The Client with Alterations in Urinary Elimination

1
The Client with Alterations in Urinary Elimination

• Sherry A. Burrell, RN, MSN
• Rutgers University-Camden Campus
• Nursing III
• Lecture Date 10/25/04

2
Functions of the Kidney

• Elimination of Metabolic Wastes
• Blood Pressure Regulation
• Red Blood Cell Production
• Vitamin D Synthesis
• Prostaglandins Synthesis
• Electrolyte Fluid Balances
• Acid-Base Balances

3
Elimination of Waste Products

• All metabolic processes that occur within the
  body produce waste products that the kidneys must
  filter-out of circulation then excrete via urine.
• i.e. urea, uric acid and creatinine
• Clinically metabolic waste products can be a
  measure of renal function
• Urea
• Measured clinically by BUN (blood urea nitrogen)
  the end-product of the protein catabolism result
  of ammonia breakdown in liver.
• Can also be affected by other factors i.e.
  hydration status dietary intake of proteins
• Creatinine
• A end-product of protein metabolism result of
  muscle breakdown
• More reliable indicator of renal function in
  comparison to BUN.

4
Blood Pressure Regulation

• Maintenance of blood volume altering peripheral
  vascular resistance (PVR) by activating RAAS.
• Specialized (JGA) cells in the kidney Respond to
  decreased renal blood flow and decreased
  glomerular pressures by releasing ReninSNS
  stimulation
• Activating Angiotension I ? Lungs ? Angiotension
  II vasoconstriction (increased PVR ?BP)
• Renal arterioles constricted too ? renal blood
  flow pressures
• Angiotension II
• Stimulates aldosterone release from the adrenal
  gland Na H2O retention in the distal tubules.
• In addition, ? RBF stimulates ADH released from
  the posterior pituitary additional water
  retention at the distal tubules and collecting
  duct.
• Both increase blood volume ? BP renal blood
  flow.

5
RBC Production

• RBC Production
• Erythropoietin is a hormone that controls RBC
  (erythrocyte) production in bone marrow.
• Secreted in response to decreased amount of
  oxygen delivered to kidneys.
• Anemia or hypoxia

6
Vitamin D Prostaglandin Synthesis

• Vitamin D from food sources must be converted
  into its active form by the kidneys.
• Active Vitamin D is needed for absorption of
  calcium by the renal tubules and the intestines
• Promoting bone and teeth metabolism
• Prostaglandins
• Primarily locally-acting, vasodilating substances
• PGE1 or PHE2 counter the effects of RAAS and
  the SNS on the kidneys

7
Acid-Base Electrolyte Balances

• Renal Considerations
• Potassium
• Hyperkalemia seen in renal failure
• EKG flattened P waves widened QRS complex ST
  segment depression and peaked T waves
• Hypokalemia seen with the use of diuretics
• EKG prolonged PR interval, flattened T wave or
  U wave
• PVCs ?deteriorates can cause VT or V-fib
• Na, Ca, phosphorous magnesium balances
• Thalen See pp. 748-749, tables 30-2 30-3

8
Fluid Balance Considerations

• Antidiuretic Hormone (ADH)
• The presence of ADH increased reabsorption of
  H20 from the distal tubules and collecting ducts,
  therefore increased circulating volume
• Aldosterone
• Part of the sequel of RAAS increasing Na and
  water reabsorption from the distal tubules More
  Na and H2O in general circulation
• Natriuretic Peptides (Atrial or B-type)
• Stretch receptors in heart activate in response
  to increased volume countering the effects of
  RAAS vasodilation and Na H2O excretion by
  kidneys

9
Acid-Base Balance

• Kidneys regulate day-to-day acid-base balances
• The nephron at the site of the renal tubules
  regulate acid-base balances in accordance to the
  bodys needs.
• CO2 H20 ? H2CO3 ? H HCO3
• LUNGS Carbonic
  Kidneys
• Acid

10
Renal Failure

• Is a severe impairment or a total lack of renal
  function which leads to disturbances in all body
  systems.
• Classification according to onset
• Acute Developing within hours to days with
  little time to adjust to the biochemical changes,
  but is potentially reversible.
• Chronic Insidious progressive development over
  a period of several years allows for some
  adjustment to biochemical changes, but is
  irreversible and always necessitates some form of
  dialysis or transplantation for long-term
  survival.

