Chapter 44 Management of Patients With Renal Disorders

Management of Patients
With Renal Disorders
Renal Disorders
• Fluid and electrolyte imbalances
• Most accurate indicator of fluid loss or gain in
an acutely ill patient is weight
Causes of Acute Renal Failure
Reduced cardiac output and heart failure
Obstruction of the kidney or lower urinary
• Obstruction of renal arteries or veins
Acute Renal Failure:
Is a sudden and almost complete loss of kidney function ( decreased GFR)
normal urine volume.
Categories of ARF:
Prerenal: as a result of impaired blood flow to the kidney
Interrenal: as a result of actual parenchymal damage to the
glomeruli and kidney tubule.
Post renal: as a result of obstruction somewhere distal to
the kidney, such as Ureterovesical reflux.
Phases of ARF:
Initial period: begins with initial insult
The oliguria period( less than 400ml/day): Characterized by
increase serum urea, creatinine, K, uric acid, organic acids,
and magnesium. The uremic symptoms first appears which
is life-threatening such as Hyperkalemia.
The diuresis period: gradually increasing urine output, lab
values stop rising and start to decrease
The recovery period: signals the improvement of renal
function and may take 3-12 months, lab results return to
the normal levels
Clinical manifestations:
• Oliguria, anuria (less than 50 ml/day), or normal urine
output are not as common.
• Increased serum creatinine, and BUN level
• Pt may appear critically ill and lethargic, with nausea,
vomiting, and diarrhea.
• Skin and mucous membrane are dry from dehydration
and the breath may have the odor of the urine (uremic
• Drowsiness, headache, muscle twitching, and seizures
Assessment and diagnostic findings:
Changes in the urine
Changes in the kidney contour ( ultrasound)
Increase BUN and creatinine levels
Hyperkalemia, hypocalcemia,
• Anemia
• Metabolic acidosis
Medical management:
• Manage fluid and electrolyte imbalance
• Diuretics may be given
• Adequate blood flow to the kidney ( by low doses of dopamine 1-3
• Dialysis may be initiated to prevent serious complications of ARF
• Treat Hyperkalemia:
1. administer Kayexalate ( orally or by retention edema)
2. intravenouse glucose and insulin or calcium gluconate
3. sodium bicharbonate to elevate plasma PH which cause potassium to
move into the cell.
4. Finally decrease the dietary intake of potassium
• Correction of Acidosis and elevated phosphorus level ( by aluminum
hydroxide---- phosphate binding agent)
• Nutritional therapy
Nursing Management
Monitor fluid and electrolyte balance
Reduce metabolic rate
Promote pulmonary function
Prevent infection
Provide skin care
Provide support
Chronic renal failure:
• Or ESRD is a progressive irreversible
deterioration in renal function in which the
body’s ability to maintain metabolic and fluid
and electrolyte balance fails, resulting in
uremia or azotemia ( retention of urea and
other nitrogenous wastes in the blood)
• May caused by systemic disease such as DM,
hypertension, chronic glomerulonephritis…
Causes of Chronic Renal Failure
Diabetes mellitus
Chronic glomerulonephritis,
Pyelonephritis or other infections
Obstruction of urinary tract
Hereditary lesions
Vascular disorders
Medications or toxic agents
Clinical manifestations:
• Neurologic: Weakness, fatigue, confusion, inability to concentrate,
tremors, seizures, behavior changes
• Integumentary: gray-bronze color skin, dry, pruritis, ecchymosis, thin
brittle nails
• Cardiovascular: hypertension, pitting edema, periorbital edema,
pericardial friction rub, engorged neck veins, pericarditis, pericardial
effusion, hyperkalemia, hyperlipidemia
• Pulmonary: signs of pulmonary edema
• Gastrointestinal: Ammonia odor to breath, mouth ulceration and
bleeding, anorexia, constipation or diarrhea
• Hematology: anemia
• Musculoskeletal: muscle cramps, loss of muscle strength, bone pain,
bone fracture
Assessment and diagnostic findings
GFR: by obtaining a 24 hr urine collection for
creatinine clearance.
