Final lecture
Acute and Chronic Kidney failure &
management
Student learning objectives
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Compare the patho/causes of ARF & CKD
Prioritize nursing care for pts with AKI/ CKD
Understand pre & post care of dialysis patients
Teach importance of adherence therapy for post
transplant patients, and community resources
available for self-management
Discuss the mechanism of peritoneal dialysis and
hemodialysis as a therapy
Discuss interventions to prevent AKI & CKD
Collaborate care with other health care team to
↓risk of infection and injury
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Acute Renal failure or
acute kidney injury
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Pathophysiology
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Types
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r/t ↓perfusion, damage or obstruction
Prerenal
Intrarenal
Postrenal
Prerenal azotemia/uremia
Causes (see table 68-4) many
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Hypovolemic shock
Heart failure
Sepsis
Pyelonephritis
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ARF cont..
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Rapid decrease in kidney function leads to
collection of metabolic wastes in the body
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More prevalent in hospitalized pts up to 40%
Can be transient, nurses role is critical
Monitor oliguria/azotemia, kf & diagnostics
Interventions critical in care:
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Maintain bp (MAP 65), monitor wt, edema, UO
Monitor electrolytes, hydration/replacement
• Diuretics use, fluid bolus, calcium CB
• Catabolism or protein breakdown/ prevent muscle
• Enteral or parenteral
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Dialysis- continuous vs intermittent
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Acute renal failure cont..
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Continuous dialysis
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Only in icu/ different methods
special training for HD nurse
Acute syndrome may be reversible with
prompt interventions
10% of pts require chronic dialysis/ transplant
Follow up care require
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Frequent medical visits, blood/urine test, diet
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Acute/vs chronic KD
characteristics
Acute
 Onset- sudden
 Nephron involvement- 5095%
 Duration- may not
progress/ full recovery
possible
 Prognosis- good when kf
is maintained or returned,
high mortality with long
illness or dialysis
Chronic
 Gradual months to years
 Vary by stage,
symptomatic >75% loss
&dialysis with >90%
 progressive and
permanent
 Fatal without dialysis,
reduced life span,
complex issues even with
optimal treatment.
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Chronic kidney disease
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Terms to understand
GFR- direct measurement, what is normal GFR?
Azotemia- buildup of nitrogen-based waste
Uremia
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Uremic syndrome
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azotemia with clinical manifestations of
Metallic taste, anorexia, n/v, itching/uremic “frost” on the
skin, edema, dyspnea, muscle cramps, hiccups
The systemic clinical & laboratory manifestations
of end stage kidney disease
Renin- angiotensin- aldosterone function
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Etiology/Genetic Risk
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The causes are complex >100 dx process
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Incidence/prevalence
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Two main cause of dialysis are HTN & DM
African- American at higher risk with htn
Is increasing, particularly among older people
25% pts die in the 1st yr of dialysis
Health promotion
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Focus on prevention and progression
Patient teaching on diet, water wt, smoking,
lifestyle, bp control, drugs, and treating uti’s.
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Chronic Kidney Disease (CKD)
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CKD
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Progressive, irreversible kidney injury; kidney function
does not recover
To poor to sustain life it becomes ESKD
Stages and nursing interventions:
Stages
GFR
1- at risk
>90ml/min
2- mild
60-89ml/min
3- moderate
30-59ml/min
4- severe CKD
15-29ml/min
5- end stage KD
<15ml/min
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Effects of CKD
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Kidney changes
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Metabolic changes
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Few nephrons trying to compensate
↑BUN and decreased UO, risk for?
Urea and creatinine
Electrolyte changes
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Sodium
Potassium
Acid-base imbalance
Calcium and phosphorus
 Renal
osteodystrophy
 Crystal formation from excess Ca+/Phos
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Effects of CKD Changes (Cont.)