11
General Symptoms

• Weakness
• Fatigue
• Dyspnea
• Peripheral edema
• Nocturia
• Nausea

• Metallic taste in mouth
• Loss of appetite
• Rapid weight gains
• Pruritus
• Dry, scaly skin

12
Health History

• The nurse elicits information regarding
• Past medical and familial medical history
• Recent Changes
• Urinary patterns
• General n/v, fatigue, lethargy or changes in
  mentation
• Personal habits sleep or work
• Recent weight gains or losses need to be explored
• Medications (current recent)
• Over-the-counter and prescribed medications
• Recent events
• Trauma (presence of pain), infection, illicit
  drug use or expose to nephrotoxic substances

13
Physical Assessment

• Inspection
• Bleeding
• Flank or posterior thorax
• Grey-Turner sign for renal trauma
• Volume
• Neck and hand veins
• Skin Turgor
• Oral Mucosa
• Edema
• Lower extremities, orbital or sacral area

(See Thalen pp. 738 Table 29-2 Box 29-2)
14
Physical Assessment Cont.,

• Auscultation
• Volume
• Heart Sounds
• Blood pressure
• Orthostatic hypotension
• Lungs Dyspnea / added breath sounds
• Other Considerations
• Mentation
• IO and Daily Weights
• Hemodynamic monitoring
• CVP (NL 2-6 mmHg) / PAOP (NL 5-12 mmHg)

15
Laboratory Studies

• Serum Studies
• BUN (9-20mg/dl)
• Creatinine (0.7-1.5 mg/dl)
• HH
• Albumin
• Electrolytes
• K, Na, Ca, Magnesium Phosphate
• (Thalen pp. 748 Table 30-2 and pp. 738-739)

16
Laboratory Studies Cont.,

• Urine Studies
• Urine Analysis (UA)
• Color, appearance, pH, specific gravity, glucose,
  protein, WBC, RBC and casts.
• Culture Sensitivity (CS)
• Bacteria
• Urinary Collection
• 24 Hour Urine
• i.e. creatinine or electrolytes
• Spot / Random Urine
• First a.m. void preferred
• Combination Studies
• Creatinine Clearance (110-120 ml/min)
• 24 hour urine and a serum sample
• Equivalent to GFR best overall indicator of
  renal function

17
Diagnostic Studies

• Renal Radiological Examinations
• Kidney-ureter-bladder (KUB)
• An X-ray which identifies the position, size and
  shape of the kidneys and the urinary tract
• Assist in identifying renal masses
• i.e. renal calculi, tumors or cysts
• Intravenous pyelogram (IVP)
• A series of x-rays following injection of
  radiopaque-contrast dye.
• Allows visualization of the internal renal
  tissue.
• Check Allergies watch contrast !!

18
Diagnostics Cont.,

• Other (Non-invasive) Renal Studies
• Renal Ultrasound
• Size and shape of kidneys and urinary tract may
  reveal fluid accumulation, obstructions from
  masses (solid or fluid )
• Renal Computed Tomography (CT)
• I.V. radiopaque-contrast dye can be done without
• Cross-sectional view of the kidneys and urinary
  tract
• Can assess renal perfusion and identify masses
  (fluid or solid), tissue necrosis or hemorrhage
• Renal Magnetic Resonance Imaging (MRI)
• High-energy radiofrequency waves provide
  three-dimensional views clearer images
• Can assess trauma, lesions, malformations of
  vessels or tubules and necrosis

19
Diagnostics Cont.,

• More-Invasive Renal Studies
• Renal Angiography
• Interventional radiology procedure
• Visualize renal blood flow
• Can also, detect stenosis, clots, cysts or
  necrosis
• Renal Biopsy
• Gold standard to diagnosis specific renal
  disease Last resort in critically-ill client
• Percutaneous U/S guided / fluoroscopy
• Open

20
Acute Renal Failure (ARF)

• Sudden loss of kidney function over a period of
  hours or days
• Characterized by
• A rapid ? GFR
• Retention of metabolic waste
• A progressive ? BUN and ? Creatinine (Azotemia)
• Associated with
• Classic finding of Oliguria (UO lt 400ml/day)
• UO may also be normal or increased
• Fluid, electrolyte and acid-base imbalances
• Usually reversible with prompt treatment

21
Classification of ARF

• Acute renal failure is often classified according
  to location of the insult
• Prerenal
• Before the kidneys ? Blood flow to kidneys
• Occurs in about 50-70 of all ARF cases
• Intrarenal
• Within the kidneys actual damage to kidneys
• Occurs in about 20-30 of all ARF cases
• Postrenal
• After the kidneys obstruction of urinary
  excretion
• Occurs in about 1-10 of all ARF cases

22
Pre-Renal ARF

• It occurs when renal blood flow is decreased
  before reaching the kidney.
• ? Renal Perfusion ? GFR leading to Oliguria
• Most common type of ARF
• Common Causes
• Hypotension (severe and abrupt)
• Hypovolemia
• Low Cardiac Output States
• Treatment to correct cause, if not corrected it
  may cause intrarenal failure i.e. acute tubular
  necrosis (ATN)

