GUT Part 4- ARF, CRF and Other Disorders

Urinary Tract Urinary Tract DisordersDisorders

Renal FailureRenal Failure

Renal FailureRenal Failure

Results when the kidneys cannot remove Results when the kidneys cannot remove wastes or perform regulatory functionswastes or perform regulatory functions

A systemic disorder that results from many A systemic disorder that results from many different causesdifferent causes

Acute renal failureAcute renal failure is a reversible syndrome is a reversible syndrome that results in decreased that results in decreased glomerular filtration glomerular filtration rate (rate (GFR) and oliguriaGFR) and oliguria

Chronic renal failure (ESRD) Chronic renal failure (ESRD) is progressive; is progressive; irreversible deterioration of renal function irreversible deterioration of renal function results in azotemiaresults in azotemia

Common Characteristics inCommon Characteristics inARF and CRFARF and CRF

↓ ↓ waste product excretionwaste product excretion

chaotic acid and base regulationchaotic acid and base regulation

elevation of electrolyteselevation of electrolytes

water retentionwater retention

↓ ↓ production of erythropoietinproduction of erythropoietin

↓↓active vitamin D secretionsactive vitamin D secretions

↑ ↑ renin activationrenin activation

Acute Renal FailureAcute Renal Failure


Sudden interruption of kidney Sudden interruption of kidney function to regulate fluid and function to regulate fluid and electrolyte balance and remove toxic electrolyte balance and remove toxic products from the bodyproducts from the body

Most common and important Most common and important manifestation: OLIGURIAmanifestation: OLIGURIA

Kidney FunctionKidney FunctionThe Nephron produces The Nephron produces urine to eliminate wasteurine to eliminate waste

Impaired urine production Impaired urine production and azotemiaand azotemia

Secretes Erythropoietin Secretes Erythropoietin to increase RBCto increase RBC ANEMIAANEMIA

Metabolism of Vitamin DMetabolism of Vitamin D Calcium and Phosphate Calcium and Phosphate imbalancesimbalances

Produces bicarbonate Produces bicarbonate and secretes acidsand secretes acids Metabolic ACIDOSISMetabolic ACIDOSIS

Excretes excess Excretes excess POTASSIUMPOTASSIUM HYPERKALEMIAHYPERKALEMIA


PATHOPHYSIOLOGYPATHOPHYSIOLOGY

1.1. Pre-renal failurePre-renal failure

1.1. Intra-renal failureIntra-renal failure

1.1. Post-renal failurePost-renal failure


PATHOPHYSIOLOGYPATHOPHYSIOLOGYPrerenal CAUSE: Prerenal CAUSE:

Factors interfering with perfusion and Factors interfering with perfusion and resulting in diminished blood flow and resulting in diminished blood flow and glomerular filtrate, ischemia, and oliguriaglomerular filtrate, ischemia, and oliguria

Include CHF, cardiogenic shock, acute Include CHF, cardiogenic shock, acute vasoconstriction, diabetes mellitus, vasoconstriction, diabetes mellitus, hemorrhage, burns, traumatic accidents, hemorrhage, burns, traumatic accidents, septicemia, hypotension, anaphylaxissepticemia, hypotension, anaphylaxis


PATHOPHYSIOLOGYPATHOPHYSIOLOGYIntrarenal CAUSE:Intrarenal CAUSE:

Conditions that cause direct damage to Conditions that cause direct damage to the nephrons the nephrons Include acute tubular necrosis (ATN), Include acute tubular necrosis (ATN), endocarditis, malignant hypertension, endocarditis, malignant hypertension, acute glomerulonephritis, tumors, blood acute glomerulonephritis, tumors, blood transfusion reactions, hypercalcemia, transfusion reactions, hypercalcemia, nephrotoxins (certain antibiotics, x-ray nephrotoxins (certain antibiotics, x-ray dyes, pesticides, anesthetics)dyes, pesticides, anesthetics)


PATHOPHYSIOLOGYPATHOPHYSIOLOGYPostrenal CAUSE: Postrenal CAUSE:

Mechanical obstruction anywhere from Mechanical obstruction anywhere from the tubules to the urethra the tubules to the urethra

Includes calculi, BPH, tumors, strictures, Includes calculi, BPH, tumors, strictures, blood clots, trauma, and anatomic blood clots, trauma, and anatomic malformationmalformation

Pre-RenalPre-Renal

Decreased renal tissue perfusion Decreased renal tissue perfusion from:from:– DM (most common)DM (most common)– HypovolemiaHypovolemia– Shock Shock – HemorrhageHemorrhage– Burns Burns – Impaired cardiac outputImpaired cardiac output– Diuretic therapyDiuretic therapy

Intra-RenalIntra-RenalAGN acute glomerulonephritisAGN acute glomerulonephritisInfection of kidney due to immune responseInfection of kidney due to immune responsePrevious infection from group A beta hemolytic Previous infection from group A beta hemolytic streptococcusstreptococcusS/SxS/Sx – proteinuria, hematuria, oliguria, edema – proteinuria, hematuria, oliguria, edema and HPNand HPNCGN chronic glomerulonephritisCGN chronic glomerulonephritisNon infectious slowly developing disease Non infectious slowly developing disease S/SxS/Sx – same with AGN – same with AGNNephrotic SyndromeNephrotic SyndromeSeverely damaged glomerular activity that leads Severely damaged glomerular activity that leads to increased capillary permeabilityto increased capillary permeabilityS/SxS/Sx – proteinuria, hypoalbuminemia, edema – proteinuria, hypoalbuminemia, edema and hyperlipidemiaand hyperlipidemiaCaused by CGN, DM and SLECaused by CGN, DM and SLE

