Title: Paediatric Renal Nursing Care
1Paediatric Renal Nursing Care Principles of
Treatment
- Cathy Poole
- Lecturer Practitioner
2AIMS
- To outline the definition of acute renal failure
linked to basic physiology - To define the causes of acute renal failure
- To discuss the principles of management of
children with acute renal failure
3OBJECTIVES
- At the end of this session you should be able to
- Discuss the definition and causes of acute renal
failure - Describe the management of children in acute
renal failure
4DEFINITIONS OF ARF
- The syndrome is characterised by a sudden in
parenchymal function which is usually but not
always reversible - This produces disturbance of water, electrolyte,
acid base balance and nitrogenous waste products
blood pressure.
5PATHOPYSIOLOGY(1)
- Severe reduction in renal blood flow (RBF)
- Often occurs despite normal systemic arterial
pressure - This leads to reduced GFR and renal cortical
blood flow - This stimulates renin and aldosterone secretion
6PATHOPHYSIOLOGY(2)
- Na and H20 are retained
- Thus decreasing urinary output
7Mortality and Morbidity
- Outcomes of ARF in paeds viewed as potentially
reversible. - Mortality rates lt than those in adults.
- Mortality is related to the nature of the primary
disease process as opposed to the renal failure
itself.
8(No Transcript)
9ORIGINS Of ARF
- Prerenal origins compromise renal perfusion
leading to a GFR. - Intrarenal failure is the result of damage to the
renal parenchymal cells. (acute tubular necrosis
ATN) - Post renal ARF arises from urine out flow
obstruction
10PRERENAL(1)
- Hypovolaemia
- Hypotension
- Hypoxia
11INTRARENAL(1)
- GlomerulonephritisSLE
- Vascular Disorders
- Tumours
- Acute Tubular Necrosis (ATN)
- Acute Interstitial Nephritis
- Developmental Abnormalities
12? Pathophysiology of ATN
- NB. This is not completely understood
- related events include-
- induction by hypoxia of nitric oxide synthases
with increased production of nitric oxide - vasoconstriction
- liberation of toxic endothelial factors
- tubular obstruction by desquamated cells and
casts..
13POST RENAL
- Obstructive Uropathy
- Vesico-ureteric Reflux (bilateral)
- Acquired
14Investigations in ARF (1)
- Dipstick Blood protein
- Microscopy RBC, WBC, casts crystals
- Culture sensitivity
- Na, SG/osmolality
15Investigations in ARF (2)
- Plasma urea, creatinine, Na, K, Cl, Ca
- Blood gases
- FBC Film
- Ultrasound of abdomen
- X-ray chest
16Management of ARF
- Fluid balance
- Electrolyte disturbances
- Acid-base disturbances
- Drugs
- Nutrition
- Family Centred Care..
17Water Balance emergent care.
- ? Fluid depletion IV saline 5 ml/kg/bolus
rapidly, repeated until adequate circulating
volume - ? Fluid overload loop diuretic in escalating
doses up to max. 10 mg/kg. If unsuccessful,
dialysis or haemofiltration.
18Fluid Requirements
- Insensible losses
- Preterm30 ml/kg/day
- Infants 20 ml/kg/day
- Children15 ml/kg/day
- Urine output
- GIT losses
- Other losses, e.g. 10-14 increase for each 1?C
fever
19Prevention is better than cure..
- Be alert for potential acute renal failure
related to- - Poor systemic perfusion
- Inadequate renal perfusion
20Nursing Care
- Hourly intake / output record
- output lt1-2 ml/kg/hr
- ? Catheterise for accuracy
- ? Repeat samples for osmolality / SG
- Monitor colour of urine
- Assess systemic perfusion...
21- i.e. Warm skin
- Strong peripheral pulses
- Brisk capillary refill
- Mucous membranes should be pink moist
- Support cardiovascular function as needed
- ? Fluid challenge
- ? Colloid
- ? Inotropic agents or vasodilators if systemic
perfusion does not improve
22- Digoxin, dobutamine or dopamine
- Which increase myocardial contraction
- Tension development relaxation occur fast with
relatively little increase in O2 demand - ? administer diuretic agents
23Nursing Considerations (1)
- Potential fluid volume excess related to-
- Oliguria
- Excessive fluid administration
- Sodium water retention
24Nursing Care
- Input/output
- ? Fluid restriction 300ml/m2 BSA/day plus urine
output - Minimise fluid utilisation i.e flushing lines,
diluting medication - Administer diuretics
- Monitor for signs of hypervolaemia
25Nursing Considerations (2)
- Potential electrolyte imbalance related to-
- Decreased renal potassium excretion
- Increased renal sodium excretion
- Decreased renal excretion of phosphate,
calcium-phosphate precipitation decreased renal
activation of Vitamin D
26Nursing Care (a)
- Monitor UEs
- Watch K intake
- Monitor for signs of hyperkalaemia
- ? Peaked T wave
- Arrythmias
- Muscle weakness
- Action needed to reduce serum K
- ? dialyse
27Nursing Care (b)
- Watch for hyponatraemia
- change in consciousness
- muscle cramps
- anorexia
- abnormal reflexes
- Cheyne-stokes respiration
- or seizures
28Nursing Care (c)
- Watch for hypocalcaemia
- muscle tingling or changes in muscle tone
- Seizures
- Tetany
- ve Chvostek sign ( twitching of side of face
when the facial nerve is tapped in front of the
ear) - Drugs antacid phosphate binders Vit D
29Nursing Considerations (3)
- Potential metabolic acidosis related to-
- Poor systemic perfusion associated with pre-renal
failure - Decreased renal ability to excrete hydrogen ions
30Nursing Care (a)
- Assist with arterial blood gases
- Administer medication i.e. Na Bicarbonate
- Reassess serum K
31Nursing Considerations (4)
- Potential drug toxicity related to-
- Reduced renal excretion of drugs or drug
metabolites
32Nursing Care (a)
- Review patients drug doses and administration
schedule - Note clinical signs of toxicity
- Document report
33Nursing Considerations (5)
- Potential for infection related to-
- Multiple invasive catheters
- Compromised nutritional intake
- Poor nutritional status ?
34Nursing Care (a)
- Meticulous hand washing by all !!!!!!
- Adhere to unit policy for all dressing changes
- Monitor temp WBC
- Assess all skin puncture sites
- Swabs, blood cultures urine etc if infection
suspected - Administer antibiotic therapy if prescribed
35Nursing Considerations (6)
- Potential pain related to-
- Multiple invasive catheters treatments
- Neuropathies associated with electrolyte
imbalances
36Nursing Care (a)
- Assess for evidence of pain using local pain
assessment tool - Assess severity
- Administer analgesia as prescribed
- Careful positioning
- Family support
37Nursing Consideration (7)
- Skin integrity, impaired related to-
- Uraemia
- Nursing Care-
- Keep skin warm dry
- Change patients position frequently
- Nursing aids ?..
38Nursing Considerations (8)
- Nutrition, altered, less than body requirements
- Nursing Care-
- Dietetic involvement
- Record intake
- Observe restrictions
- J. Kennedy Renal Disorders
39Drug Therapies
- In pairs
- List the medications commonly used in ARF Rx
- Feed back
40Treatment goals
- Elimination of K
- Correction of Na imbalance
- Maintenance of normal calcium Phosphate
- Correction of metabolic acidosis
- Maintain Bp
- Treat convulsions