Usually develops over hours or days

PROGRESSIVE INC. IN BUN, CREATININE, AND POTASSIUM

 Occurs with or without oliguria Potentially reversible Can take 3 mos. to 1 yr. for kidneys to heal

If ARF does not improve after 1-2 mos. becomes CHRONIC RENAL FAILURE

progressine, IRREVERSABLE destruction of the nephron in BOTH kidneys

Systemic disease involving every organ

W/O dialysis pt. will die within 3 days!

What are the causes of ARF?

Prerenal conditions

(involve hypoperfusion of the kidneys)

Intrarenal Conditions

(Actual damage to the kidney tissue)

Post renal conditions

(Obstruction to urine flow)

Caused by conditions outside kidneys

Due to impaired blood flow

ie. Heart failure, Hypotension, MI, Hemorrhaging, Any condition that results in a loss of cardiac output)

Problem with the kidneys themselves

 Actual parenchymal damage to the glomeruli or kidney tubules

May lead to loss of renal function and/or ACUTE TUBULAR NECROSIS (ATN)

Most common cause of acute renal failure

Ischemic or toxic insult to the nephrons

Often leads to chronic reanl failure (CHF) and End Stage Renal Disease (ESRD)

Causes:

 Burns, Crush Injuries, Infections, ANTIBIOICS (Vancomycin), NSAIDS, ACE inhibitors, X-RAY DYES, Insecticides

Always check BUN, Creatinine, I&O, before giving meds!Increase fluids!!!

Caused by obstruction distal to the kidneys leading to a drop in GFR

Causes:

Urinary Tract Obstruction, Tumors(Prostate and Bladder), BPH, Renal Calculi

Initiation Phase

Oliguria Phase

 Diuresis phase

Recovery Phase

Initial insult until oliguria develops

Identified by changes in lab studies

 Immediate intervention may prevent progression

Changes in Urine Output: <400 ml/24 hrs. (oliguria) or < 50ml./24 hrs (anuria)

Fluid electrolyte abnormalities and uremia occurs

MAY LEAD TO LIFE THREATENING DYSRHYMIAS

 MOST DANGEROUS PHASE

THE LONGER THIS PHASE LASTS, THE POORER THE PROGNOSIS FOR FULL RECOVERY OF KIDNEY FUNTION

Oliguria or anuria

 BUN > 30

Creatinine >1.5,

Hyperkalemia( >5.5)

P & Mg inc. Calcium dec.,

Sodium dec., Protenuria, Fluid volume excess.

Metabolic acidosis, Anemia,

Specific gravity dec. 1.010 (normal 1.015-1.025)

Can last 3 - 12 months

Lab values slowly return to norma;

Pt. extremely fatigued and debilitated

Appears abruptly,

 Dec. in urinary output,

Edema, Protenuria, Azotemia, Anemia, HTN,

May have nausea and vomiting,

 May appear critically ill

EVERY SYSTEM IS AFFECTED

May not appear for 1 week after injury

Careful history (meds, past ARF,trauma, dx. tests involving dye, DM, heart disease, HTN)

 Be aware of meds that are nephrotoxic (ACE inhibitors, NSAIDS, Vancomycin, Anesthesia)

Check BUN & creatinine when giving meds

 Keep pt. hydrated

Prevent UTI's

Maintain fluid balance, Daily weights, I & O, Frequent V/S;lung sounds,

Daily checks of BUN, creatinine, electrolyes,

 fluid intake and loss,

Careful prevention of fluid overload

INTAKE APPROX. 500 + 24 HR. FLUID LOSS OF PREVIOUS DAY

Kayexelate w/ Sorbitol (diarrhea to dec. K)

Glucose w/ insulin and/or calcium gluconate

 (used in an emergency to drive K into cells)

Sodium Bicarbonate

 (neutralized blood pH which drives K into cells)

Diuretics (to reduce fluid volume) Dopamine (low dose to dilate renal arteries)

Atrial natriuretic peptide (Cardiac hormone that inhibits angiotensinII and vasopressin

(causes vasodilation and dec. in BP)

 Aluminium Hydroxide (binds phosphorous)

 O2, cardiac monitoring, critical care

MAY NEED TEMPORARY DIALYSIS

Low protein (limited to 1 gm/kg/day)

 High carbohydrate meals

 Low potassium (40 - 60 mEq/day)

 Low sodium (limited to 2 g/day)

High protein

 High calorie

Support & education for pt. and family

PROBLEMS:

Skin breakdown r/t bedrest, activity intolerance,

 Fatigue

Difficulty breathing

 Dietary and fluid restrictions

Treat like heart failure

Diabetic nephropathy 31%

Hypertension 25%

Glomerulonephritis 18%

Cystic Kidney disease 5%

 Other 21%

When GRF dec.

or creatinine clearance is <5 to 10 ml/min.

or when symptoms of CRF inc.