Post-RenalPost-RenalDue to obstruction or disruption to Due to obstruction or disruption to urine flow anywhere along the urinary urine flow anywhere along the urinary tract:tract:– CystitisCystitis– UrethritisUrethritis– PyelonephritisPyelonephritis– UrolithiasisUrolithiasis– Injuries to the bladder and urethraInjuries to the bladder and urethra– Cancer of the bladderCancer of the bladder– ProstatitisProstatitis– BPHBPH


Four phases of acute renal failure Four phases of acute renal failure (Brunner and Suddarth)(Brunner and Suddarth)

1.1. Initiation phaseInitiation phase2.2. Oliguric phaseOliguric phase3.3. Diuretic phaseDiuretic phase4.4. Convalescence or recovery phaseConvalescence or recovery phase

Acute Renal FailureAcute Renal FailureAssessment findings: The Phases Assessment findings: The Phases

of Acute Renal Failureof Acute Renal Failure1.1. Oliguric phaseOliguric phase

Urine output less than 400 cc/24 hoursUrine output less than 400 cc/24 hoursDuration 1—2 weeksDuration 1—2 weeksManifested by Manifested by dilutional hyponatremia,dilutional hyponatremia, hypocalcemia, hyperkalemiahypocalcemia, hyperkalemia, , hyperphosphatemia,, hypermagnesemia, hyperphosphatemia,, hypermagnesemia, and metabolic acidosisand metabolic acidosisDiagnostic tests: BUN and creatinine Diagnostic tests: BUN and creatinine elevatedelevated

Acute Renal FailureAcute Renal FailureAssessment findings: The Three Assessment findings: The Three

Phases of Acute Renal FailurePhases of Acute Renal Failure2. 2. Diuretic phaseDiuretic phase

Diuresis may occur (output 3—5 Diuresis may occur (output 3—5 liters/day) due to partially regenerated liters/day) due to partially regenerated tubule’s inability to concentrate urinetubule’s inability to concentrate urineDuration: Duration: 2—3 weeks2—3 weeks; manifested by ; manifested by hyponatremia, hypokalemia, and hyponatremia, hypokalemia, and hypovolemiahypovolemiaDiagnostic tests: BUN and creatinine Diagnostic tests: BUN and creatinine slightly elevatedslightly elevated


Assessment findings: The Three Assessment findings: The Three Phases of Acute Renal FailurePhases of Acute Renal Failure

3. 3. Recovery or convalescent phase: Recovery or convalescent phase: Renal function stabilizes with gradual Renal function stabilizes with gradual improvement over next 3—12 monthsimprovement over next 3—12 months

Clinical Course:Clinical Course:

Oliguric-anuric phaseOliguric-anuric phasemmay last 7-14 days ay last 7-14 days

Non-oliguric or high output RFNon-oliguric or high output RFnitrogenous waste products are still nitrogenous waste products are still

high in the blood.high in the blood.

Diuresis PhaseDiuresis Phasereturn to normal urine output in 1 to 3return to normal urine output in 1 to 3

monthsmonths

Convalescent Recovery PeriodConvalescent Recovery Periodmay take 6 months to 1 year from the initial may take 6 months to 1 year from the initial onsetonset

Collaborative Problems/Potential Collaborative Problems/Potential ComplicationsComplications

HypocalcemiaHypocalcemia

HyperkalemiaHyperkalemia

PericarditisPericarditis

Pericardial effusionPericardial effusion

Pericardial tamponadePericardial tamponade

HypertensionHypertension

AnemiaAnemia

Bone diseasesBone diseases


Laboratory Findings:Laboratory Findings:1.1. Urinalysis: Increase urine Urinalysis: Increase urine

osmolalityosmolality2.2. BUN and creatinine levels BUN and creatinine levels

increasedincreased3.3. Hypokalemia or HyperkalemiaHypokalemia or Hyperkalemia4.4. Hyponatremia to HypernatremiaHyponatremia to Hypernatremia5.5. AnemiaAnemia6.6. ABG: metabolic acidosisABG: metabolic acidosis

Acute Renal Failure Acute Renal Failure ManagementManagement

I&OI&OWeighingWeighingInfection monitoringInfection monitoringExamine gross and occult blood in urineExamine gross and occult blood in urineDiet (CHON moderate, increase CHO)Diet (CHON moderate, increase CHO)Electrolyte managementElectrolyte managementNeurologic assessmentNeurologic assessment

Nursing Process—Assessment of the Nursing Process—Assessment of the Patient With Renal FailurePatient With Renal Failure

Fluid statusFluid status

Nutritional statusNutritional status

Patient knowledgePatient knowledge

Activity toleranceActivity tolerance

Self-esteemSelf-esteem

Potential complicationsPotential complications

Nursing Process—Diagnosis of the Nursing Process—Diagnosis of the Patient With Renal FailurePatient With Renal Failure

FVE related to decreased GFR and sodium FVE related to decreased GFR and sodium retentionretentionRisk for infection related to reduced host Risk for infection related to reduced host defensesdefensesAltered Nutrition related to catabolic state, Altered Nutrition related to catabolic state, anorexiaanorexiaRisk for internal bleeding related to stress Risk for internal bleeding related to stress ulcerulcerAltered thought processes related to effects Altered thought processes related to effects of uremic toxins to CNSof uremic toxins to CNS

Nursing Process—Planning the Care of Nursing Process—Planning the Care of the Patient With Renal Failurethe Patient With Renal Failure

Goals include maintaining IBW Goals include maintaining IBW without excess fluid, without excess fluid,

Maintenance of adequate nutritional Maintenance of adequate nutritional intake, intake,

Increased knowledge, participation in Increased knowledge, participation in activities within tolerance, improved activities within tolerance, improved self-esteem, and absence of self-esteem, and absence of complicationscomplications


