Chronic Renal FailureChronic Renal Failure

BSN IV Group 13BSN IV Group 13

NCM 501204LNCM 501204L

Ms. Connie BlancoMs. Connie Blanco

IntroductionIntroduction Chronic kidney diseaseChronic kidney disease (CKD), also known as (CKD), also known as

chronic renal diseasechronic renal disease, is progressive loss of renal , is progressive loss of renal function over an extended period of time through function over an extended period of time through five stages. five stages.

Each stage is a progression through an abnormally Each stage is a progression through an abnormally low and deteriorating glomerular filtration rate.low and deteriorating glomerular filtration rate.

It has multiple etiologies, but all result in loss of It has multiple etiologies, but all result in loss of nephron number and function.nephron number and function.

In 2002, Kidney diseases were the 10In 2002, Kidney diseases were the 10thth leading leading cause of mortality in the Philippines, with 2.3% cause of mortality in the Philippines, with 2.3% share from total deaths. (source: DOH.gov.ph)share from total deaths. (source: DOH.gov.ph)

Normal Anatomy and Normal Anatomy and PhysiologyPhysiology

AnatomyAnatomy

Two bean shaped, dark red organs, Two bean shaped, dark red organs, 12 cm x 6 cm x 3 cm12 cm x 6 cm x 3 cm

Retroperitoneal (one posterior to Retroperitoneal (one posterior to liver, the other, to the spleen)liver, the other, to the spleen)

Adrenal gland located above the liverAdrenal gland located above the liver Protected by cushions of fatProtected by cushions of fat Average blood flow:1200 mL/minAverage blood flow:1200 mL/min

PhysiologyPhysiology

Functions of the kidneys:Functions of the kidneys: Fluid and electrolyte balanceFluid and electrolyte balance Removal of wasteRemoval of waste Acid – Base BalanceAcid – Base Balance Regulates blood pressure and plasma Regulates blood pressure and plasma

volumevolume ErythropoiesisErythropoiesis

PathophysiologyPathophysiology

PathophysiologyPathophysiology

All major organ systems are affected by All major organ systems are affected by renal failure. Prevalence of symptoms is renal failure. Prevalence of symptoms is a function of the glomerular filtration a function of the glomerular filtration rate (GFR), which averages 120 mL/min rate (GFR), which averages 120 mL/min in a healthy adult. As the GFR falls to in a healthy adult. As the GFR falls to less than ~20% of normal, symptoms of less than ~20% of normal, symptoms of uremia may begin to occur. They almost uremia may begin to occur. They almost are invariably present when the GFR are invariably present when the GFR decreases to less than 10% of normal.decreases to less than 10% of normal.

Signs and symptoms of renal failure Signs and symptoms of renal failure are due to overt metabolic are due to overt metabolic derangements resulting from derangements resulting from inability of failed kidneys to regulate inability of failed kidneys to regulate electrolyte, fluid, and acid-base electrolyte, fluid, and acid-base balance; they are also due to balance; they are also due to accumulation of toxic products of accumulation of toxic products of amino acid metabolism in the serum.amino acid metabolism in the serum.

Stage 1 CKD is mildly diminished renal Stage 1 CKD is mildly diminished renal function, with few overt symptoms.function, with few overt symptoms.

Stage 5 CKD is a severe illness and Stage 5 CKD is a severe illness and requires some form of renal replacement requires some form of renal replacement therapy (dialysis or renal transplant). therapy (dialysis or renal transplant). Stage 5 CKD is also called end-stage renal Stage 5 CKD is also called end-stage renal disease (ESRD), chronic kidney failure disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).(CKF) or chronic renal failure (CRF).

Stage 1 CKDStage 1 CKD >90 mL/min/1.73 m2>90 mL/min/1.73 m2 Slightly diminished function; Kidney damage* with normal or increased Slightly diminished function; Kidney damage* with normal or increased

GFRGFR Stage 2 CKDStage 2 CKD 60-89 mL/min/1.73 m260-89 mL/min/1.73 m2 Mild reduction in GFR with kidney damage. Mild reduction in GFR with kidney damage.