Hyperkalemia - glucose & insulin,

calcium gluconate, low K foods

Anemia-  Epogen (erythropoiten SQ)

Renal osteodystrophy -

Aluminum Hydroxide to dec. Phosphorous

HTN control w/ ACE Inhibitors and/or

calcium cjhannel blockers

dec. calcium levels,inc. phosphorous levels, abnormal vitamin D levels, 

elevated aluminum levels 

aluminum antacids to bind Phosphorous and inc. calcium levels or Calcium Carbonate (Give w/ food) CHF,pulmonary edema

 fluid restrictions, dec. Na, diuretics, digoxin

Regulate proteins, fluids, Na, and K

Give high density proteins

Restrict proteins pre-dialysis;

once in dialysis may have protein intake inc.

 Fluids - 500-600ml greater than previous day's output

Blood is removed fromarterial end

& returned to venous end

Requires shunts, grafts, or fistulas

 must "mature" before use (2-6 wks)

 Takes 3 - 8 hrs. 3 x/wk.

What are the nursing considerations

for a patient on hemodialysys?

Bruit

Thrill

Neurovascular assessment

 NO BLOOD PRESSURE OR

BLOOD DRAWS FROM GRAFT SITE!!!

What are the complications of

Hemodialysis?

Hypotension (nausea, vomiting;tachycardia, dizziness)

 Painful muscle cramps (due to fluid shift)

Exsanguination (bleeding),

Dysrhythmias

 DIALYSIS DISEQUILIBRIUM SYNDROME

What are the S/S of

Dialysis Disequilibrium syndrome?

Cerebral fluid shifts

Headache,

 nausea vomiting,

restlessness,

decreased LOC

What is Continuous Ambulatory

Petitoneal Dialysis (CAPD)?

Inserted in to peritoneal cavity of the abdomen

Can be done at home

 req. lots of pt. ed.

 Takes about 1 hour

(inflow 10 min. dwell 30 min. drain 20 min)

 every 4 hrs.

Same pts. can dwell overnight

ADL's can be carried out between exchanges

INFECTION (Peritonits) #1 complication!!

Hygiene

 Observe for cloudy Dialystate return

(NOTIFY PHYSICIAN IMMEDIATELY)

Effluent or Dialysate should be clear or yellow and slightly frothy

(first few times may be bloody)

 CLOUDY IS SIGN OF INFECTION!!!

Slow gentle dialysis

Arterial blood passes through a small dialyser

works by convection

Mean artrial pressure of 60 is needed

 Only done in critical care areas

What is the Nursing Care/

 Assessment with Dialysis?

Assess for:

 Other chronic diseases,

Episodes of hypotension,

 Meds or dietary substitutes that may be toxic to the kidneys

Compliance w/ therapy

Lifestyle and social/job concerns

 Assess for recent abdominal surgery or trauma

Head to toe Assessment

What are the nursing care

outcomes for a pt. on dialysis?

Reestablishes and maintaines "dry" weight

Adheres to fluid and diet restrictions

Uses measures to protect access device

 and be safe from injury

Remains infection free

Fluid volume regulation - CHF

 Skin care - Pruitis

Dietary support

Comfort/Rest

 Prevention of injury & infection - osteporosis

Emotional support

 Patient and family education

HOLD MEDS UNTIL AFTER

HEMODIALYSIS ESP. HTN MEDS!!!

Rejection is #1 problem

Acute -

usually reversible

Signs: Inc. BUN and Creatinine, fever, weight gain, dec. urine output blood pressure inc and tenderness over transplanted kidney

Chronic :

over months to years, irreversible, no treatment

Other problems:

Infection, HTN, Malignancies, Recurrence of kidnay disease, Atherosclerosis,

Asceptic bone necrosis - due to steroids