MEDSURGII: RENAL FAILURE

diuretic phase

when kidneys start to recover inc in UOP electrolyte depletion d/t fluid loss hypovolemia/hypotension

clinical mani of integumetary

yellow skin pruritis, dry skin, uremic frost (ammonia on skin) petechiae and bruising

hemodialysis

3 days/wk, 3-4hrs assess before: thrill, bruit, fluid status, BP, weight, lung/heart sounds, edema, elect assess after: elect, bun, creat, fluid status (HA, confusion, heart/lung, BP), bleeding, meds

kidney failure GFR

<15

normal GFR

>90, most important indicator of a problem

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The intended outcome of this diet is to:

Act as a diuretic. Reduce demands on the liver. Help maintain urine acidity. Prevent the development of ketosis.!

causes of post renal failure

BPH, prostate/bladder cancer, calculi, trauma

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?

Blood urea nitrogen (BUN) level of 22 mg/dl (1.2 mmol/L) Serum creatinine level of 1.2 mg/dl (0.1 mmol/L) Temperature of 100.2° F (37.8° C) Urine output of 250 ml/24 hours!

A client with acute renal failure has the following laboratory results: Hemoglobin 9.2 g/dL Blood urea nitrogen 22 mg/dL Creatinine 0.7 mg/dL Potassium 4.8 mEq/L Based on these findings, which of the following should the nurse administer?

Calcium gluconate Potassium chloride Furosemide Erythropoietin!

ultrafiltration

ECF moves into the dialysate d/t pressure gradient

indications for dialysis

GFR <15 hyperkal metab acid vol overload neuro impairment

diagnostic tests

H&P BUN, creat, na, k, pH, bicarb, HgB, Hct urinanalysis KUB (kid/ureter/blad scan)

A client with chronic renal failure (CRF) has a hemoglobin of 10.2 g/dl and hematocrit of 40%. Which of the following would be a primary finding?

Presence of edema and fluid volume overload Presence of dyspnea and cyanosis Presence of fatigue and weakness! Presence of thrush and circumoral pallor

In the oliguric phase of acute renal failure, the nurse should assess the client for:

Pulmonary edema.! Metabolic alkalosis. Hypotension. Hypokalemia.

function of kidneys

Regulate fluid volume Regulate acid base balance Regulate electrolyte balance Eliminate wastes from the body Influence hormone and immune regulation

When teaching a client with chronic renal failure who is taking antibiotics about signs and symptoms of potential nephrotoxicity to report, the nurse should encourage the client to promptly report which of the following changes in the urine? Select all that apply.

Straw-colored. Cloudy.! Smoky.! Pink.!

A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The physician has ordered 2 units of packed red blood cells (RBCs). Prior to initiating the blood transfusion the nurse should determine if? Select all that apply.

There is an I.V. access with the appropriate tubing and normal saline as the priming solution! There is a signed informed consent for transfusion therapy! Blood typing and cross-matching is documented in the medical record! The vital signs have been taken and documented in accordance with facility policy and procedure! There is the second unit of blood in the medication room The client has an identification bracelet!

A client with acute renal failure is undergoing hemodialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which of the following assessments is the priority?

Vital signs Laboratory values Neurological status! Pain in the flank region

A primary health care provider prescribes regular insulin 10 units intravenously (IV) along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

a) Hypercalcemia b) Hypernatremia c) Hypermagnesemia d) Hyperkalemia!

common cause of acute

acute tubular necrosis

fluid restriction in ARF

add all losses from previous day +additional 600 for insensible loss this amount will be allowed as intake the next day

clinical mani hematologic system

anemia (kids can't do EPO) bleeding tendencies (platelet dysfxn) infection Labs: RBC, H+H, WBC, Fe

onset phase

begins with onset, hours/days

uremia

clinical manifestation of waste accumulation underlying cause of majority of systemic effects

recovery phase

continues until renal function is fully restored and can last 12mos GFR inc

types of peritoneal dialysis

continuous ambulatory PD: pt manually performs exchange, 4 exchanges per day with 4-10hr dwell time automate PD: machine controls exchange during sleep 4-5 exchanges in night, 1-2 day