Stage 3 CKDStage 3 CKD 30-59 mL/min/1.73 m230-59 mL/min/1.73 m2 Moderate reduction in GFR; diagnosis of CRDModerate reduction in GFR; diagnosis of CRD

Stage 4 CKDStage 4 CKD 15-29 mL/min/1.73 m215-29 mL/min/1.73 m2 Severe reduction in GFRSevere reduction in GFR

Stage 5 CKD Stage 5 CKD GFR <15 mL/min/1.73 m2GFR <15 mL/min/1.73 m2 Established kidney failure (CRF/ESRD)Established kidney failure (CRF/ESRD)

(*Kidney damage is defined as pathologic abnormalities or markers of damage, including (*Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies.)abnormalities in blood or urine test or imaging studies.)

AssessmentAssessment

Skin: Pallor, yellow skin; Thin, dry, brittle nailsSkin: Pallor, yellow skin; Thin, dry, brittle nails Chest: DyspneaChest: Dyspnea Cardiovascular: OrthopneaCardiovascular: Orthopnea Gastrointestinal:Gastrointestinal: Genitourinary:Genitourinary: Neurology: Decreased attention span; AsterixisNeurology: Decreased attention span; Asterixis Psychology: Sleep disturbances (restlessness)Psychology: Sleep disturbances (restlessness) Others: (+) HypertensionOthers: (+) Hypertension

LabsLabs Urine

– Volume: usually less than 400 mL/24 hrs.– Color: cloudy– Specific gravity: less than 1.015– Sodium: more than 40 mEq/L– Creatinine clearance: may be significantly

decreased (less than 80 mL/min.) in early failure, less than 10mL/min. in ESRD

Other tests:– ECG: may be abnormal; reflecting electrolyte

and acid-base balance.

Blood– BUN/CR: elevated, usually in proportion. Creatinine level

of 12mg/dL suggests ESRD. A BUN of. 25 mg/dl is indicative of renal damage

– CBC: Hb decreased because of anemia , usually less than 7-8 g/dL

– RBC.: Life span decreased because of erythropoietin deficiency and azotemia

– ABG: pH decreased, metabolic acidosis (less than 7.2)– Potassium: elevated related to retention and cellular

shifts (acidodis) or tissue (RBC Hemolysis). Potassium may also be decreased if client is on potassium-wasting diuretics or when client is receiving dialysis treatment.

– Magnesium, phosphorus: Elevated– Calcium, phosphorus: Decreased– Proteins (especially albumin): Decreased serum level

may reflect protein loss via urine, fluid shifts, decreased intake, or decreased synthesis be cause of lack of amino acids

Predisposing Factors and Predisposing Factors and Precipitating FactorsPrecipitating Factors

Diabetes MellitusDiabetes Mellitus HypertensionHypertension Disorders of the Renal SystemDisorders of the Renal System

– Chronic GlomurulonephritisChronic Glomurulonephritis– PyelonephritisPyelonephritis– Urinary Tract ObstructionUrinary Tract Obstruction– Polycystic Kidney DiseasePolycystic Kidney Disease

Vascular DisorderVascular Disorder InfectionInfection Nephrotoxic Agents and medicationsNephrotoxic Agents and medications

– LeadLead– CadmiumCadmium– MercuryMercury– ChromiumChromium– Long term Analgesics useLong term Analgesics use

Common ManifestationsCommon Manifestations Cardiovascular Cardiovascular

ManifestationsManifestations HPNHPN Pitting Edema (water / sodium Pitting Edema (water / sodium

imbalance)imbalance) Heart FailureHeart Failure Pulmonary EdemaPulmonary Edema PericarditisPericarditis Acute MIAcute MI DysrhythmiasDysrhythmias

Hematologic Hematologic Anemia (erythropoesis Anemia (erythropoesis

compromise)compromise) Thrombocytopenia Thrombocytopenia ImmunosupressionImmunosupression

ElectrolyteElectrolyte Hypo/Hyperkalemia Hypo/Hyperkalemia Dilutional HyponatremiaDilutional Hyponatremia HypocalcemiaHypocalcemia HypermagnesemiaHypermagnesemia AcidosisAcidosis

GastroIntestinalGastroIntestinal AnorexiaAnorexia Metallic TasteMetallic Taste Mouth Ulceration and Mouth Ulceration and

bleedingbleeding Nausea and VomitingNausea and Vomiting HiccupsHiccups Constipation or diarrheeaConstipation or diarrheea Uremic FetorUremic Fetor GI BleedingGI Bleeding

