2023 Management of Patients With Kidney Disorders (PDF)

College of Applied Medical Sciences (NUR351) Management of Patients With Kidney Disorders Renal failure result when the kidneys are unable to remove the body's metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the...

College of Applied Medical Sciences (NUR351) Management of Patients With Kidney Disorders Renal failure result when the kidneys are unable to remove the body's metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids because of impaired renal excretion and lead to a disruption in endocrine and metabolic functions as well as fluid and electrolyte, and acid base disturbance. Definition: Renal failure is a systemic disease and is a final common pathway of many different kidney and urinary tract diseases. Acute renal failure is a sudden and almost complete loss of kidney function (decreased GFR) over a period of hours to days.  Causes of Acute Renal Failure: 1- Prerenal Failure: Fluid volume depletion Impaired cardiac efficiency Vasodilatation (sepsis, anaphylaxis, or antihypertensive medications)  Causes of Acute Renal Failure: 2- Intrarenal Failure: Prolonged renal ischemia Nephrotoxic agents (gentamicin, tobramycin, radiopaque contrast agents) Acute pyelonephritis Acute glomerulonephritis  Causes of Acute Renal Failure: 3- Postrenal Failure: Urinary tract obstruction ( calculi, tumors, benign prostatic hyperplasia, strictures, or blood clots)  Phases of Acute Renal Failure: 1- The initiation phase: It begins with the initial insult (an event which causes damage to a tissue or organ) and ends when oliguria develops.  Phases of Acute Renal Failure: 2- The oliguria phase: It is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, intracellular cations, potassium and magnesium). It takes from 10 to 20 days. The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL Uremic symptoms first appear in this phase and life- threatening conditions such as hyperkalemia develop.  Phases of Acute Renal Failure: 3- The diuresis phase: The patient experiences a gradually increasing urinary output, which signals that glomerular filtration has started to recover. Uremic symptoms may still be present. The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to increase. Clinical Manifestation:  Lethargy  Persistent nausea, vomiting and diarrhea  Dry skin and mucus membrane  Uremic fetor (the breath may have the odor of urine) When the excess urea in your body reacts with saliva, it forms ammonia  Drowsiness  Headache  Muscle twitching and Seizures  Prevention: 1- Provide adequate hydration to patients at risk for dehydration: Surgical patient before, during, and after surgery Patient undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (eg, barium enema, intravenous pyelograms) especially elderly who have adequate renal reserve (the capacity of the kidney to increase glomerular filtration rate ) Patient with neoplastic disorders or disorders of metabolism (gout) and those receiving chemotherapy Prevention: 2- Prevent and treat shock promptly with blood and fluid replacement 3- Monitor central venous and arterial pressures and hourly urine output of critically ill patient to detect the onset of renal failure early 4- Treat hypotension promptly 5- Continually assess renal function (urine output, laboratory values) when appropriate Prevention: 6- Take precautions to ensure the appropriate blood is administered to the correct patient in order to avoid sever transfusion reaction, which can cause renal failure. 7- Prevent and treat infection promptly 8- Pay special attention to wounds, burns, and other precursors of sepsis 9- Give special care to patient with indwelling catheters to prevent infections from ascending to urinary tract Prevention: 10- To prevent toxic drug effects: Closely monitor dosage Duration of use Blood levels of all medications metabolized on excreted by the kidneys  Medical Management: a- Pharmacologic Therapy:  Hyperkalemia is the most life threatening of the fluid and electrolytes so the patient is monitored for hyperkalemia by serial serum electrolyte levels, ECG changes and changes in clinical status. The elevated serum potassium is reduced by administering ion- exchange resin (sodium polystyrene sulfonate) orally or by retention enema.  Medical Management: a- Pharmacologic Therapy: If a retention enema is administered (the colon is the major for potassium exchange), a rectal catheter with a balloon may be used to facilitate retention if necessary. The patient should retain resin for 30 to 45 minutes to promote potassium removal.  After-ward, a cleansing enema may be prescribed to remove the resin as a precaution against fecal impaction.  Medical Management: a- Pharmacologic Therapy:  A patient with a high and rising level of serum potassium often requires immediate dialysis.  Intravenous glucose and insulin or calcium gluconate may be used to as emergency and temporary measures to treat hyperkalemia. Glucose and insulin drive potassium into cells so lowering serum potassium temporary. Calcium gluconate protect heart from effect of rising serum potassium.  Medical Management: a- Pharmacologic Therapy:  All external sources of potassium (food, salt substitutes, and medications) are eliminated or reduced.  Diuretics are used to treat hypervolemia.  Low-dose dopamine (1 to 3 mg/kg) is often used to dilate renal arteries.  Correction of acidosis and elevated phosphate levels.  