial artery and vein in the

forearm for the purpose of

attachment to a dialysismachine

� Complications: Infection,

Bleeding

� Rarely used except for

continuous renal

replacement therapy

(CRRT)

b) Internal Arteriovenous Fistula

� internal fistula that

creates an anastamosis

between an artery and a

� Most commonly in the

forearm

� Native -- Need healthy

vessels

� 4- 6 wks to mature

� Accessed with two large

gauge needles

c) Arteriovenous Graft (AVG)

� created using asynthetic material that

is self-healing

� Used in patients who

have poor vessels

(hypertension, D.M.)

� Graft matures usually

2- 4 wks� Complications: > clots,

infection, steal

syndrome

Nursing Care

� 1. ³Thrill´- nurse must check for a vibrationover the area of anastamosis each shift.

� 2. ³Bruit´- nurse must listen with a

stethoscope for an audible swish.� *Report loss of either stat to physician

� Teach patient how to check for ³Thrill´

before going home.� Can eat double their usual protein (since

urea & creatinine excreted)

d) VAS Catheter

� Temporary vascular access

when quick or short term

use is expected.

� A large bore catheter (14-

16) is placed in subclavian,

internal jugular or femoral

� Catheter has a double

lumen (blue and red), onefor blood removal and one

for blood return

Care of Double-lumen catheter

� Never flush or draw blood from thiscatheter for any reason!

� Each ³tail´ contains 1500u of heparinplaced there by dialysis nurse toprevent clotting off of vessels.

� No blood draws or B/P from that arm.

� If removed- apply pressure withsandbags for long time to preventhemorrhage.

Nursing Care for patient with HD

� Pre-Procedure

� Check meds to be held or given (Give

insulin and Digoxin, hold all B/P meds)

� Vital Signs

� Weigh patient, lung sounds

� Check site

During Procedure

� Dialysis nurse is usually with patient. She/he willmonitor v.s. q 15 min.

� Hypotension is a common problem

� Patient may eat while on HD if stable

� Weigh patient (before and after)

� Lab tests

Complications with

Hemodialysis

� 1) Hypotension ± As fluid removed

� 2) Muscle cramps

± Rapid removal of Na and H20� 3) Bleeding

± Heparin used

� 4) Hepatitis

� 5) Sepsis� 6) Disequilibrium syndrome (hypotonic soln)

± Cerebral fluid shifts

2. Peritoneal Dialysis

Large surface of the

peritoneum is used

as asemipermeable

membrane for

performing clinical

dialysis

Phases of PD- called an ³Exchange´

� 1) Inflow- ± prescribed amount of solution (2L of warmed,

sterile Dialysate) is infused through the catheter over 10 min.

� 2) Dwell- ± Diffusion and Osmosis occur while the solution sits

in the peritoneal cavity

± Typical ³dwell´ time is 20-30 min., but can be 8 hrsor >.

� 3) Drain- ± Fluid drained, takes 15-30 min.

± Patient may need to change position

± Continuous Ambulatory Peritoneal

Dialysis (CAPD) ± esp pt with Diabetes

� Approx 2L dialysate 4 x/day

� Dwell times of 4 to 10 hrs

± Automated Peritoneal Dialysis (APD)

� Automated cycler times and controls the fill,

dwell and drain phases

� 4 or > exchanges/night

± May use 1 or > daytime manual the day

Types of Peritoneal Dialysis

Technique

� Catheter placed (usually surgically) through theanterior abdominal wall.

� A common catheter is the ³Tenckhoff´, a silicone

rubber tubing (about25

cm long) that has a cuff that anchors it and prevents migration.

� Complications of catheter insertion: ± perforation of the bladder, bowel or major blood

vessels.

� Catheter must be irrigated periodically withheparinized dialysate to keep it free of blood andfibrin.

Nursing Care for Patient with PD

� Pre-procedure ± Assess site for any s/s of infection.

± Take baseline V.S.

� During procedure ± Assess for pain, watch V.S., watch equipment for any

leaks, etc.

� Post-procedure ± Assess amount of outflow (should match what you

put in or be a little more),

± Assess for hernias and pulmonary complications

± Watch for abnormal color of returned fluid (milky or white could indicate peritonitis)

Complications

� 1) Exit site infection

� 2) Peritonitis

� 3) Abdominal pain/Back pain/Shoulder pain

(decrease rate)� 4) Outflow problems

� 5) Hernias

� 6) Bleeding

� 7) Pulmonary complications: atelectasis,pneumonia

� 8) Protein Loss

� 9) CHO3 and lipid abnormalities

� 3. Continuous Renal Replacement

Therapy (CRRT)

� CAVH (Continuous arterial-venous

hemofiltration)

± Blood flows through semipermeable filter

and extracorpeal circuit

± Removes only excess fluid

� CAVHD (Continuous arteriovenoushemodialysis)

± Same as above but uses dialysate and

solute removed

� CVVH (Continuous venous-venous

hemofiltration)

± Continuous fluid removed

� CVVHD (Continuous venous-venous

hemodialysis)

± Solutes and fluids

T t t f R l F il

Treatment for Renal Failure

� Nursing Interventions

± monitor I&O

± integrity of circulatory access

± monitor hemofiltration system

± prevent infection

± monitor circulation

Kidney Transplantation

� Not enough supply for the demand for organs

± 54,000 pts awaiting cadaveric kidneytransplants about 8000 performed in 2002

± Waiting period up to 4 years� 90-95% success rate

� reverse many of the pathophysiologicchanges associated with renal failure.

Donor Sources

� 1. Cadaver donors ± Kidneys removed after death

± can be preserved up to 72 hours.

�2. Live donors ± most often blood relatives, but can be other donors if

blood type matches.

� Method ± Laparscopic donor nephrectomy

± Traditional ³Open Nephrectomy´ used less often

Surgical procedure

� old kidneys left inplace

� new donor kidney is

grafted into theInternal Iliac arteryand Vein

� Once blood flow isestablished to thenew kidney itbecomes firm andpink

Post-op Care

** Maintenance of fluid & electrolyte balance

� Large diureses if kidney is functional(up toa 1L/hr)

� Fluid replaced mL for mL or dehydrationand shock can occur.

� Sudden decrease in urine output in early

postop period a priority concern

Complications post-op

� Rejection (early/late)

� Infection

� Cardiovascular disease� Malignancies

� Recurrence of original renal disease

renal failure critically ill[1]

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