PulmonaryPulmonary CracklesCrackles Thick, tenacious sputumThick, tenacious sputum Depressed cough reflexDepressed cough reflex Pleuritic painPleuritic pain SOBSOB TachypneaTachypnea Kussmaul BreathingKussmaul Breathing Uremic PneumonitisUremic Pneumonitis

DermatologicDermatologic Gray-bronze skin color Gray-bronze skin color

(urochromes)(urochromes) PruritisPruritis Dry, flaky skinDry, flaky skin EcchymosisEcchymosis PurpuraPurpura Thin, brittle nailsThin, brittle nails Coarse, thin hairCoarse, thin hair Uremic FrostUremic Frost

Neurologic Neurologic WeaknessWeakness Uremic EncephalopathyUremic Encephalopathy Altered LOCAltered LOC DisorientationDisorientation AsterixisAsterixis Inability to concentrateInability to concentrate Muscle twitchingMuscle twitching AgitationAgitation ConfusionConfusion SeizuresSeizures Peripheral Neuropathy Peripheral Neuropathy

(Burning feet sensation) (Burning feet sensation)

Restless Leg syndromeRestless Leg syndrome

MusculoskeletalMusculoskeletal Muscle crampsMuscle cramps Loss of muscle strengthLoss of muscle strength Renal osteodystrophy Renal osteodystrophy

(osteomalacia)(osteomalacia)

Uremia

Multi-system manifestations

Precipitating Factors Predisposing Factors

Physical damage to nephrons (i.e. Nephrosclerosis)

Decreased Kidney Function(decrease GFR)

Case Data and Case Data and Nursing Nursing

ConsiderationsConsiderations

Patient DataPatient Data

Felipe Tigley, a 61 yr old male, Felipe Tigley, a 61 yr old male, resident of Ranudo St., Cogon resident of Ranudo St., Cogon Ramos, Cebu City, was admitted to Ramos, Cebu City, was admitted to VSMMC for dyspnea. He is VSMMC for dyspnea. He is hypertensive. The patient had hypertensive. The patient had already been hospitalized previously already been hospitalized previously in the same institution for a similar in the same institution for a similar case. case.

Nursing CareNursing Care

Common Nursing DiagnosesCommon Nursing Diagnoses– Fluid volume excessFluid volume excess– Imbalanced nutritionImbalanced nutrition– Knowledge DeficitKnowledge Deficit– Activity IntoleranceActivity Intolerance– AnxietyAnxiety– Disturbed thought processDisturbed thought process

Disturbed Thought ProcessDisturbed Thought Process 1. Assess patient’s attention span/ distractibility and ability 1. Assess patient’s attention span/ distractibility and ability

to make decisions or problem-solve.to make decisions or problem-solve. 2. Ascertain from SO client’s usual level of mentation.2. Ascertain from SO client’s usual level of mentation. 3. Perform neurological assessments as indicated and 3. Perform neurological assessments as indicated and

compare with baseline.compare with baseline. 4. Provide quiet / calm environment.4. Provide quiet / calm environment. 5. Reorient to time/ place/ person as needed.5. Reorient to time/ place/ person as needed. 6. Present reality concisely and briefly and do not challenge 6. Present reality concisely and briefly and do not challenge

illogical thinking.illogical thinking. 7. Listen with regard.7. Listen with regard. 8. Provide for nutritionally well balanced diet. Encourage 8. Provide for nutritionally well balanced diet. Encourage

client to eat.client to eat. 9. Establish a regular schedule for expected activities.9. Establish a regular schedule for expected activities. 10. Promote adequate rest and undisturbed periods for 10. Promote adequate rest and undisturbed periods for

sleep. sleep.