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Cardiac changes
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Hypertension
Hyperlipidemia
Heart failure
Pericarditis
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Hematologic changes
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Sac become inflamed by uremic toxins or infection
↓erythropoietin levels, ↓life of RBC from deficiencies like
Iron, folic acid or uremia
GI changes
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From uremia- urea breaks down to ammonia cause
halitosis (bad breath) and stomatitis, PUD, colitis
Ulcer may form in stomach/intestine, bleeding
May be r/t Bun, Cr and acidosis
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Clinical Manifestations
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Neurologic
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Cardiac
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Breath smells like urine & kussmaul respirations
Skeletal
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Fluid overload, htn, HF, pericarditis, arrhythmia's
Respiratory
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r/t uremic syndrome can range from lethargy, sz or
coma if untreated, tremors, low concentration
May resolve with dialysis
Generalized weakness, lethargy or no energy
Skin
Depending on stage dry, flaky, dusky, itchy
 Urinary; making urine or not
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Assessments
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Psychosocial
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Laboratory
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Disrupt many aspects of life
Assess their understanding of dx/ treatment
Impact on their personal/social life
Kft, cbc and chemistry including LFT’s
Uremia? GFR- estimated/calculated
Imaging
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? Bones for renal osteodystrophy
Kidneys usually shrink from atrophy /fibrosis
US or CT
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Priority Nursing diagnosis
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Managing fluid volume
Preventing pulmonary edema
Increase cardiac output
Enhance nutrition
Preventing infection
Preventing injury- fracture, drugs
Managing fatigue
Reducing anxiety
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Priority Nursing Care
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Dietary restrictions
Uremic frost
Muscle strength, energy
Family members
Excess fluid volume
Decreased cardiac output
Recombinant human erythropoietin
Interdisciplinary team
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Hemodialysis nurse/ centers
Patient’s ability to get there
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Common drug therapy for CKD
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Diuretics
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Vitamins and minerals
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Lasix, Bumex
Calcium acetate/carbonate, Renagel
Ferrous sulfate, calcitriol
Sensipar (control pth excess)
ESA’s
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Procrit iv or sq 3x/week
Aranesp Iv or sq once/week
Special consideration for abx, opioids, diuretics,
insulin, heparin and anti-hypertensive.
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Hemodialysis
Renal Replacement Therapy (RRT)
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Intermittent HD- most common RRT
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Patient selection
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Remove excess fluid & waste products
Restore chemical/ electrolyte balance
Uremic syndrome, symptomatic causes
Dialysis settings
Procedure
Anticoagulation
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To prevent blood clotting during dialysis
Heparin is the most common
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Subclavian Dialysis Catheters
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Hemodialysis Circuit
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Vascular Access
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Arteriovenous (AV) fistula or graft for longterm permanent access
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Hemodialysis catheter, dual or triple lumen, or AV
shunt for temporary access
Time is needed for anastomosis (connection) for
the AV fistula to develop; up to 4months
Fistula ↑venous blood flow up to 400ml/min
Precautions
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Assess for circulation in the extremity
Bruit or a thrill how?
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Vascular Access Complications
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Thrombosis or stenosis
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↑pressure in the vein cause thickening so ↓flow
Stenosis by balloon therapy
Infection
Aneurysm formation in the fistula from
repeated punctures
Ischemia- from the fistula
Heart failure
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shunting the blood from arterial to venous system
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Hemodialysis Nursing Care
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Drugs
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Dialyzable or not?
Postdialysis assessment
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Hypotension
Headache
Nausea, vomiting
Malaise, dizziness
Bleeding
Temperature
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Complications of Hemodialysis
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Dialysis disequilibrium syndrome
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↓mental status, sz to coma
r/t rapid change/reduction in electrolytes
Mild symptoms n/v/ha, fatigue or restlessness
Slow down the rate
Cardiac event
Reaction to dialyzers
Hypoglycemia
Hemorrhage
Infection- from contamination
Consideration for older adults
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Peritoneal Dialysis
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PD
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Patient selection
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allows exchange of wastes, fluids & electrolytes to
occur in peritoneal cavity
Involves siliconized rubber catheter placed into
abdominal cavity for infusion of dialysate
No toleration to anti-coagulants,
vascular access problem,
as a temporary use
Procedure
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Usually 1-2L of dialysate infused by gravity
3 phases; infuse, dwell and outflow
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Peritoneal dialysis cont.