Nursing InterventionsNursing InterventionsMonitor fluid and Electrolyte BalanceMonitor fluid and Electrolyte Balance

Reduce metabolic rateReduce metabolic rate

Promote pulmonary functionPromote pulmonary function

Prevent infectionPrevent infection

Provide skin careProvide skin care

Provide emotional supportProvide emotional support


Nursing InterventionsNursing Interventions1. 1. Monitor and maintain fluid and Monitor and maintain fluid and

electrolyte balance.electrolyte balance.Measure l & O every hour. Note Measure l & O every hour. Note excessive losses in diuretic phaseexcessive losses in diuretic phaseAdminister IV fluids and electrolyte Administer IV fluids and electrolyte supplements as ordered.supplements as ordered.Weigh daily and report gains.Weigh daily and report gains.Monitor lab values; assess/treat fluid and Monitor lab values; assess/treat fluid and electrolyte and acid-base imbalances as electrolyte and acid-base imbalances as needed needed


Nursing interventionsNursing interventions2. 2. Monitor alteration in fluid volume.Monitor alteration in fluid volume.

Monitor vital signs, PAP, PCWP, CVP as Monitor vital signs, PAP, PCWP, CVP as needed to monitor excess fluids that may needed to monitor excess fluids that may lead to CHF.lead to CHF.Weigh client daily.Weigh client daily.Maintain strict I & O records.Maintain strict I & O records.

Assess for signs and symptoms of fluid Assess for signs and symptoms of fluid volume excess; keep accurate I&O and volume excess; keep accurate I&O and daily weight recordsdaily weight records

Acute Renal FailureAcute Renal FailureNursing interventionsNursing interventions2. 2. Monitor alteration in fluid volume.Monitor alteration in fluid volume.

Limit fluid to prescribed amountsLimit fluid to prescribed amounts

Identify sources of fluidIdentify sources of fluid

Explain to patient and family the rationale Explain to patient and family the rationale for the restriction for the restriction

Assist patient in coping with the fluid Assist patient in coping with the fluid restrictionrestriction

Provide or encourage frequent oral hygieneProvide or encourage frequent oral hygiene


Nursing InterventionsNursing Interventions3. 3. Assess every hour for Assess every hour for hypervolemiahypervolemia

– Maintain adequate ventilation.Maintain adequate ventilation.– Restrict FLUID intakeRestrict FLUID intake– Administer diuretics and Administer diuretics and

antihypertensives antihypertensives

Acute Renal FailureAcute Renal FailureNursing InterventionsNursing Interventions4. 4. Promote optimal nutritional status.Promote optimal nutritional status.

Administer TPN as ordered.Administer TPN as ordered.With enteral feedings, check for residual With enteral feedings, check for residual and notify physician if residual volume and notify physician if residual volume increases.increases.Restrict protein intake to 1 g/kg/dayRestrict protein intake to 1 g/kg/dayRestrict POTASSIUM intakeRestrict POTASSIUM intakeHigh Carbohydrate DietHigh Carbohydrate Diet, calcium , calcium supplementssupplements

Imbalanced NutritionImbalanced Nutrition

Assess nutritional status, weight changes, and Assess nutritional status, weight changes, and lab datalab data

Assess patient nutritional patterns and history; Assess patient nutritional patterns and history; note food preferencesnote food preferences

Provide food preferences within restrictionsProvide food preferences within restrictions

Encourage high-quality nutritional foods while Encourage high-quality nutritional foods while maintaining nutritional restrictionsmaintaining nutritional restrictions

Assess and modify intake related to factors that Assess and modify intake related to factors that contribute to altered nutritional intake, ie, contribute to altered nutritional intake, ie, stomatitis or anorexiastomatitis or anorexia

Adjust medication times related to meals Adjust medication times related to meals


Nursing InterventionsNursing Interventions5. 5. Prevent complications from Prevent complications from impaired mobility impaired mobility (pulmonary (pulmonary embolism, skin breakdown, and embolism, skin breakdown, and atelectasis) atelectasis) 6. 6. Prevent fever/infection.Prevent fever/infection.

– Assess for signs of infection.Assess for signs of infection.– Use strict aseptic technique for wound Use strict aseptic technique for wound

and catheter care.and catheter care.


Nursing InterventionsNursing Interventions7. 7. Support client/significant others and Support client/significant others and reduce/ relieve anxiety.reduce/ relieve anxiety.

– Explain pathophysiology and relationship Explain pathophysiology and relationship to symptoms.to symptoms.

– Explain all procedures and answer all Explain all procedures and answer all questions in easy-to-understand termsquestions in easy-to-understand terms

– Refer to counseling services as neededRefer to counseling services as needed

8. 8. Provide care for the client receiving Provide care for the client receiving dialysis dialysis

Risk for Situational Low Self-Risk for Situational Low Self-EsteemEsteem

Assess patient and family responses to Assess patient and family responses to illness and treatmentillness and treatment

Assess relationships and coping patternsAssess relationships and coping patterns

Encourage open discussion about changes Encourage open discussion about changes and concernsand concerns

Explore alternate ways of sexual expressionExplore alternate ways of sexual expression

Discuss role of giving and receiving love, Discuss role of giving and receiving love, warmth, and affectionwarmth, and affection


Nursing InterventionsNursing Interventions8. 8. Provide client teaching and discharge Provide client teaching and discharge

planning concerningplanning concerningAdherence to prescribed dietary regimenAdherence to prescribed dietary regimenSigns and symptoms of recurrent renal Signs and symptoms of recurrent renal diseasediseaseImportance of planned rest periodsImportance of planned rest periodsUse of prescribed drugs onlyUse of prescribed drugs onlySigns and symptoms of UTI or respiratory Signs and symptoms of UTI or respiratory infection need to report to physician infection need to report to physician immediatelyimmediately

Chronic Renal FailureChronic Renal Failure


Gradual, progressive irreversible Gradual, progressive irreversible destruction of the kidneys causing destruction of the kidneys causing severe renal dysfunction. severe renal dysfunction.

