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Chapter 75

Interventions for Clients with

Acute and Chronic RenalFailure

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Acute Renal Failure

Pathophysiology

Types of acute renal failure include: Prerenal

Intrarenal

Postrenal

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Phases of Acute Renal

Failure Phases of rapid decrease in renalfunction lead to the collection of

metabolic wastes in the body.

Phases include: Onset

Oliguric

Diuretic Recovery

Acute syndrome may be reversible with

prompt intervention.

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Assessment

History

Clinical manifestations

Laboratory assessment

Radiographic assessment

Other diagnostic assessments such as

renal biopsy

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Drug Therapy

Cardioglycocides Vitamins and minerals Biologic response modifiers

Phosphate binders Stool softeners and laxatives Monitor fluids Diuretics Calcium channel blockers

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Treatment

Diet therapy Protein 40 g/day if not on dialysis

Protein 1 to 1.5 g/kg per day if on dialysis

Sodium 60 to 90 mEq/day

Potassium restricted to 60 to 70 mEq/day

Fluid equal the urine output plus 500 mL

Dialysis therapies Hemodialysis

Peritoneal dialysis

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Continuous RenalReplacement Therapy Standard treatment

Major disadvantage, bleeding caused by

anticoagulants

Dialysate solution

Vascular access Jugular or subclavian

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Continuous RenalReplacement Therapy Continuous arteriovenous hemofiltration

Used for the hemodynamically unstable

Continuous venovenous hemofiltration Used for critically ill

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Posthospital Care

If renal failure is resolving, follow-up care

may be required.

There may be permanent renal damage

and the need for chronic dialysis or eventransplantation.

Temporary dialysis is appropriate for

some clients.

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Chronic Renal Failure

Progressive, irreversible kidney injury;

kidney function does not recover

Azotemia

Uremia

Uremic syndrome

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Stages of Chronic RenalFailure Diminished renal reserve

Renal insufficiency

End-stage renal disease

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Stages of Chronic RenalFailure

Changes Kidney Metabolic

Urea and creatinine Electrolytes

Sodium Potassium Acid-base balance Calcium and phosphorus

(Continued)

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Stages of Chronic RenalFailure

Changes (Continued) Cardiac Hypertension

Hyperlipidemia

Congestive heart failure

Uremic pericarditis

Hematologic

Gastrointestinal

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Clinical Manifestations(Chart 75-7) Neurologic

Cardiovascular

Respiratory

Hematologic

Gastrointestinal

Urinary

Skin

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Imbalanced Nutrition:Less Than BodyRequirements Interventions include:

Dietary evaluation for: Protein Fluid

Potassium Sodium Phosphorus

Vitamin supplementation

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Excess Fluid Volume

Interventions: Monitor clients intake and output.

Promote fluid balance.

Assess for manifestations of volume excess: Crackles in the bases of the lungs

Edema

Distended neck veins

Drug therapy includes diuretics.

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Decreased Cardiac Output

Interventions: Control hypertension with calcium channel

blockers, ACE inhibitors, alpha- and beta-

adrenergic blockers, and vasodilators. Instruct client and family to monitor blood

pressure, clients weight, diet, and drug

therapy.

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Risk for Infection

Interventions include: 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 include: Drug therapy (chart 75-3)

Education to prevent fall or injury, pathologic

fractures, bleeding, and toxic effects ofprescribed drugs

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Fatigue

Interventions: Assess for vitamin deficiency, anemia, and

buildup of urea.

Administer vitamin and mineral supplements. Administer erythropoietin therapy for bone

marrow production.

Give iron supplements as needed.

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Anxiety

Interventions include: 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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Potential for PulmonaryEdema Interventions:

Assess the client for early signs of pulmonary

edema.

Monitor serum electrolyte levels, vital signs,oxygen saturation levels, hypertension.

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Hemodialysis

Client selection

Dialysis settings

Works using passive transfer of toxins by

diffusion

Anticoagulation needed, usually heparin

treatment

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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 fortemporary access

Precautions

Complications

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Hemodialysis NursingCare Postdialysis care:

Monitor for complications such as

hypotension, headache, nausea, malaise,

vomiting, dizziness, and muscle cramps. Monitor vital signs and weight.

Avoid invasive procedures 4 to 6 hours after

dialysis.

Continually monitor for hemorrhage.

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Complications ofHemodialysis Dialysis disequilibrium syndrome

Infectious diseases

Hepatitis B and C infections

HIV exposureposes some risk for

clients undergoing dialysis

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Peritoneal Dialysis

Procedure involves siliconized rubber

catheter placed into the abdominal cavity

for infusion of dialysate.

Types of peritoneal dialysis: Continuous ambulatory peritoneal

Automated peritoneal

Intermittent peritoneal Continuous-cycle peritoneal

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Complications

Peritonitis

Pain

Exit site and tunnel infections

Poor dialysate flow

Dialysate leakage

Other complications

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Nursing Care DuringPeritoneal Dialysis Before treating, evaluate baseline vital

signs, weight, and laboratory tests.

Continually monitor the client for

respiratory distress, pain, and discomfort. Monitor prescribed dwell time and initiate

outflow.

Observe the outflow amount and patternof fluid.

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Renal Transplantation

Candidate selection criteria

Donors

Preoperative care

Immunologic studies

Surgical team

Operative procedure

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Postoperative Care

Urologic management

Assessment of urine output hourly for 48

hours.

Complications include: Rejection

Acute tubular necrosis

(Continued)

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Postoperative Care(Continued)

Thrombosis

Renal artery stenosis

Other complications

Immunosuppressive drug therapy Psychosocial preparation