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Types
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Continuous ambulatory (CAPD)
Automated
Intermittent
Continuous-cycle
CAPD- more common
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Fluid, duration and times (exchanges) prescribed
No machine is necessary
Help not needed but elderly may need it
Usually overnight
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Continuous Ambulatory Peritoneal
Dialysis (CAPD)
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Peritoneal Dialysis Exchange
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Automated Peritoneal Dialysis
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Complications of PD
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Peritonitis
Pain
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Exit site/tunnel infections
Poor dialysate flow
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? Constipation
Dialysate leakage
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Initially or from cold fluids
May be less fluid
Other complications
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Bowel or bladder perforation, infection
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Nursing Care for Peritoneal Dialysis
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Before treatment: Evaluate baseline vital
signs, weight, laboratory tests
Continually monitor patient for respiratory
distress, pain, discomfort
Monitor prescribed dwell time, initiate outflow
Assess blood glucose levels
Observe outflow amount and pattern of fluid
May be retaining?
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Kidney Transplantation
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Not a cure but treatment
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Candidate selection criteria
Donors
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Wait time about 2yrs
Living related donor 90% success rate
No systemic dx/infection
No CA, htn, or kidney dx
Adequate kidney fx, psych eval for motivation
Preoperative care
Immunologic studies
Operative procedure
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Transplanted Kidney
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Postoperative Care
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Urologic management
Assessment of hourly urine output ×48hrs.
Complications
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Rejection
Acute tubular necrosis
Thrombosis
Renal artery stenosis
Wound problems like hematomas or abscess
Infection
Immunosuppressive drug therapy
Psychosocial preparation
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A 68-year-old woman has chronic kidney disease and a
history of type 2 diabetes. Two weeks ago, she had
surgery to place a vascular graft access for
hemodialysis.
Which precaution will the nurse follow to ensure the
function of the AV graft?
A.
B.
C.
D.
Insert an IV and run saline at 10 mL/hr.
Keep the patient’s arm elevated on two pillows.
Monitor blood pressure and radial pulses in both arms.
Check for a bruit and thrill by auscultation and palpation
over the site.
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(Cont.)
The patient is to have hemodialysis this
morning.
Which drug should be held until after the
dialysis treatment?
A.
B.
C.
D.
Calcium
Multivitamin
Atenolol (Tenormin)
Glyburide (DiaBeta)
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(Cont.)
After dialysis, the patient’s daughter asks why the
dialysis nurses weigh her mother before and after the
dialysis treatment.
What is the nurse’s best response?
A. “It is part of the protocol for dialysis.”
B. “It ensures that she is getting adequate nutrition.”
C. “It estimates the amount of fluid and sodium your mother is
retaining and how much is taken off during dialysis.”
D. “It is essential for calculating the fluid restriction your
mother will receive on non-dialysis days.”
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(Cont.)
After dialysis, which instruction should the nurse
provide to the student nurse who is helping to
provide care for the patient?
A. Expect the patient’s blood pressure to be higher
after dialysis.
B. The patient’s weight will most likely be increased
after dialysis.
C. Expect the patient’s temperature to be higher
after dialysis.
D. The patient’s clotting studies will need to be
drawn after dialysis.
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(Cont.)
As the patient is preparing to discharge, the
patient should be taught to restrict which
elements in her diet? (Select all that apply.)
A.
B.
C.
D.
E.
Potassium
Phosphorus
Calcium
Protein
Vitamins
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