Chronic Renal Failure & Dialysis PDF

Chronic renal Handwashing failure Dr. Esmat Sayed 1 Definition: Chronic renal failure involves progressive, irreversible destruction of the nephrons in both kidneys. 2  Causes – Glomerulonephritis and chronic pyelonephri...

Chronic renal Handwashing failure Dr. Esmat Sayed 1 Definition: Chronic renal failure involves progressive, irreversible destruction of the nephrons in both kidneys. 2  Causes – Glomerulonephritis and chronic pyelonephritis. – Diabetic nephropathy. – Hypertensive nephrosclerosis. – Sickle cell anemia. – Systemic lupus erythematosus. – HIV- associated nephropathy. – Prostatic and bladder tumors. Ureter obstruction. Calculi. – Poly cystic kidney disease. Renal infarction 3  Stages of Chronic renal failure CKD has been classified into five stages. Stage 5 results when the kidneys cannot remove the body’s metabolic wastes or perform their regulatory functions; thus, renal replacement therapies are required to sustain life. Screening and early intervention are important, because not all patients progress to stage 5 CKD. Treatment of hypertension, anemia, and hyperglycemia and detection of proteinuria all help to slow disease progression and improve patient 4 outcomes.  Stages or Chronic renal failure 5  Pathophysiology of Chronic renal failure In the early stages of CKD, there can be significant damage to the kidneys without signs or symptoms. The pathophysiology of CKD is not yet clearly understood, but the damage to the kidneys is thought to be caused by prolonged acute inflammation that is not organ specific and thus has subtle systemic manifestations. 6  Clinical Manifestations – Neurologic: Weakness, fatigue; confusion; disorientation; tremors; seizures; asterixis (is a brain-related symptom that affects your muscles; restlessness of legs; burning of soles of feet; behavior changes. – Integumentary: Gray-bronze skin color; dry, flaky ‫ قشر‬skin; pruritus; ecchymosis; thin, brittle nails, thinning hair. – Cardiovascular: Hypertension; pitting edema; pericardial friction rub; engorged neck veins; pericardial effusion; pericardial 7 tamponade; hyperkalemia; hyperlipidemia.  Clinical Manifestations, cont……….. – Pulmonary: Crackles; thick, tenacious sputum; depressed cough reflex; pleuritic pain; shortness of breath; tachypnea; Kussmaul-type respirations; uremic pneumonitis; “uremic lung”. – Gastrointestinal; Ammonia odor to breath (“uremic fetor”); metallic taste; mouth ulcerations and bleeding; anorexia, nausea, and vomiting; hiccups; constipation or diarrhea; ; bleeding from gastrointestinal tract. 8  Clinical Manifestations, cont……….. – Hematologic: Anemia; thrombocytopenia. – Reproductive: Amenorrhea; testicular atrophy; infertility; decreased libido. – Musculoskeletal: Muscle cramps; loss of muscle strength; renal osteodystrophy; bone pain; bone fractures; foot drop. 9  Complications – Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) – Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis – Hypertension due to sodium and water retention and malfunction of renin–angiotensin–aldosterone system. 10  Complications – Anemia due to decreased erythropoietin production, decreased RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis. – Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels. 11  Medical Management The goal of management Goals of medical management: Stabilization of internal environment. Control of fluid and electrolyte imbalance. Absence of infection. Absence of bleeding. Control of blood pressure. Absence of toxicity of medications Control of anorexia or nausea. Control of itching. 12  Medical Management Pharmacological Therapy Nutritional therapy Dialysis. Renal transplantation 13  Pharmacologic therapy – Calcium and Phosphorus Binders. − Antacids: Hyperphosphatemia and hypocalcemia are treated with aluminum based antacids. − Antihypertensive and Cardiovascular Agents. − Antiseizure Agents. − Erythropoietin (Epogen). 14  Nutritional Therapy – Adequate caloric intake and vitamin supplementation. − Protein is restricted because urea, uric acid. − The allowed protein must be of high biologic value (dairy products, eggs, meats). High-biologic-value proteins are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair. − The fluid allowance is 500 to 600 mL more than the previous day’s 24-hour urine output. 15  (Renal transplantation) Surgical Management –One healthy kidney can perform the work of two. –Donors for a transplant are selected from compatible living donors –Any potential donor with a history of hypertension, malignant disease, or diabetes is excluded. 16 Potential nursing diagnoses for these patients: - Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water - Imbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting, dietary restrictions, and altered oral mucous membranes - Deficient knowledge regarding condition and treatment regimen - Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure - Low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction 17 Dialysis Definition: Dialysis occurs with the movement of fluid and particles across a semipermeable membrane.  Goals of dialysis Removal of metabolic waste products. therapy: Maintenance of safe concentration of electrolytes. Correction of acid base imbalance. Removal of excess fluid. Physiologic principles of dialysis: Diffusion: ✓Involve the movements of particles from area of greater concentration to an area of less concentration. Diffusion results in the movements of urea, creatinine and uric acid from the patient's blood into the dialysate solution. Physiologic principles of dialysis: Osmosis:: ✓Involve movement of water excess across a semipermeable membrane from an area of lesser concentration to an area of greater concentration of particles. Physiologic principles of dialysis: fluid moves under Ultra filtration: high pressure to an area of lower pressure Types of dialysis Peritoneal dialysis Hemodialysis The process of removing metabolic wastes and water from blood by use of the living semi permeable membrane (the