Medical Management: b- Nutritional Therapy:  Weighting patient daily  Limit dietary protein to about 1g/kg during the oliguric phase (High protein intake may lead to increased intraglomerular pressure)  High carbohydrate meals to meeting energy needs  Restrict foods that containing potassium and phosphorus (bananas, citrus fruits and juices, coffee).  Medical Management: b- Nutritional Therapy:  Potassium intake is limited to 40 to 60 mEq/day, and sodium is restricted to 2g/day  After diuretic phase, the patient is placed on a high-protein, high-caloric diet and is encouraged to resume activities gradually.  Nursing Management: Monitoring Fluid and Electrolyte Balance:  The nurse monitors closely the patient's serum electrolyte levels and physical indicators of these complications.  The nurse screening carefully all parenteral therapy, all oral intake, and medications for potassium content.  Nursing Management: Monitoring Fluid and Electrolyte Balance:  Monitor patient fluid status  Accurate daily weight, as well as record of intake and output  Report any deterioration in fluid and electrolytes immediately to physician  Prepare for emergency treatment  Nursing Management: Reducing Metabolic rate:  Bed rest reduces exertion and metabolic rate during the most acute stage of the disease.  Fever and infection, which increase metabolic rate, are prevented and treated promptly.  Nursing Management: Promoting Pulmonary Function:  Assist patient to turn, cough, and take deep breaths frequently Preventing Infection:  Asepsis is essential with invasive lines and catheters to minimize the risk of infection.  Avoid an indwelling catheter to reduce risk of UTIs.  Nursing Management: Providing Skin Care:  Massaging of boney prominences  Turning patient frequently  Bathing patient with cool water to provide comfort and prevent skin breakdown  Nursing Management: Providing Support:  The purpose and rational of treatment is explained to the patient and family by the physician.  High level of anxiety and fear need repeated explanation and clarification by the nurse.  Causes: Systemic Diseases, such as diabetes mellitus (leading cause) Hypertension Chronic glomerulonephritis Pyelonephritis Obstruction of urinary tract  Causes: Hereditary lesions, such as in polycystic kidney disease Vascular disorders Infections Medications Toxic agents  Stages of Chronic Renal Disease: Stage 1: Reduced Renal Reserve: It characterized by a 40% to 75% loss of nephron function. The patient usually does not have symptoms because the remaining nephrons are able to carry out the normal functions of the kidney.  Stages of Chronic Renal Disease: Stage 2: Renal Insufficiency: It occurs when 75% to 90% of nephron function is lost. The serum creatinine and blood urea nitrogen rise, the kidney loss its ability to concentrate urine and anemia develop. The patient may report polyuria and nocturia.  Stages of Chronic Renal Disease: Stage 3: End- Stage Renal Disease (ESRD): The final stage of renal failure occurs when there is less than 10% nephron function remaining. All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired. ESRD is evidenced by elevated creatinine and blood urea nitrogen levels as well as electrolyte imbalance. Once the patient reaches this point, dialysis is usually indicated.  Clinical Manifestations:  Neurologic Weakness and fatigue Confusion Inability to concentrate Disorientation Tremors Seizures Astreixis Restlessness of legs Burning of soles of feet Behavior changes  Clinical Manifestations:  Integumentary Gray-bronze skin color Dry, flaky skin Pruritis Ecchymosis Purpura Thin, brittle nails Coarse, thinning hair  Clinical Manifestations:  Cardiovascular Hypertension Pitting edema (feet, hands, sacrum) Periorbital edema Pericardial friction rub Engorged neck vein Pericarditis Pericardial effusion Pericardial tamponade Hyperkalemia  Clinical Manifestations:  Pulmonary Crackles Thick, tenacious sputum Depressed cough reflex Pleuritic pain Shortness of breath Tachypnea Kussmaul-type respirations (fast, deep breaths) Uremic Pneumonitis (uremic lung) (increased permeability of the alveolar capillary interfaces, leading to interstitial edema  Clinical Manifestations:  Gastrointestinal Ammonia odor to breath "uremic fetor“ (excess urea in your body reacts with saliva) Metallic taste Mouth ulcerations and bleeding Anorexia, nausea, vomiting Hiccups Constipation or diarrhea Bleeding from gastrointestinal tract (high urea level are prone to develop upper GI symptoms and mostly show erosive gastritis)  Clinical Manifestations:  Hematologic Anemia Thrombocytopenia  Reproductive Amenorrhea Testicular atrophy Infertility Decreased libido  Clinical Manifestations:  Musculoskeletal Muscle cramps Loss of muscle strength Renal osteodystrophy (bone mineralization deficiency) Bone pain Bone fractures Foot drop  Complications: Hyperkalemia Pericarditis Hypertension Anemia Bone disease and metastatic calcification (When there is too much phosphorus in the blood, it pushes the calcium out from your bones). Metastatic calcification is deposition of calcium salts in otherwise normal tissue, because of elevated serum levels of calcium.  Medical Management:  Pharmacologic Therapy:  Antihypertensive and cardiovascular agents  Erythropoietin: Anemia associated with chronic renal failure is treated with recombinant human erythropoietin (Epogen). Anemic patients (hematocrit less than 30%) present with nonspecific symptoms, such as malaise, general fatigability, and decreased activity tolerance.  