Nursing Care and Interventions in Managing Chronic Renal Failure

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Nursing Care and Interventions in Managing
Chronic Renal Failure

• Keith Rischer RN, MA, CEN

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Todays Objectives

• Review the pathophysiology and causes of chronic
  renal failure (CRF).
• Contrast lab findings and physiologic changes
  associated with acute vs. chronic renal failure.
• Identify relevant nursing diagnosis statements
  and prioritize nursing care for clients with CRF
  including dietary modifications.
• Compare and contrast the following treatment
  modalities peritoneal dialysis, hemodialysis,
  and continuous renal replacement therapies.
• Identify nursing care priorities with
  hemodialysis and peritoneal dialysis.
• Prioritize teaching needs of clients with CRF.

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PathoStages of Chronic Renal Failure

• Diminished renal reserve
• GFR ½ normal
• Compensation w/healthy nephrons
• Renal insufficiency
• Nephrons destroyedremaining adapt
• BUN, creatinine, uric acid elevate
• Priorities fluid volume, diet, control of HTN,
• End-stage renal disease
• Severe fluid, acid-base imbalances
• Dialysis needed or will die

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PathoPhysiologic Changes

• Kidney
• Decreased GFR
• Poor H2O excretion
• Metabolic
• BUN and creatinine increased
• Electrolytes
• Sodium- later stages sodium retention
• Potassium increased
• EKG changes
• Kayexelate
• Acid-base balance metabolic acidosis
• Calcium decreased and phosphorus increased

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PathoPhysiologic Changes

• Cardiac
• Hypertension
• Hyperlipidemia
• Congestive heart failure
• Uremic pericarditis
• Hematologic
• anemia
• Gastrointestinal
• Halitosis
• Stomatitis
• PUD

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PathoPhysiologic Changes

• Neurologic
• lethargy
• Uremic encephalopathy
• Respiratory
• pulmonary effusion
• SOB
• Urinary
• proteinuria, oliguria, dilute
• Skin
• dry, pallor, pruritus, ecchymosis

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Drug Therapy chart 75-3 p.1737

• Cardioglycides
• Digoxin/Lanoxin
• Calcium channel blockers
• Diuretics
• Vitamins and minerals
• Folic Acid
• Ferrous Sulfate
• Biologic response modifiers
• Erthropoetin (Epogen)
• Phosphate binders
• Aluminum hydroxide
• Stool softeners and laxatives

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Excess Fluid Volume

• Interventions
• Monitor IO
• Promote fluid balance
• Daily weights
• 1 kg1liter fluid
• Assess for manifestations of volume excess
• Crackles in the bases of the lungs
• Edema
• Distended neck veins
• Diuretics
• Contraindicated w/ESRD

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Decreased Cardiac Output

• Interventions
• Control hypertension
• calcium channel blockers
• ACE inhibitors
• alpha- and beta-adrenergic blockers
• vasodilators.
• Education
• monitor blood pressure
• clients weight
• Diet
• Drug regimen

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Potential for Pulmonary Edema

• Interventions
• Assess for early signs of pulmonary edema
• Restlessness/anxiety
• Tachycardia
• Tachypnea
• oxygen saturation levels
• Crackles in bases
• Hypertension

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Imbalanced Nutrition

• Interventions
• Dietary evaluation for
• Protein
• Fluid
• Potassium
• Sodium
• Phosphorus
• Vitamin supplementation
• Iron
• Water soluable vitamins
• Calcium
• Vitamin D

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Risk for Infection

• Interventions
• Meticulous skin care
• Preventive skin care
• Inspection of vascular access site for dialysis
• Monitoring of vital signs for manifestations of
  infection

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Risk for Injury

• Interventions
• Drug therapy
• Education
• prevent fall
• Injury
• pathologic fractures
• bleeding
• toxic effects of prescribed drugs
• Digoxin
• Narcotics
• Heparin or Coumadin

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Fatigue

• Interventions
• Assess for vitamin deficiency
• Administer vitamin and mineral supplements
• anemia
• Give iron supplements as needed
• Erythropoietin therapy
• Buildup of urea

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Anxiety

• Interventions
• Health care team involvement
• Client and family education
• Continuity of care
• Encouragement of client to ask questions and
  discuss fears about the diagnosis of renal failure

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Indications for Dialysis

• Uremia
• Persistent hyperkalemia
• Uncompensated metabolic acidosis
• Fluid volume excess unresponsive to diuretics
• Uremic pericarditis
• Uremic encephalopathy

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Hemodialysis

• Client selection
• Irreversible renal failure
• Expectation for rehab
• Acceptance of regimen
• Dialysis settings
• Acute-hospital
• Out patient centers

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HemodialysisPatho

• Diffusion
• Dialysate
• Lytes and H2O
• Dialyzer
• Anticoagulation
• Heparin to prevent blood clots in dialyzer or
  tubing

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Vascular Access

• Arteriovenous fistula, or arteriovenous graft for
  long-term permanent access
• Hemodialysis catheter, dual or triple lumen, or
  arteriovenous shunt for temporary access
• Precautions
• Bruit thrill
• BP restrictions
• Complications
• Thrombosis
• CMS

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Hemodialysis Nursing Interventions

• Predialysis care
• Medications to holdwhy?
• Postdialysis care
• Monitor for complications such as hypotension,
  headache, nausea, malaise, vomiting, dizziness,
  muscle cramps.
• Monitor vital signs and weight.
• sepsis
• Avoid invasive procedures 4 to 6 hours after
  dialysis.
• Continually monitor for hemorrhage.
• Assess for thrill
• No BP or blood draws on arm

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Peritoneal Dialysis

• Phases
• Inflow
• Dwell
• Drain
• Contraindications
• history of abd surgeries
• recurrent hernias
• excessive obesity
• preexisting vertebral disease
• severe obstructive pulmonary disease

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Complications of Peritoneal Dialysis

• Peritonitis (cloudy outflow)
• Pain
• Exit site and tunnel infections
• Poor dialysate flow
• Dialysate leakage
• Monitor color of outflow
• cloudy (peritonitis)
• brown (bowel)
• bloody (first week OK)
• urine (bladder)

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Nursing Care During Peritoneal Dialysis

• Pre PD
• Vital signs pre and q 15-30 during
• Weight
• laboratory tests
• Continually monitor the client for
• respiratory distress
• pain
• discomfort
• Monitor prescribed dwell time and initiate
  outflow
• Observe outflow amount pattern of fluid

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Education Priorities

• Pathophysiology and manifestations
• Complications
• When to call the doctor
• Keep record of all labs
• Take medications and follow plan of care set out
  by case manager
• Monitor weight, fatigue levels closely