The result is The result is AZOTEMIAAZOTEMIA to to UREMIAUREMIA

Dialysis or kidney transplant is Dialysis or kidney transplant is necessarynecessary


Progressive inability, over months to Progressive inability, over months to years, of the kidneys to respond to change years, of the kidneys to respond to change in body fluids and electrolyte composition in body fluids and electrolyte composition with an inability of the kidneys to produce with an inability of the kidneys to produce sufficient urine.sufficient urine.

GFR is less than 20% of normal and GFR is less than 20% of normal and creatinine is greater than 5 mg/dL.creatinine is greater than 5 mg/dL.

Chronic Renal FailureChronic Renal FailureRisk FactorsRisk Factors

Polycystic kidney diseasePolycystic kidney disease

Chronic glomerulonephritisChronic glomerulonephritis

Chronic urinary obstructionChronic urinary obstruction

Chronic pyelonephritisChronic pyelonephritis

Severe hypertensionSevere hypertension

Congenital or acquired renal artery Congenital or acquired renal artery stenosis and vascular disordersstenosis and vascular disorders

Systemic lupus erythematosusSystemic lupus erythematosus

Chronic Renal FailureChronic Renal FailureRisk FactorsRisk Factors

Diabetes mellitus Diabetes mellitus worldwide leading causeworldwide leading cause

Hereditary lesionsHereditary lesions

Medications or toxic agentsMedications or toxic agents

Recurrent infectionRecurrent infection

Exacerbations of nephritisExacerbations of nephritis

Chronic Renal FailureChronic Renal FailurePathophysiologyPathophysiology

Destruction of glomeruli -> reduced Destruction of glomeruli -> reduced glomerular filtration rate -> retention glomerular filtration rate -> retention of metabolic waste products -> of metabolic waste products -> decreased urine output -> severe fluid, decreased urine output -> severe fluid, electrolyte, acid-base imbalances -> electrolyte, acid-base imbalances -> azotemia -> uremia -> deathazotemia -> uremia -> death

Chronic Renal FailureChronic Renal FailureClinical Course:Clinical Course:

Decreased renal reserve Decreased renal reserve 40-70% GFR40-70% GFR

Renal insufficiencyRenal insufficiency 20-40% GFR20-40% GFR

Renal failureRenal failure 15-20% 15-20% GFRGFR

End-Stage Renal DiseaseEnd-Stage Renal Disease 15% GFR15% GFR

(Both kidneys are severely affected and (Both kidneys are severely affected and renal function is absent)renal function is absent)


PATHOPHYSIOLOGYPATHOPHYSIOLOGYSTAGE 1STAGE 1= reduced renal reserve, 40-= reduced renal reserve, 40-75% loss of nephron function75% loss of nephron function

STAGE 2STAGE 2= renal insufficiency, 75-90% = renal insufficiency, 75-90% loss of nephron functionloss of nephron function

STAGE 3STAGE 3= end-stage renal disease, = end-stage renal disease, more than 90% loss. more than 90% loss. DIALYSIS IS THE DIALYSIS IS THE TREATMENT! TREATMENT!

3 Stages of Chronic Renal Failure3 Stages of Chronic Renal Failure1.1. Early stage (renal impairment) Early stage (renal impairment)

unaffected nephrons compensate for the unaffected nephrons compensate for the lost nephrons which is 50% (40-75%) lost nephrons which is 50% (40-75%) and above of functional renal tissueand above of functional renal tissue

2.2. Second stage (renal insufficiency)Second stage (renal insufficiency) more than 75%-90% of the functional more than 75%-90% of the functional renal tissue is destroyed. GFR 20-40%renal tissue is destroyed. GFR 20-40%

3.3. Third stage (end-stage renal disease-Third stage (end-stage renal disease-ERSD) ERSD) more than 90% of the functional more than 90% of the functional tissue is destroyed.tissue is destroyed. GFR is less than GFR is less than 15%15%


DermatologicDermatologic dry skindry skin, pruritus, uremic , pruritus, uremic frostfrost

CNSCNS seizures, altered LOC, seizures, altered LOC, anorexia, fatigueanorexia, fatigue

CVSCVS Acute MI, edema, Acute MI, edema, hypertension, pericarditishypertension, pericarditis

PulmoPulmo Uremic lungsUremic lungs

HemaHema AnemiaAnemia

MusculoskeletalMusculoskeletal loss of strength, foot drop, loss of strength, foot drop, osteodystrophyosteodystrophy

Chronic Renal FailureChronic Renal FailureClinical AssessmentClinical Assessment

AmmoniaAmmonia in skin (UREMIC FROST) and in skin (UREMIC FROST) and alimentary tract by bacterial interaction alimentary tract by bacterial interaction with with ureaurea- inflammation of mucous - inflammation of mucous membranes - Stress Ulcermembranes - Stress UlcerRetention of PhosphateRetention of Phosphate – decreased – decreased serum calcium- muscle spasms- tetany serum calcium- muscle spasms- tetany and increased parahormone release- and increased parahormone release- demineralization of bone.demineralization of bone.Failure of tubular mechanisms Failure of tubular mechanisms to regulate to regulate blood bicarbonate- blood bicarbonate- metabolic acidosismetabolic acidosis- - hyperventilationhyperventilation

Chronic Renal FailureChronic Renal FailureClinical AssessmentClinical Assessment

Urea osmotic diuresis Urea osmotic diuresis - flushing effect on - flushing effect on tubules - decreased reabsorption of tubules - decreased reabsorption of sodium - sodium - sodium depletion sodium depletion