Medical Management:  Nutritional Therapy:  Careful regulation of protein intake, the allowed protein usually of high biological value (complete protein supplies all essential amino acids necessary for growth and tissue repair) as egg, dairy product and meats.  Balance sodium intake to replace sodium loss  Some restriction of potassium  Fluid intake to balance fluid loss  Nursing Diagnoses of Chronic 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 of Chronic Renal Failure:  Infection, high-risk for impairment related to lowered resistance  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  Nursing Interventions: Monitoring 1. Vital Signs and Fluid Balances Daily Weights & Assess For Edema 2. Laboratory Results , CBC; WBC & Urinalysis / Culture & Sensitivity Electrolytes & Acid-Base Balances 3. Signs and Symptoms of Infection  Nursing Interventions: Maintain 1. Diet Restrictions /Supplements 2. Fluids Restrictions 3. Bed rest / Semi-Fowler‘s 4. Quiet Environment  Nursing Interventions: Prevent Infection 1. Avoid unnecessary use of Foley catheters 2. Aseptic technique with invasive line care, Pulmonary Care 3. Skin & Mouth Care  Dialysis Dialysis as Supportive treatment of chronic renal failure Dialysis may peritoneal dialysis or haemodialysis.  Peritoneal dialysis In peritoneal dialysis, solution is instilled in the peritoneal cavity. Excess substances in the blood enter the Dialysate and needed substances in the Dialysate enter the blood, then the Dialysate is removed.  Peritoneal dialysis Advantages Disadvantages 1. Inexpensive. 1. There is slow correction of 2. Hemodynamic ally fluid and electrolyte tolerated. disturbances. 3. Low risk. 2. There is high risk of 4. No vascular access. peritonitis. 5. No anticoagulant 3. Leakage of peritoneal therapy. dialysate.  Peritoneal dialysis Requires insertion of a catheter for peritoneal access. During peritoneal dialysis, the catheter should be monitored for signs of potential complications: – An obstructed catheter may be cause by kinking, air lock, fibrin clot. – Extrinsic obstruction is related to constipation abdominal distension. – If catheter extravasations are found, dialysis route should temporarily discontinued allow adequate wound healing with closure of the seal between the peritoneum and catheter.  Haemodialysis: In haemodialysis, (dirty) arterial blood flows into the dialyzer in a hemodialysis machine, toxins and excess fluid pass through an artificial membrane into dialysate solution, needed electrolytes and other elements from the solution pass through the membrane and into the "clean" blood, which is then returned to the patient's venous system. Arteriovenous (AV) shunt/Fistula requires surgical intervention; it is preferred for continuous AV hemofiltration.  Haemodialysis Advantages Disadvantages 1. Fluid and electrolyte 1. Expensive. abnormalities are corrected 2. Vascular access is required, risk rapidly. of complications, infection, 2. Better tolerated. obstruction, or thromboembolic 4. The insertion site evaluated for event. signs of local infection daily. 3. Anticoagulant therapy is required, associated risk of haemorrhage. Nursing Process: The Care of the Hospitalized Patient on Dialysis Assessment Protect vascular access; assess site for patency, signs of potential infection, do not use for blood pressure or blood draws Carefully monitor fluid balance, IV therapy, accurate I&O, IV administration pump s/s of uremia and electrolyte imbalance, regularly check lab data Monitor cardiac/respiratory status carefully Cardiovascular medications must be held prior to dialysis Interventions Monitor all medications and medication dosages carefully Address pain and discomfort Stringent infection control measures Dietary considerations: sodium, potassium, protein, fluid, individual nutritional needs Skin care: pruritus, keep skin clean and well moisturized, trim nails, and avoid scratching CAPD ‐ continuous ambulatory peritoneal dialysis catheter care  Renal transplantation: The organ may be donated by a living person or removed from a cadaver. Selecting a donor. Transplant patients face the prospect of organ rejection: – Hyper acute rejection occurs immediately after transplantation. No effective treatment available. – Acute rejection occurs 1 to 2 weeks after transplantation. Prompt management with intravenous Solu-Medrol usually reverses symptoms. – Chronic rejection occurs over months or years. Immunosuppressive medications and diet slow-but rarely reverse-rejection. The Five E's: Bridges To Renal rehabilitation: Encouragement: Patients, families, and staff need encouragement to adopt a positive attitude toward rehabilitation. Education: Patients need to understand their disease. They need to learn strategies for successful adaptation to dialysis and how to maximize functional status, among many other subjects.  The Five E's: Bridges To Renal rehabilitation: Exercise: Exercise is critical to rehabilitation, just as with heart disease. Employment: The primary goal is to allow dialysis patients to keep their current jobs whenever possible. If not possible, vocational rehabilitation counseling should be used. Evaluation: Systematic evaluation of rehabilitation outcomes is necessary to identify and measure which interventions have made an impact.