• Na and water retention
• Acidosis
• Anemia
• Ca and Ph imbalance
• Complications:
1. Hyperkalemia
2. Hypertension
3. anemia, Bone disease
Medical management:
• Antacids: To treat hyperphosphatemia and hypocalcemia
(Aluminum-based antiacide bind with phosphorus in the
GI tract)
• antihypertensive cardiovascular agents
• Antiseizure agents
• Erythropoietin
• Nutritional therapy
• Dialysis
Glomerular Diseases
An inflammation of the glomerular capillaries
Acute nephritic syndrome
Chronic glomerulonephritis
Nephrotic syndrome
Acute Glomerulonephritis:
• Is inflammation of the glomerular capillaries.
• Is primarily disease of children older than 2 yrs, but
can appear at nearly any age
• Pathophysiology: Throat infection with hemolytic
sterptococcal, acute viral infection (upper RTI,
mumps, hepatitis B), and antigens outside the body
such as medications, foreign serum
Clinical manifestation:
1. Hematuria (primary feature),
2. Cola-colored appearance of the urine (RBC’s, protein
3. Proteinuria, BUN and serum creatinine levels may rises as
urine output drops
4. The patient may be anemic, edema and hypertension,
headache, malaise, and flank pain
Elderly pt. may c/o circulatory overload with dyspnea,
engorged neck veins, cardiomegaly and pulmonary edema.
Sequence of Events in
Acute Glomerulonephritis
Assessment and diagnostic findings:
Kidneys become large, swollen, and congested
Kidney biopsy
Elevated serum IgA
Hypertensive Encephalopathy,
heart failure,
pulmonary edema
Medical management
Corticosteroids and immunosuppressant medication,
Dietary protein is restricted when renal impairment developed
Sodium restriction (in hypertensive Pt, edema, and heart failure)
Loop diuretics
Antihypertensive medication may given.
Nursing Management:
Give enough CHO to reduce catabolism of protein
education for safe and effective self-care at home
Chronic Glomerulonephritis
• Causes include repeated episodes of acute
glomerular nephritis, hypertensive
nephrosclerosis, hyperlipidemia, and other
causes of glomerular damage.
• Symptoms vary; may be asymptomatic for years,
as glomerular damage increases, before signs and
symptoms develop of renal insufficiency/failure.
• Abnormal laboratory tests include urine with
fixed specific gravity, casts, and proteinuria; and
electrolyte imbalances and hypoalbuminemia.
• Medical management is determined by
Nursing Management Chronic
Potential fluid and electrolyte imbalances
Cardiac status
Neurologic status
Emotional support
Teaching self-care
Renal Failure
• Results when the kidneys cannot remove
wastes or perform regulatory functions
• A systemic disorder that results from many
different causes
• Acute renal failure is a reversible syndrome
that results in decreased GFR and oliguria
• Chronic renal failure (ESRD) is a progressive,
irreversible deterioration of renal function
that results in azotemia
Nursing Process: The Care of the Patient
with Renal Failure—Assessment
Fluid status
Nutritional status
Patient knowledge
Activity tolerance
Potential complications
Nursing Process: The Care of the Patient
with Renal Failure—Diagnoses
Excess fluid volume
Imbalanced nutrition
Deficient knowledge
Risk for situational low self-esteem
Collaborative Problems/Potential
Pericardial effusion
Pericardial tamponade
Bone disease and metastatic calcifications
Nursing Process: The Care of the Patient
with Renal Failure—Planning
• Goals may include maintaining of IBW without
excess fluid, maintenance of adequate
nutritional intake, increased knowledge,
participation of activity within tolerance
improved self-esteem, and absence of
Excess Fluid Volume
• Assess for signs and symptoms of fluid volume
excess, and keep accurate I&O and daily weights
• Limit fluid to prescribe amounts
• Identify sources of fluid
• Explain to patient and family the rationale for the
• Assist patient to cope with the fluid restriction
• Provide or encourage frequent oral hygiene
Imbalanced Nutrition
• Assess nutritional status; weight changes and lab data
• Assess patient nutritional patterns and history; note food
• Provide food preferences within restrictions
• Encourage high-quality nutritional foods while
maintaining nutritional restrictions
• Assess and modify intake related to factors that
contribute to altered nutritional intake, eg, stomatitis or
• Adjust medication times related to meals
Risk for Situational Low Self Esteem
• Assess patient and family responses to illness
and treatment
• Assess relationships and coping patterns
• Encourage open discussion about changes and
• Explore alternate ways of sexual expression
• Discuss role of giving and receiving love,
warmth, and affection
Is the process used to remove fluid and uremic waste products from the body
when the kidneys are unable to do so.