Waste product retention Waste product retention - depressed - depressed bone marrow function - decreased bone marrow function - decreased circulating RBC’s – renal tissue hypoxia - circulating RBC’s – renal tissue hypoxia - decreased erythropoietin production - decreased erythropoietin production - further depression of bone marrow - further depression of bone marrow - AnemiaAnemia

Chronic Renal FailureChronic Renal FailureLaboratory Diagnostic TestLaboratory Diagnostic Test

ElectrolytesElectrolytes– K+, Na, PhosporusK+, Na, Phosporus

BUN & CreatinineBUN & CreatinineABGs, CBCABGs, CBCUrinalysisUrinalysisRenal ultrasoundRenal ultrasoundIVPIVPRenal BiopsyRenal Biopsy

Chronic Renal Failure:Chronic Renal Failure:Laboratory DiagnosticsLaboratory Diagnostics

Serum Crea Serum Crea – elevated (normal 0.5-1.5 mg/dl) – elevated (normal 0.5-1.5 mg/dl) Serum BUNSerum BUN – elevated (normal 10-30 mg/dl) – elevated (normal 10-30 mg/dl)Serum electrolytes Serum electrolytes – all electrolytes are elevated – all electrolytes are elevated except for HCO3 and Calciumexcept for HCO3 and CalciumCBCCBC – anemia (due to reduced erythropoietin – anemia (due to reduced erythropoietin production)production)Renal Ultrasonography Renal Ultrasonography – to estimate renal size – to estimate renal size and obstructionand obstructionSerum uric acidSerum uric acid – elevated (normal 2.7-7.7mg/dl) – elevated (normal 2.7-7.7mg/dl)Phenolsulfonphthalein (PSP) excretionPhenolsulfonphthalein (PSP) excretion- - decreased/low (normal 60 to 75%) decreased/low (normal 60 to 75%)

Chronic Renal FailureChronic Renal FailureMedical ManagementMedical Management

Medications:Medications:1. NaHCO3 administration 1. NaHCO3 administration

2. Blood Volume Expanders2. Blood Volume Expanders

3. Diuretics3. Diuretics

4. Antacids & H2 Receptor Antagonist4. Antacids & H2 Receptor Antagonist5. Potassium & Phosphate binding 5. Potassium & Phosphate binding 6. Give vit D and calcium supplement6. Give vit D and calcium supplement7. Manage electrolyte imbalance7. Manage electrolyte imbalance

Important DrugsImportant Drugs

Aluminum hydroxide Aluminum hydroxide

(Amphogel)(Amphogel)Binds with PHOSPHATE Binds with PHOSPHATE to decrease phosphorusto decrease phosphorus

KayexalateKayexalate Binds with POTASSIUM Binds with POTASSIUM to manage hyperkalemiato manage hyperkalemia

DiureticsDiuretics To decrease edemaTo decrease edema

Erythropoietin (Epogen)Erythropoietin (Epogen) To increase RBCTo increase RBC

Anti-HypertensivesAnti-Hypertensives To manage To manage HypertensionHypertension

Chronic Renal FailureChronic Renal FailureNursing DiagnosisNursing Diagnosis

Fluids and electrolytes imbalanceFluids and electrolytes imbalance

Impaired skin integrity related to uremic frostImpaired skin integrity related to uremic frost

Constipation related to fluid restriction and Constipation related to fluid restriction and phosphate binding agent administrationphosphate binding agent administration

High risk for injury (fracture) related to High risk for injury (fracture) related to osteoclast activityosteoclast activity

Non compliance to therapeutic regimen related Non compliance to therapeutic regimen related to restrictions imposed by CRF and its to restrictions imposed by CRF and its treatmenttreatment

Chronic Renal FailureChronic Renal FailureNursing DiagnosisNursing Diagnosis

Other Nursing DiagnosisOther Nursing Diagnosis

FatigueFatigue

Ineffective individual copingIneffective individual coping

Body image disturbanceBody image disturbance


Nursing InterventionsNursing Interventions1. 1. Prevent neurological Prevent neurological

complications.complications.Assess every hour for signs of uremia Assess every hour for signs of uremia (fatigue, apathy, confusion, (fatigue, apathy, confusion, restlessness, seizure, loss of appetite, restlessness, seizure, loss of appetite, decreased urine output, elevated decreased urine output, elevated blood pressure, edema of face and blood pressure, edema of face and feet, itchy skin)feet, itchy skin)


Nursing InterventionsNursing Interventions1. 1. Prevent neurological Prevent neurological

complications.complications.Assess for changes in mental Assess for changes in mental functioning.functioning.Orient confused client to time, place, Orient confused client to time, place, date, and personsdate, and personsInstitute safety measures to protect Institute safety measures to protect client from falling out of bed.client from falling out of bed.


Nursing InterventionsNursing Interventions2. 2. Promote optimal GI function.Promote optimal GI function.

Assess/provide care for stomatitisAssess/provide care for stomatitisMonitor nausea, vomiting, anorexiaMonitor nausea, vomiting, anorexiaAdminister antiemetics as ordered.Administer antiemetics as ordered.Assess for signs of Gl bleedingAssess for signs of Gl bleeding


Nursing InterventionsNursing Interventions3. 3. Monitor/prevent alteration in fluid Monitor/prevent alteration in fluid and electrolyte balanceand electrolyte balance4. 4. Assess for hyperphosphatemia Assess for hyperphosphatemia (paresthesias, muscle cramps, (paresthesias, muscle cramps, seizures, abnormal reflexes), and seizures, abnormal reflexes), and administer administer aluminum hydroxidealuminum hydroxide gels gels (Amphojel) as ordered(Amphojel) as ordered


Nursing InterventionsNursing Interventions5. 5. Promote maintenance of skin Promote maintenance of skin

integrity.integrity.Assess/provide care for pruritus.Assess/provide care for pruritus.Assess for uremic frost (urea Assess for uremic frost (urea crystallization on the skin) and bathe crystallization on the skin) and bathe in plain waterin plain water

6. 6. Provide care for client receiving Provide care for client receiving dialysis.dialysis.