Risk for Fluid Volume ExcessRisk for Fluid Volume Excess 1. Note client’s age, current level of hydration, and mentation.1. Note client’s age, current level of hydration, and mentation. 2. Note presence of vomiting, liquid stool; inspect drainage 2. Note presence of vomiting, liquid stool; inspect drainage

devices.devices. 3. Monitor BP responses to activities. 3. Monitor BP responses to activities. 4. Adjust fluid intake to avoid dehydration and4. Adjust fluid intake to avoid dehydration and overload.overload. 5 Evaluate for signs and symptoms of hyperkalemia and 5 Evaluate for signs and symptoms of hyperkalemia and

monitor serum potassium levels.monitor serum potassium levels. 6.Inspect neck veins for engorgement and extremities for 6.Inspect neck veins for engorgement and extremities for

edema.edema. 7.Instruct patient about importance of adhering to7.Instruct patient about importance of adhering to diet plan.diet plan. 8. Evaluate mentation.8. Evaluate mentation. 9. Monitor for signs and symptoms of hypovolemia or 9. Monitor for signs and symptoms of hypovolemia or

hypervolemia (eg, urinary output, daily weight, serum hypervolemia (eg, urinary output, daily weight, serum electrolyte concentrations).electrolyte concentrations).

10. Observe skin and mucous membranes.10. Observe skin and mucous membranes.

DrugsDrugs

Lasix (Furosemide)Lasix (Furosemide) Capoten (Captopril)Capoten (Captopril) Epogen (Erythropoietin)Epogen (Erythropoietin) Phosphagel (Aluminum Phosphate)Phosphagel (Aluminum Phosphate) Apo-Diazepam (Diazepam)Apo-Diazepam (Diazepam)

Lasix (Furosemide)Lasix (Furosemide) Classification: Loop DiureticsClassification: Loop Diuretics

Contraindication: Anuria; hypersensitivityContraindication: Anuria; hypersensitivity

Route and dosage: initial dose for hypertension is 80 mg, Route and dosage: initial dose for hypertension is 80 mg, usually divided into 40 mg twice a day. usually divided into 40 mg twice a day.

Side Effects:Side Effects:- systemic vasculitis - systemic vasculitis - interstitial nephritis- interstitial nephritis- necrotizing angitis- necrotizing angitis - thrombocytopenia - thrombocytopenia

Nursing responsibilities:Nursing responsibilities:– Monitor BP frequentlyMonitor BP frequently

Capoten(Captopril)Capoten(Captopril) Classificaiton: ACE inhibitorClassificaiton: ACE inhibitor

Contraindication: hypersensitive to Captopril or other ACE Contraindication: hypersensitive to Captopril or other ACE inhibitorinhibitor– Route and Dosage: PO 6.25-25 mg t.i.d., may increase to Route and Dosage: PO 6.25-25 mg t.i.d., may increase to

50 mg t.i.d. (max 450mg/day)50 mg t.i.d. (max 450mg/day)

Side effects: Agranulocytosis, angioedema.Side effects: Agranulocytosis, angioedema.

Nursing Responsibilities:Nursing Responsibilities:– Monitor BP closely following the first dose. A sudden Monitor BP closely following the first dose. A sudden

exaggerated hypotensive response may occur with in 1 exaggerated hypotensive response may occur with in 1 – 3 hours of first dose, especially in those with high BP or – 3 hours of first dose, especially in those with high BP or on a diuretic and restricted salt intake.on a diuretic and restricted salt intake.

Epogen(Erythropoietin)Epogen(Erythropoietin) Classification: Recombinant human erythropoietinClassification: Recombinant human erythropoietin

Contraindication: Hypersensitivity to human albumin; Contraindication: Hypersensitivity to human albumin; uncontrolled hypertension.uncontrolled hypertension.

Route and Dosage: IV/SQ , 50 to 100 units/kg 3 times/wk.Route and Dosage: IV/SQ , 50 to 100 units/kg 3 times/wk.

Side Effects:Side Effects:– DVT DVT - Seizure - Seizure - URTI - URTI – SOBSOB - Chest pain- Chest pain

Nursing responsibilities:Nursing responsibilities: - Advise CRF patient to continue to follow dietary and dialysis - Advise CRF patient to continue to follow dietary and dialysis

prescriptions while taking this medication. prescriptions while taking this medication. - Advise patient that iron supplementation will probably be - Advise patient that iron supplementation will probably be

needed and to take iron supplement as prescribed.needed and to take iron supplement as prescribed. - Inform patient that drug may be associated with risk of - Inform patient that drug may be associated with risk of

seizures during first 90 days of treatment and to avoid driving or seizures during first 90 days of treatment and to avoid driving or performing other hazardous tasks during this period.performing other hazardous tasks during this period.