Acute dialysis: is indicated when there is a high and rising level of serum
potassium, fluid overload, impeding pulmonary edema, increased acidosis,
pericarditis, and sever confusion. May also used to remove toxin from the
Chronic or maintenance dialysis: is indicated in ESRD, in the presence of
uremic signs and symptoms affecting all the body systems ( nausea,
vomiting, sever anorexia, increasing lethargy, mental confusion).
Hyperkalemia, fluid overload not responsive to diuretics and fluid
The objective of Hemodialysis are
1. to extract toxic nitrogenous substances from the blood
2. and to remove excess water.
Indicated for:
1. the patient who are acutely ill and require short-term
dialysis (day to weak)
2. and for patient with ESRD who require long-term or
permanent therapy.
A dialyzer or artificial kidney serves as a synthetic,
semipermeable membrane.
Hemodialysis System
Principles of Hemodialysis:
1.Diffusion principle: dialysate ( is a solution
made up of all the important electrolytes in
their ideal Extracellular concentrate.
2.Osmosis principle:
3.Ultrafiltration principle
• A predialysis assessment include: patient’s
history and clinical findings, response to
previous dialysis treatment, and laboratory
• Evaluates fluid balance before dialysis
treatment so that corrective measures may be
initiated at the beginning of the procedure:
blood pressure, pulse, Wt, intake and output,
tissue turgor, dry Wt or ideal WT
• Check the equipment
• Access to the circulation is gained by inserting two large
gauge needles to a graft or fistula
• Blood being to flow through the tubing, assisted by the
blood pump
• A clamped saline bag always is attached to the circuit,
just before the blood pump to use it if hypotension
• Heparin infusion can be attached to the circuit
• Blood flows into the compartment of the dialyzer, where
exchange of fluid and waste products takes place
• Blood leaving the dialyzer passes through an air detector
that shuts down the blood pump if any air is detected
• After the located time finished, dialysis is terminated by
clamping off blood from the patient, opening the saline
line, and rinsing the circuit to return the patient’s blood
• The nurse should monitor, support, assessing, and
educating the patients.
Vascular Access:
Subclavian, internal Juglar, and femoral catheter (venous
Arteriovenous Fistula: created surgically, provide long-term
access for hemodialysis, the fistula takes 4-6 weeks to
mature before it is ready for use, the patient instructed to
perform exercise to increase the size of these vessels,
venipunctures is contraindicated in the arm with fistula,
assess for the thrill.
Hemodialysis Catheter
3. Synthetic graft:
• An arteriovenous graft can be created by subcutaneously
interposing a biological, semibiologic, or synthetic graft
material between an artery and vein
• The graft is created when the patient’s vessels are not
suitable for a fistula ( DM)
• Graft usualy placed in the forearm, upper arm, or upper
• Complication such as thrombosis, infection, aneurysm
formation and stenosis at the site of anastomosis are
more frequent than fistula
Internal Arteriovenous Fistula and Graft
Complication of Hemodialysis:
Atherosclerotic cardiovascular disease an, Angina and
Disturbance of lipid metabolism (hypertriglyceridemia)
Peripheral vascular insufficiency
Gastric ulcer
Disturbed calcium metabolism that lead to bone pain and
1. Sleep problem
2. Fluid overload, malnutrition, infection, neuropathy and
3. Hypotension, nausea, vomiting, Dysrhythmias, chest
4. Painful muscle cramping
5. Air embolism
6. Dialysis disequilibrium result from cerebral fluid shift (
headache, nausea, vomiting, restlessness, decrease
level of consciousness and seizures
Long term management for Hemodialysis:
Pharmacologic therapy: the dosage of medications need to
adjust for patient undergoing hemodialysis and monitored closely to
ensure that blood and tissue levels of these medications are
maintained without toxic accumulation.