Nursing InterventionsNursing Interventions7. 7. Monitor for bleeding Monitor for bleeding

complications, prevent injury to complications, prevent injury to client.client.Monitor Hgb, hct, platelets, RBC.Monitor Hgb, hct, platelets, RBC.Hematest all secretions.Hematest all secretions.Administer hematinics as ordered Administer hematinics as ordered (precautions for hypertension).(precautions for hypertension).Avoid lM injectionsAvoid lM injections


Nursing InterventionsNursing Interventions8. 8. Promote/maintain maximal Promote/maintain maximal

cardiovascular function.cardiovascular function.Monitor blood pressure and report Monitor blood pressure and report significant changes.significant changes.Auscultate for pericardial friction rub.Auscultate for pericardial friction rub.Perform circulation checks routinely.Perform circulation checks routinely.Administer diuretics as ordered and Administer diuretics as ordered and monitor output.monitor output.Modify drug dosesModify drug doses

Chronic Renal FailureChronic Renal FailureNursing InterventionsNursing Interventions

9.9. Control HyperkalemiaControl HyperkalemiaInfusion of Infusion of hypertonic glucose and insulinhypertonic glucose and insulin to to force potassium into cells; force potassium into cells; calcium gluconate calcium gluconate (IV) to reduce myocardial irritability from (IV) to reduce myocardial irritability from potassium. potassium.

Sodium bicarb Sodium bicarb (IV) to correct acidosis(IV) to correct acidosis

Kayexalate Kayexalate

- Orally or rectally (enema) to remove - Orally or rectally (enema) to remove excess potassiumexcess potassium

Diuretics Diuretics - mannitol, furosemide- mannitol, furosemide


10. 10. Maintain fluid and electrolyte Maintain fluid and electrolyte balance and nutritionbalance and nutrition

Monitor daily weight & include CVPMonitor daily weight & include CVP

Fluid D5 ½ NSS, blood productsFluid D5 ½ NSS, blood products

Know how to calculate fluid replacementKnow how to calculate fluid replacement

Diet high in carbohydrates, low protein Diet high in carbohydrates, low protein and low potassium based on valuesand low potassium based on values


11.11. Maintain fluid and electrolyte Maintain fluid and electrolyte balance and nutritionbalance and nutrition

DietDiet

MedicationsMedications

Input & 0utputInput & 0utput


12. 12. Employ comfort measures that Employ comfort measures that reduce distress and support physical reduce distress and support physical functionfunction

ActivityActivity

HygieneHygiene

Skin CareSkin Care

CommunicationCommunication


13. 13. Goal: Health TeachingGoal: Health Teaching

Dietary restrictionsDietary restrictions

Daily weightDaily weight

DialysisDialysis

TransplantTransplant

Chronic Renal FailureChronic Renal FailureTreatment Options for Renal FailureTreatment Options for Renal Failure

HemodialysisHemodialysis

Peritoneal dialysisPeritoneal dialysis

Continuous renal replacement Continuous renal replacement therapies (CRRT)therapies (CRRT)

Chronic Renal FailureChronic Renal FailureEvaluationEvaluation

Return of kidney function- normal Return of kidney function- normal creatinine levels (< 1.5 mg/dL)creatinine levels (< 1.5 mg/dL)

Normal urine outputNormal urine output

Resume normal life patternResume normal life pattern– Takes about 3 months after onsetTakes about 3 months after onset

Chronic Renal FailureChronic Renal FailureEvaluationEvaluation

Compliance with dietary restriction- no Compliance with dietary restriction- no signs of protein excess (nausea & signs of protein excess (nausea & vomiting)vomiting)

No signs fluid / sodium excess (edema, No signs fluid / sodium excess (edema, weight gain) weight gain)

Acceptance of chronic illness (no Acceptance of chronic illness (no indication of indiscretion, destructive indication of indiscretion, destructive behavior, suicidal tendency)behavior, suicidal tendency)

Polycystic Kidney Polycystic Kidney DiseaseDisease

Polycystic Kidney DiseasePolycystic Kidney Disease

Description:Description:Is a cystic formation and hypertrophy of Is a cystic formation and hypertrophy of the kidneys, which lead to the kidneys, which lead to cystic rupture, cystic rupture, infection, the formation of scar tissue, infection, the formation of scar tissue, and damaged nephronsand damaged nephronsNo way is known to arrest the progress No way is known to arrest the progress of the destructive cystsof the destructive cystsThe ultimate result of this disease is The ultimate result of this disease is renal failurerenal failure


Types of Polycystic Kidney DiseaseTypes of Polycystic Kidney DiseaseInfantile Polycystic DiseaseInfantile Polycystic Disease

An inherited autosomal recessive trait An inherited autosomal recessive trait that results in the death of the infant that results in the death of the infant within a few months after birthwithin a few months after birth

Adult Polcystic DiseaseAdult Polcystic DiseaseAn autosomal dominant trait that results An autosomal dominant trait that results in end-stage renal disease in end-stage renal disease


Assessment:Assessment:Flank, lumbar, or abdominal painFlank, lumbar, or abdominal painFever and chillsFever and chillsUTIsUTIsHematuria, proteinuria, pyuriaHematuria, proteinuria, pyuriaCalculusesCalculusesHypertensionHypertensionPalpable abdominal masses and Palpable abdominal masses and enlarged kidneysenlarged kidneys