peritoneum) Hemodialysis Definition: It is the process of removing metabolic waste and water from blood by use of a semipermeable membrane of on artificial kidney Hemodialysis system A. Dialyzers: Dialyzers are hollow-ber devices containing thousands of tiny capillary tubes that carry the blood through the dialyzer. b. Vascular Access Access to the patient’s vascular system must be established to allow blood to be removed, cleansed, and returned to the patient’s vascular system at rates between 200 and 800 mL/minute. Types of access: Temporally Access: Subclavian- Internal Jugular - Femoral Catheters. Permanent access: Arteriovenous Fistula - Arteriovenous Graft Temporally Access Immediate access to the patient’s circulation for acute hemodialysis is achieved by inserting a double-lumen or multi-lumen catheter into the subclavian, internal jugular, or femoral vein. This method of vascular access involves some risk (eg, hematoma, pneumothorax, infection, thrombosis of the subclavian vein, and inadequate flow) Permanent access Fistula : Is created surgically (usually in the forearm) by joining (anastomosing) an artery to a vein, either side to side or end to side. The fistula takes 4 to 6 weeks to mature before it is ready for use. This gives time for healing. The patient is encouraged to perform exercises to increase the size of these vessels (eg, squeezing a rubber ball for forearm fistulas). Arteriovenous fistula Graft: An arteriovenous graft. Usually, a graft is created when the patient’s vessels are not suitable for a fistula. Patients with compromised vascular systems (eg, from diabetes) often need to have a graft to undergo hemodialysis. Grafts are usually placed in the forearm, upper arm, or upper thigh. Infection and thrombosis are the most common complications of arteriovenous grafts. Graft: Indications of hemodialysis: - May be used in the treatment of both acute and chronic renal failure. - The procedure is usually carried out three time / week - Uncontrolled hyperkalemia. - Fluid overload. - Peritonitis. - Sever acidosis. Contraindications: 1. Sever homodynamic instability. 2. Acute and sever bleeding. 3. Intolerance to systemic heparinization.  Advantages: 1. More efficient, faster process. 2. Can be used for temporary or permanent dialysis. 3. Shorter time for treatment needed (3 – 4 h, 3-4 time per week).  Disadvantages: 1.Required trained personnel and sophisticated equipment. 2.Requires heparinization. 3.Require maintenance of vascular access. 4.Expensive to maintain.  Complications of hemodialysis: 1. Hypotension: may occur during the treatment as fluid is removed. Nausea and vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension. 2. Painful muscle cramping: may occur, usually late in dialysis as fluid and electrolytes rapidly leave the extracellular space. Complications of hemodialysis: 3. Exsanguination: may occur if blood lines separate or dialysis needles accidentally become dislodged. 4. Dysrhythmias: may result from electrolyte and pH changes or from removal of antiarrhythmic medications during dialysis. Complications of hemodialysis: 5. Air embolism : is rare but can occur if air enters the vascular system. 6. Chestpain : may occur in patients with anemia or arteriosclerotic heart disease. Complications of hemodialysis: 7. Dialysis disequilibrium : results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is more likely to occur in acute renal failure or when blood urea nitrogen levels are very high (exceeding 150 mg/dL). Nursing process for hemodialysis: Nursing assessment: - Assess postural changes of blood pressure especially at the completion of dialysis. - Check all vital signs. - Assess heart and lung sounds. - Assess fluid status before and after the process. - Monitor intake and output. - Weight the patient before and after dialysis. Nursing assessment cont………… Assess mental status. Monitor electrolyte value. Check for patency of vascular access. Observe and report any numbness, pain or swelling in the extremity distal to the access. Assess the patient's and family's knowledge concerning dialysis, vascular access and dietary and medical regimen. Assess support system and the patient's coping mechanism.  Nursing process for Hemodialysis dialysis Nursing Nursing intervention diagnosis : 1. Observe for and report signs 1. Risk for fluid and symptoms of fluid excess or overload. deficit related 2. Assess for signs and symptoms to renal failure of fluid deficit. or fluid over 3. Record accurately the load measurements of inflow and outflow. 4. Observe for and report signs of outflow problem. 5. Maintain intake and output. 6. Weight the patient daily. Nursing Nursing intervention diagnosis : 1. The nurse assesses the vascular access for 2. Risk for potency infection 2. Takes precautions to ensure that the related to extremity with the vascular access is not vascular used for measuring blood pressure or for obtaining blood specimens; access. 3. Tight dressings, restraints, or jewelry over the vascular access are to be avoided as well. 4. The bruit over the venous access site must be evaluated at least every 8 hours.  Cont., Nursing diagnosis Nursing intervention 2. Risk for infection related 5. Absence of a palpable thrill or audible bruit may indicate blockage to vascular access. or clotting in the access device. 6. The nurse observes the patient for signs and symptoms of infection, such as redness, tenderness, swelling, drainage from the site, and fever. 7. Provide adequate site care. 8. Use aseptic techniques when changing dressing. 9. Monitor vital signs. 10.Teach patient and family to recognize signs & symptoms of infection. Nursing diagnosis : Nursing intervention 3. Ineffective coping related to effect of 1. Instruct the patient and long term family in all areas of the hemodialysis. treatment. 2. Allow for questions and verbalization of fears and concerns. 3. Provide support for decision made by the patient and family. 4. Encourage active participation in the patient's care by the patient and the family.  Bibliotheca Alexandrina 48