Example are antihypertensive medication which should not be taking at
the day of dialysis to prevent hypotension.
II. Nutritional and fluid therapy:
To minimize uremic symptoms and fluid and electrolyte imbalances.
To maintain good nutrition status through adequate protein calories,
vitamin, and minerals intake
3. To enable patient to eat a palatable and enjoyable diet.
Protein intake should be restricted to about 1 g/kg ideal
body wt/day, High biologic quality protein ( contain
essential amino acids) should be taken ( eggs, milk, meat,
poultry, and fish)
Sodium is usually restricted to 2-3 g/day
Fluids are restricted to amount equal to the urine output
plus 500ml to keep interdialytic wt gain under 1.5 kg.
Potassium restriction ( Average 1.5 to 2.5 g/day).
Nursing Management of the Hospitalized
Patient on Dialysis
• Protect vascular access; assess site for patency and signs of potential
infection, and do not use it for blood pressure or blood draws
• Monitor fluid balance indicators and monitor IV therapy carefully; keep
accurate I&O and IV administration pump records
• Assess for signs and symptoms of uremia and electrolyte imbalance;
regularly check lab data
• Monitor cardiac and respiratory status carefully
• Monitor blood pressure; antihypertensive agents must be held on
dialysis days to avoid hypotension
• Monitor all medications and medication dosages carefully;
avoid medications containing potassium and magnesium
• Address pain and discomfort
• Implement stringent infection control measures
• Monitor dietary sodium, potassium, protein, and fluid;
address individual nutritional needs
• Provide skin care: prevent pruritus; keep skin clean and well
moisturized; trim nails and avoid scratching
Nursing Management:
I. Meeting psychosocial needs: Give the patient and their Families
the opportunity to express feelings of anger and concern over the
limitations that disease and treatment impose.
• Treatment of depression with antidepressant agents
• Referring the pt and family to clinical nurse specialists, and
• Assess noncompliant pt for the impact of renal failure and it’s
treatment on the pt and family and the coping strategies that may use
• Helps pt to identify safe, effective coping strategies to cope with everpresent problems and fears
II. Teaching patient self care:
III. Teaching patient about Hemodialysis
IV. Continuing care.
The five E’s: Bridges to Renal rehabilitation:
1. Encouragement,
2. Education,
3. Exercise,
4. Employment, and
5. Evaluation
Peritoneal Dialysis:
The goals are to remove toxic substances and
metabolic wastes and to reestablish normal fluid and
electrolyte balance.
May be treatment of choice for:
Patient with renal failure who are unable or unwilling
to undergo hemodialysis or renal transplantation.
An initial treatment for renal failure while patient is
being evaluated for a hemodialysis program, or when
access to the blood stream is not possible
3. Patient who are susceptible to the rapid fluid,
electrolyte, and metabolic changes that occur during
hemodialysis ( pt with DM, Cardiovascular diseases,
older patients, and those who may be at risk for
adverse effects of systemic heparin).
4. Pt with sever hypertension, congestive heart failure, and
pulmonary edema ( not responsive to usual treatment
Peritoneal Dialysis
Peritoneal Dialysis
Principles underlying peritoneal dialysis:
• In peritoneal dialysis, the peritoneal serves as the
semi permeable membrane ( provide about 22,000
square cm surface area)
• Sterile dialysate fluid is introduced into the
peritoneal cavity through an abdominal catheter at
• Urea, creatinine, metabolic end products are cleared
from the body by diffusion and osmosis
• It is usually takes 36-48 hours to achieve with peritoneal
dialysis what hemodialysis achieve in 6-8 hours
• Urea is cleared at rate of 15-20 ml/min where creatinine is
removed more slowly
• Ultrafiltration (water removal) occurs in peritoneal dialysis
through an osmotic gradient created by using a dialysate
fluid with dextrose concentration.