Nursing Interventions:Nursing Interventions:Monitor for gross hematuria which Monitor for gross hematuria which indicates indicates cyst rupturecyst ruptureIncrease sodium and water intake Increase sodium and water intake because sodium loss rather than because sodium loss rather than retention occursretention occursPrepare the client for Prepare the client for percutaneous cyst percutaneous cyst puncturepuncture for relief of obstruction or for for relief of obstruction or for draining an abscess draining an abscess


Nursing Interventions:Nursing Interventions:Provide bed rest if ruptured cysts and Provide bed rest if ruptured cysts and bleeding occurbleeding occurAdminister antihypertensives as Administer antihypertensives as prescribedprescribedPrepare the client for dialysis or renal Prepare the client for dialysis or renal transplantationtransplantationEncourage the client to seek genetic Encourage the client to seek genetic counselingcounseling

Renal TumorsRenal Tumors

Renal TumorsRenal TumorsKidney tumors may be benign or malignant, Kidney tumors may be benign or malignant, bilateral or unilateralbilateral or unilateral

Common sites of metastasis include the: Common sites of metastasis include the:

bone bone

lungs lungs

liver, spleen liver, spleen

other kidneyother kidney

The exact cause of renal carcinoma is unknownThe exact cause of renal carcinoma is unknown

Accounts for 3% of U.S. cancer deathsAccounts for 3% of U.S. cancer deaths

Renal TumorsRenal TumorsRisk FactorsRisk Factors

Male sex Male sex

Increased BMI Increased BMI

Tobacco useTobacco use

ManifestationsManifestations

Painless gross hematuria Painless gross hematuria

Dull flank pain Dull flank pain

Palpable renal mass in flankPalpable renal mass in flank

Renal TumorsRenal TumorsSurgical and Medical Management Surgical and Medical Management

Radical nephrectomyRadical nephrectomy, involve removal of , involve removal of the entire kidney, adjacent adrenal gland, the entire kidney, adjacent adrenal gland, and renal artery and vein and renal artery and vein

Laparoscopic nephrectomyLaparoscopic nephrectomy, and , and partial partial nephrectomy nephrectomy

Renal artery embolizationRenal artery embolization

Palliative radiation therapy Palliative radiation therapy

Use of chemotherapy is limitedUse of chemotherapy is limited

Renal TumorsRenal Tumors

Kidney SurgeryKidney SurgeryPreoperative considerationsPreoperative considerationsPerioperative concernsPerioperative concernsPostoperative managementPostoperative management– Potential hemorrhage and shockPotential hemorrhage and shock– Potential abdominal distention and paralytic Potential abdominal distention and paralytic

ileusileus– Potential infectionPotential infection– Potential thromboembolismPotential thromboembolism

Renal TumorsRenal TumorsPostoperative Nursing ManagementPostoperative Nursing Management

Assessment: Assessment: include all body systems, pain, include all body systems, pain, fluid, and electrolyte status; patency and fluid, and electrolyte status; patency and adequacy of urinary drainage systemadequacy of urinary drainage system

Nursing Diagnoses:Nursing Diagnoses: ineffective airway ineffective airway clearance, ineffective breathing pattern, acute clearance, ineffective breathing pattern, acute pain, fear and anxiety, impaired urinary pain, fear and anxiety, impaired urinary elimination, and risk for fluid imbalanceelimination, and risk for fluid imbalance

Complications: Complications: bleeding, pneumonia, bleeding, pneumonia, infection, and DVTinfection, and DVT


Monitor vital signsMonitor vital signs

Monitor abdomen for distention caused by Monitor abdomen for distention caused by bleedingbleeding

Monitor for hypotension, decreases in urinary Monitor for hypotension, decreases in urinary output, and alterations in level of output, and alterations in level of consciousness as indicating signs of consciousness as indicating signs of hemorrhagehemorrhage

Monitor for signs of adrenal insufficiencyMonitor for signs of adrenal insufficiency

In clients with In clients with adrenal insufficiencyadrenal insufficiency, a large , a large urinary output followed by hypotension and urinary output followed by hypotension and subsequent oliguria occurs subsequent oliguria occurs


Administer fluids and packed red blood cells Administer fluids and packed red blood cells intravenously as prescribedintravenously as prescribed

Monitor intake and output and daily weightMonitor intake and output and daily weight

Monitor for a urinary output of 30 to 50 ml an Monitor for a urinary output of 30 to 50 ml an hour to ensure adequate renal function hour to ensure adequate renal function

Monitor urine for specific gravityMonitor urine for specific gravity

Maintain semi-Fowler positionMaintain semi-Fowler position

Monitor for signs of respiratory complications Monitor for signs of respiratory complications related to surgeryrelated to surgery


Encourage coughing and deep-breathing Encourage coughing and deep-breathing exercises exercises

Monitor bowel sounds for paralytic ileusMonitor bowel sounds for paralytic ileus

Apply antiembolism stockings as prescribedApply antiembolism stockings as prescribed

Do not irrigate (unless specifically prescribed) Do not irrigate (unless specifically prescribed) or manipulate the nephrostomy tube if in placeor manipulate the nephrostomy tube if in place

Administer pain medications as prescribedAdminister pain medications as prescribed

Renal TumorsRenal TumorsPatient TeachingPatient Teaching

Instruct both patient and family about:Instruct both patient and family about:Care of drainage systemCare of drainage systemStrategies to prevent complicationsStrategies to prevent complicationsSigns and symptomsSigns and symptomsFollow-up careFollow-up careFluid intakeFluid intakeHealth promotion and health screeningHealth promotion and health screening

Renal and Bladder Renal and Bladder TraumaTrauma

Renal & Bladder TraumaRenal & Bladder Trauma

May be classified on the basis of theMay be classified on the basis of the

Mechanism of the injury Mechanism of the injury

1. Blunt injuries 1. Blunt injuries

2. Penetrating injuries (stabbing, gunshot 2. Penetrating injuries (stabbing, gunshot wound or other objects piercing)wound or other objects piercing)

Location or severity of the injury.Location or severity of the injury.