kidney lab concern

creatinine: >1.2 BUN: >20 K+: >5 HCO: 22-26 GFR: <60

anemia in ARF/CRF

d/t decrease in erythropoietin

common cause of chronic

diabetic nephropathy

intra renal failure

direct damage to kidneys r/t drugs, hypoperf, infection/inflamm

drugs for kid fail

diuretics (vol overload) ACE inhibit/BB (HTN) Epogen (anemia) Kayexelate (hyperkal) Phoslo/Amphojel (bone weakness) vit D/Ca (bone weakness) statins (triglycerides)

drug concerns

drug toxicities digoxin antibodies opioids, nsaids

clinical mani urinary system

early: normal uop progresision: oliguria end stage: anuria urinanalysis: rbc, wbc, protein, glucose measure I/O, daily wt. fluid restrict

treating hyperka in ARF

enhance cellular uptake of K (insulin D50, Na/bicarb) increase excretion of K (kayexelate, dialysis)

collab care of ARF and CRF

fluid restriction manage hyperka nutrition asses need for rrt

nursing dx for CRF

fluid vol excess imbalanced nutrition-less risk for infect risk for injury altered thought process fatigue grieving

nephron

functional unit of kidney

onset of chronic

gradual (months/years)

clinical mani elect imbalance

hyperkalemia sodium-normal or low magnesium-inc metabolic acidosis (can't excrete acid, can't reabsorb HCO)

clinical mani cardio system

inc rick for cardiovasc disease HTN, HF, PE dysrhythms edema uremic pericarditis

azotemia

increased levels of nitrogenous waste products (urea, creatinine)

clinical mani reproductive

infertility dec libido low sprem count sex dysfxn dec estrogen/testosterone

CRF

irreversible loss of kidney fun diabetes/HTN uremia, azotemia

clinical mani of respiratory system

kussmaul dypnea pulm edema uremic pleuritis resp infect

post renal failure

mechanical obstruction to outflow of urine BPH, prostate/bladder cancer, calculi, trauma

cause of intra renal failure

nephrotoxic drugs, prolonged hypo perfusion, infection, inflamm.

clinical mani neuro system

nitrogenous waste products accumulate in brain and cause damage uremic encephalopathy (confusion, stupor, tremor, seiz) peripheral neuropathy parasthesias, twitch, seize, tremor, irritable, confused DIALYSIS

A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 ml. Urine output that's less than 50 ml in 24 hours is known as:

oliguria. polyuria. anuria.! hematuria.

phases of ARF

onset oliguric diuretic recovery

clinical mani musculo system

osteomalacia-bone demineralization osteitis fibrosa- bone softens, become deformed Tx: phosphate binder (phosLo, amphojel) activated Vit D sup (calcitrol)

complications of PD

peritonitis (cloudy outflow, inc WBC, abd pain, GI s/s, Abx tx) exit site infection abd pain/back pain pulm difficulties protein loss

nutrition for kid fail

prevent catabolism high carb, mod fat protein restriction Na/K/Mg/Phos restrict low fluid tube feed/TPN-chronic

erythropoietin

produces RBC

cause of pre renal failure

reduced blood flow to kidneys

clinical mani of GI system

stomatitis GI irritation anorexia N/V uremic fetor (ammonia on breath) malnutrition

dialysis

substances move from blood through a membrane into dialysate peritoneal and hemo

onset of acute

sudden (hours to days)

acute renal failure

sudden interruption of kidney fxn result of obstruction, decreased perf, disease of renal tissue reversible

kidney's job

to excrete urea, creatinine, synthesize and excrete ammonia

goal for ARF

treat underlying cause manage symptoms prevent complications

clinical mani metab disturb

waste product accumulation (N/V, lethargy, tremor, encephalopathy) altered carb metab (insulin resist, hyperinsulinemia) elevated triglycerides (hyperinsulin=more tris, atherosclerosis)

nutritional alterations for dialysis

watch electrolyte, fluid balance, protein, sodium PD: more protein and potassium HD: less protein and potassium

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?

Encourage oral fluids. Administer furosemide (Lasix) 20 mg I.V. Start hemodialysis after a temporary access is obtained. Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose.!

chronic renal failure

gradual, progressive, irreversible loss of renal fxn takes months/years to develop

pre renal failure

happening before the kidney reduction of blood flow to kidneys (hypovolemia/decreased CO) leads to tubular necrosis and ARF

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience:

hematuria. weight loss.! increased urine output. increased blood pressure.

oliguric phase

renal insult UOP less than 400mL/day, inc bun/inc creat, inc K/Mg/Phos, dec Na/Ca metabolic acidosis