23
Intrarenal ARF

• A condition that leads to actual damage of the
  renal tissue (parenchyma) resulting in
  malfunction of nephrons.
• Acute Tubular Necrosis (ATN)
• Damage to the renal tubules caused by ischemia or
  toxins characterized by varying degrees of
  cellular damage or death.
• Ischemic Trauma to kidneys, massive hemorrhage
  or post-surgery
• Nephrotoxic I.V. contrast dyes, heavy metals or
  antibiotics (aminoglyclosides)
• Treatment Immediate dialysis to renal increase
  blood flow and minimize damage Not always
  reversible may lead to chronic renal failure
  (CRF)

24
Postrenal ARF

• Occurs as a result of conditions that block urine
  flow distal to kidneys.
• Caused by an obstruction below the kidneys in the
  urinary tract
• Calculi (stones)
• Tumors or masses
• Blood clots
• Benign prostate hypertrophy (BPH)
• ? UO common Oliguria or anuria (UO lt 50 ml/day)
• Causes urine to back up into the kidneys
  eventually increases pressures leading to a ? GFR
  
• Treatment to eliminate cause of obstruction to
  restore normal renal function (if not may lead to
  intrarenal failure).

25
The Clinical Course

• Acute Tubular Necrosis (ATN)
• Involves four phases the client may or may not
  recover (CRF).
• Onset (Initiation) Phase
• Oliguric Phase
• Diuresis Phase
• Recovery Phase

26
Onset (Initation) Phase

• Time of insult until cellular injury
• ? Glomerular blood flow and pressure
• Only about 50 develop oliguria
• Can last hours to days
• Prompt treatment during the onset phase may
  alleviate irreversible damage

27
Oliguric / Anuric Phase

• Sometimes called the maintenance phase because
  total support of renal function is needed
• May last for days to several weeks
• 10-14 days on average
• GFR is significantly reduced
• ? BUN and ? Creatinine
• Metabolic Acidosis
• Electrolyte Imbalances (i.e. ? K, ? PO4 and
  ?Ca)

28
Diuretic Phase

• This phase lasts 1 to 3 weeks
• Improvement of GFR with slower improvement of
  tubular function.
• Polyuria (2-4 liters/day) may not be evident
  with hemodialysis therapy (more pulled off)
• Monitor for hypovolemia and electrolyte losses
  i.e. sodium and potassium
• Overall more fluid than solute loss (very dilute
  urine) !!
• Strict I Os and daily weights essential

29
Recovery Phase

• Major improvement within first 1-2 weeks of the
  recovery phase
• UO and renal function normal or near normal (if
  not permanent) usually within 1-2 years.
• Of those who survive ATN
• 62 regain normal renal function
• 33 renal insufficiency (perm. ? BUN
  Creatinine)
• 5 require long- term dialysis.

30
Clinical Manifestations

• Urinary Changes
• Decreased UO Oliguria
• Hematuria
• UA Casts, RBC, WBC protein in urine
• Fluid Volume Excess
• ? UO leads to ? fluid retention
• Distended neck veins, bounding pulse, edema
• Invasive-hemodynamic monitoring
• ? CVP and ? PAOP values

31
Clinical Manifestations

• Retention of Nitrogenous Waste Products
• ? BUN ? Creatinine (Azotemia)
• General Fatigue, pruritus, dry skin and if
  terminal uremic frost
• Neurological confusion, lethargy, convulsions,
  decreased LOC, stupor or coma
• Cardiac Dysrhythmias and BP (maybe elevated or
  normal)
• Gastrointestinal n/v, anorexia, diarrhea or
  constipation

32
Clinical Manifestations

• Electrolyte Imbalances
• Hyperkalemia
• Kidneys cant excrete 80-90 of bodys potassium
  like normal
• S/sx irritability, restlessness, weakness, n/v,
  diarrhea and abdominal pain/cramping
• Hyperphosphatemia
• Primarily excreted by kidneys ?UO decreased
  excretion
• Hypocalcemia
• The active form of Vitamin D is required for Ca
  to be absorbed only functioning kidneys can
  activate Vitamin D
• Hypermagnesemia
• Usually normal or slightly elevated
• Hyponatremia
• Sodium levels maybe decreased due to hemodilution
  from fluid overload.