1.1. Minor renal and bladder traumaMinor renal and bladder trauma

2.2. Major renal and bladder traumaMajor renal and bladder trauma

3.3. Critical renal and bladder traumaCritical renal and bladder trauma

Renal and Bladder TraumaRenal and Bladder Trauma

A A fractured pelvisfractured pelvis that causes bone that causes bone fragments to puncture the bladder is the fragments to puncture the bladder is the most common cause of bladder traumamost common cause of bladder trauma

A A blunt traumablunt trauma causes compression of causes compression of the abdominal wall causing hemorrhage the abdominal wall causing hemorrhage and destruction of kidney, ureter and and destruction of kidney, ureter and bladderbladder

Renal and Bladder TraumaRenal and Bladder TraumaAssessment:Assessment:

Anuria, hematuria Anuria, hematuria

Pain over the costovertebral area Pain over the costovertebral area (kidney trauma)(kidney trauma)

Pain over the lower abdomen radiating Pain over the lower abdomen radiating to the shoulder (Bladder trauma)to the shoulder (Bladder trauma)

Nausea and vomitingNausea and vomiting

Renal and Bladder TraumaRenal and Bladder TraumaNursing Interventions:Nursing Interventions:

Monitor vital signsMonitor vital signs

Monitor for hematuria, hemorrhage, and Monitor for hematuria, hemorrhage, and signs of shocksigns of shock

Promote bed restPromote bed rest

Monitor pain levelMonitor pain level

Prepare the client for insertion of a Prepare the client for insertion of a suprapubic catheter to aid in urinary drainage suprapubic catheter to aid in urinary drainage if prescribedif prescribed

Prepare the client for surgical repair of the Prepare the client for surgical repair of the laceration if prescribedlaceration if prescribed

Bladder CancerBladder Cancer


Most common site of cancer of the Most common site of cancer of the urinary tract (72%)urinary tract (72%)

Occurs in men 3 times more often than Occurs in men 3 times more often than women women

Peak age 50-70 years oldPeak age 50-70 years old

54,000 new cases/year….12,000 54,000 new cases/year….12,000 deaths/yeardeaths/year

Multi-focal and recurrent: 75% chance Multi-focal and recurrent: 75% chance will reoccurwill reoccur

Bladder CancerBladder CancerHallmark sign: Hallmark sign:

- Painless hematuria immediately on - Painless hematuria immediately on voidingvoiding

Predisposing Factors:Predisposing Factors:

Strong correlation with cigarette smokingStrong correlation with cigarette smoking

Exposure to chemicals (especially Exposure to chemicals (especially aniline dyes, chemicals used in paint, aniline dyes, chemicals used in paint, rubber, textiles, electrical cables)rubber, textiles, electrical cables)

Chronic bladder infectionsChronic bladder infections

Bladder CancerBladder CancerAssessment Findings:Assessment Findings:

Intermittent painless hematuria Intermittent painless hematuria

Dysuria Dysuria

Frequent urinationFrequent urination

Diagnostic Tests:Diagnostic Tests:

Cystoscopy with biopsy reveals Cystoscopy with biopsy reveals malignancymalignancy

Cytologic exam of the urine reveals Cytologic exam of the urine reveals malignant cellsmalignant cells

Bladder CancerBladder CancerMedical Management:Medical Management:

Dependent on the staging of cell typeDependent on the staging of cell type

1. Radiation Therapy1. Radiation Therapy

Usually in combination with surgeryUsually in combination with surgery

Radiation involves several cycles until Radiation involves several cycles until the mass shrinks to almost normal sizethe mass shrinks to almost normal size

Recurrence is common after a few Recurrence is common after a few months to years of completing therapymonths to years of completing therapy


2. 2. ChemotherapyChemotherapy

A. Methods include direct bladder A. Methods include direct bladder instillations, intra-arterial infusions, IV instillations, intra-arterial infusions, IV infusion, oral ingestioninfusion, oral ingestion

B. Agents include 5-fluorouracil, B. Agents include 5-fluorouracil, methotrexate, bleomycin, mitomycin-C methotrexate, bleomycin, mitomycin-C hydroxyurea, doxorubicin, hydroxyurea, doxorubicin, cyclophosphamide, cisplatincyclophosphamide, cisplatin


3. 3. Bladder Surgery Bladder Surgery Superficial: treated with excision and Superficial: treated with excision and chemotherapychemotherapyInvasive: treated with cystectomy Invasive: treated with cystectomy (removal of bladder) with radiation and (removal of bladder) with radiation and chemotherapychemotherapy


4. 4. Prophylactic immunotherapyProphylactic immunotherapy: : instillation of instillation of bacille Calmette-Guerin bacille Calmette-Guerin (used to vaccinate for TB in some (used to vaccinate for TB in some countries) used to prevent tumor countries) used to prevent tumor recurrence of superficial tumorsrecurrence of superficial tumors

Nursing Interventions:Nursing Interventions:

Provide care for the client receiving Provide care for the client receiving radiation therapy or chemotherapy and radiation therapy or chemotherapy and bladder surgerybladder surgery

THE ENDTHE END

THANK YOU!THANK YOU!CONGRATULATIONS!CONGRATULATIONS!

GUT Part 4- ARF, CRF and Other Disorders

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Transcript of GUT Part 4- ARF, CRF and Other Disorders