Phosphagel(Aluminum Phosphagel(Aluminum Phosphate)Phosphate)

Classification: Antacid Classification: Antacid Contraindication: Prolonged use of high doses in Contraindication: Prolonged use of high doses in

presence of low serum phosphate presence of low serum phosphate Route and dosage: PO 10-30 mL of regular Route and dosage: PO 10-30 mL of regular

suspension or 5-15mL of extra strength suspension or 5-15mL of extra strength suspension or 2-6 capsules or tablet 1h p.c and h.s suspension or 2-6 capsules or tablet 1h p.c and h.s

Side effects: Side effects: – Constipation Constipation – Dementia. Dementia.

Nursing responsibilities: Nursing responsibilities: – - Note number and consistency of stools. - Note number and consistency of stools.

Constipation is common and dose related. Constipation is common and dose related. Intestinal obstruction from fecal secretions has Intestinal obstruction from fecal secretions has bebe

Apo-Diazepam(Diazepam)Apo-Diazepam(Diazepam) Classification: CNS agent, anticonvulsant, anxiolytic.Classification: CNS agent, anticonvulsant, anxiolytic.

Contraindication: hypersensitivity to this drug, acute narrow angle Contraindication: hypersensitivity to this drug, acute narrow angle glaucoma.glaucoma.

Route and Dosage:IV/IM 5-10mg, repeat if needed at 10-15 min Route and Dosage:IV/IM 5-10mg, repeat if needed at 10-15 min intervals up to 30mg, then repeat if needed q2-4hours.intervals up to 30mg, then repeat if needed q2-4hours.

Side Effects:Side Effects:– Cardiovascular collapse, Cardiovascular collapse, - laryngospasm.- laryngospasm.

Nursing responsibilities:Nursing responsibilities: - Monitor for adverse reactions. Most are dose related. Physician - Monitor for adverse reactions. Most are dose related. Physician

will rely on accurate observation and reports of patient response will rely on accurate observation and reports of patient response to the drug to determine lowest effective maintenance dose.to the drug to determine lowest effective maintenance dose.

- Observe necessary preventive precautions for suicidal tendencies - Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety states accompanied by depression.that may be present in anxiety states accompanied by depression.

Discharge PlanDischarge Plan

ObjectivesObjectives– to reinforce client of his conditions and to reinforce client of his conditions and

the possible complications in the the possible complications in the absence of treatment.absence of treatment.

– for the client to demonstrate lifestyle for the client to demonstrate lifestyle modification in accordance with the modification in accordance with the treatment given.treatment given.

– for the client to be able to value the for the client to be able to value the importance of health promotion and to importance of health promotion and to prevent further damage of any body prevent further damage of any body organ.organ.

Activity: As toleratedActivity: As tolerated– fitness walkingfitness walking– stretching exercisestretching exercise– bicycling (as tolerated)bicycling (as tolerated)– joggingjogging– dancingdancing

TreatmentTreatment– Dialysis may be necessary to control Dialysis may be necessary to control

symptoms of kidney failure and to sustain symptoms of kidney failure and to sustain life.life.

– Fluids may be restricted, often to an amount Fluids may be restricted, often to an amount equal to the volume of urine produced. equal to the volume of urine produced.

– Restricting the amount of protein in the diet Restricting the amount of protein in the diet may slow the build up of wastes in the blood may slow the build up of wastes in the blood and control associated symptoms such as and control associated symptoms such as nausea and vomiting.nausea and vomiting.

– Monitor blood pressure Monitor blood pressure

Nursing InterventionsNursing Interventions– Controlling the high blood pressure with Controlling the high blood pressure with

prescribed medicationsprescribed medications– Dietary restrictions of water, protein, potassium Dietary restrictions of water, protein, potassium

and Phosphorus consumptionand Phosphorus consumption– Adjusting the doses of all medications to account Adjusting the doses of all medications to account

for loss of their elimination of those medications for loss of their elimination of those medications from the body by the diseased kidneys, so as not from the body by the diseased kidneys, so as not to let those medications accumulate to to let those medications accumulate to dangerously high levelsdangerously high levels

– Avoiding other medications and agents that are Avoiding other medications and agents that are potentially toxic to kidneyspotentially toxic to kidneys

DietDiet– low sodium dietlow sodium diet– low salt dietlow salt diet– low protein dietlow protein diet

Thank You!Thank You!