• Prepare the patient for catheter insertion and the dialysis procedure by
giving a thorough explanation of the procedure
• Consent form may be signed according to hospital policy
• Assess the pt’s anxiety, and provide support instruction
• Take the pat’s history, identifying abdominal surgery or trauma
• Examine the abdomen before the catheter is inserted.
• Ask the patient to empty the bladder and bowel just before the procedure
to avoid accidental puncture with the trocar
• Give a preoperative medication, as ordered, to enhance relaxation during
the procedure
• Broad spectrum antibiotic agent may be given to prevent
• Take and record baseline vital signs and body wt
• Warm the dialyzing fluid to body temperature or slightly
warmer to prevent hypothermia, increase urea clearance,
prevent abd pain, and dilate the vessels of the peritoneum.
• Prepare the proper concentration of dialysate and the
medication to be added ( Heparin, Potassium chloride,
antibiotic, and insulin may be added) as doctor order
Immediately before initiating the dialysis, the nurse
assembles the administrating set and tubing. The tube is
filled with the prepared dialysate to reduce the amount of
air entering the peritoneal cavity.
Preparation of equipment:
1. Peritoneal dialysis administration set,
2. peritoneal dialysis catheter set,
3. Trocar set, and
4. medication such as heparin, local anesthesia, KCL, and
broad spectrum antibiotics
Performing the exchange:
• Peritoneal dialysis involves a series of exchanges or cycles. This cycle is
repeated through the course of the dialysis which varies from 12-36 hours
1. Infusion phase: the dialysate is infused by gravity into the peritoneum.
Period about 5-10 min is usually required to infuse 2 L of fluid.
2. Dwell or equilibrium phase: is the time allows diffusion and osmosis
to occur.
3. Drainage phase: the tube is unclamped and the solution drains from
the peritoneal cavity by gravity through closed system. Usually completed
in 10-30 min. the drainage fluid is normally colorless or straw-colored and
should not be cloudy
• The entire cycle (exchange) takes 1 to 4 hours, depending
on the prescribed dwell time
• The removal of excess water is achieved by using a
hypertonic dialysate with a high dextrose concentration
that creates an osmotic gradient (1.5%, 2.5% and 4.25%
are available in several volumes from 500-3000ml).
Maintain accurate records of intake and output, and
Monitor BP and pulse frequently. Orthostatic blood
pressure changes, and increased pulse rate are
valuable clues that help the nurse evaluate the pt’s
volume status
Detect S/S of peritonitis early ( low-grade fever, diffuse
abd pain, rebound tenderness, and cloudy peritoneal
Maintain sterility of the peritoneal system
Detect and correct technical difficulties early
• Prevent constipation which decreases the clearance of
waste product and cause the patient more discomfort
• Assess for the presence of complications
1. Peritonitis ( inflammation of the peritoneum) : most
2. Leakage:
3. Bleeding
4. Long-term complications: abdominal hernia,
hypertriglyceridemia, cardiovascular diseases, low back
pain, and anorexia
Nursing Management of the
Hospitalized Patient on Dialysis (1 of 2)
• Protection of vascular access; assess site for patency and
signs of potential infection, and do not use for blood
pressure or blood draws.
• Monitor fluid balance indicators and monitor IV therapy
carefully; accurate I&O, IV administration pump.
• Assess for signs and symptoms of uremia and electrolyte
imbalance; regularly check lab data.
• Monitor cardiac and respiratory status carefully.
• Hypertension: monitor blood pressure, antihypertensive
agents must be held on dialysis days to avoid
Nursing Management of the
Hospitalized Patient on Dialysis (2 of 2)
• Monitor all medications and medication dosages carefully.
Avoid medications containing potassium and magnesium.
• Address pain and discomfort.
• Stringent infection control measures.
• Dietary considerations: sodium, potassium, protein, and
fluid; address individual nutritional needs.
• Skin care: pruritis is a common problem; keep skin clean
and well moisturized, and trim nails and avoid scratching.
• CAPD catheter care.

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