33
Clinical Manifestations

• Metabolic Acidosis (?pH ?HCO3)
• In general
• The failing renal tubules loose the ability to
  secrete H
• Impaired tubular secretion (?excretion in urine)
• H accumulates in the body ? pH
• The failing renal tubules loose the ability to
  conserve HCO3
• Impaired tubular reabsorption (? return to blood)
  
• Contributing to a decrease in ? HCO3
• Kussmauls Respirations
• Deep, rapid respirations
• Trying to compensate for acidosis by blowing off
  more CO2

34
Medical Management

• Conservative Medical Management Goals
• Prevention of ARF
• Most effective is to prevent occurrence
• Eliminate underlying cause
• Prerenal
• Optimize renal perfusion
• Intrarenal
• Supportive, remove causative ischemic or toxic
  agent
• Postrenal
• Removal of obstruction
• Support of Renal Function
• Prevent Complications

35
Medical Management Cont.,

• Fluid Balance
• Volume Deficit
• IVF or blood products
• Volume Excess
• Fluid restriction
• All measurable output 500-600ml/day (insensible
  losses)
• Daily weight, accurate IOs essential !!
• Diuretics
• Loop or osmotic diuretics
• Dialysis or hemofiltration
• Preferred method of fluid removal
• Watch I.V. placement

36
Medical Management Cont.,

• Serum Electrolytes
• Hyperkalemia
• I.V. Glucose accompanied by regular insulin
• Forces K out of serum and into cells
• I.V. Sodium Bicarbonate
• Creates temporary alkalemia moving H out of
  cells and allowing K to shift into cells.
• I.V. Calcium Gluconate
• Supportive raises threshold for cardiac
  dysrhythmias
• Polystyrene Sulfonate (Kayexalate)
• Cation exchanging resin oral, rectal or down NG
  tube resin binds with K in bowel, promoting
  elimination in stool.
• Dialysis or hemofiltration

37
Medical Management Cont.,

• Severe Metabolic Acidosis
• I.V. Sodium Bicarbonate
• High Serum Phosphorous
• Phosphorous Binding Agents
• Aluminum-hydroxide preparations / antacids
• Bind to phosphate in bowel and promotes excretion
  in stool. (i.e. Alternagel or Alu-cap)
• Calcium-based salts / antacids
• Calcium Carbonate or Calcium Acetate (PhosLo)
• Low Serum Calcium
• Oral or I.V. Supplemental doses of Calcium
• Synthetic, active-form of Vitamin D (i.e.
  Calcitrol)

38
Medical Management Cont.,

• Pharmacological Considerations
• Calcium Channel Blockers and ACE Inhibitors
• Hypertensive management
• Anemia
• RBC transfusions
• Epogen Stimulate RBC production from bone marrow
• Ferrous Sulfate and folic acid supplements
• Other Pharmacologic Considerations
• Anti-seizure medications
• Anti-emetic medications
• Anti-ulcer/ GI protective medications
• Anti-infective medications renal dosing

39
Nutritional Management

• Renal Diet (Oliguria Phase)
• Carbohydrates encouraged energy for healing
• Blood glucose control
• Dietary Restrictions
• Protein (1.0-1.5 g/kg)
• Sodium (2 grams/day)
• Potassium (40-60 meq/day)
• Phosphorus (1000mg/day)
• Phos-binders with meals stool softeners
• Fluid restrictions
• All measurable output 500-600ml/day (insensible
  losses)
• Total Parenteral Nutrition / Intralipids
• Obtain Dietician Consult

40
ARF Complications

• Chronic renal failure
• Gastrointestinal bleeding
• Convulsions (seizures)
• Cardiac dysrhythmias
• Cardiac arrest
• Heart failure

• HTN
• Pulmonary edema
• Pulmonary infection
• Anemia
• Metabolic Acidosis

41
Nursing Interventions

• Monitoring
• Vital signs
• Invasive Hemodynamics
• Fluid Electrolyte Balances
• Essential assessment
• Laboratory
• CBC
• Urinalysis / Culture
• Electrolytes Acid-Base Balances
• Be alert for signs/symptoms of imbalances
• Administer medications as ordered
• Provide support to client and significant others
• Encourage client to express feelings

42
Nursing Interventions Cont.,

• Monitor Cont.,
• Signs and symptoms of infection
• Maintain
• Diet Fluids Restrictions
• Bedrest / Semi-fowlers
• I.V. Fluids
• Quiet Environment
• Prevent Infection
• Aspetic technique
• Invasive lines
• Foley catheters avoid use when possible
• Pulmonary Care
• Skin Mouth Care

43
Nursing Education

• When to call the doctor
• Signs and symptoms of worsening renal function
• Keep follow-up appointments
• Avoid OTC medications
• Smoking Cessation
• Maintain normal weight
• Medications use, dose and side effects

• Infection Management
• Importance of good hygiene
• Recognize signs symptoms
• Rest-activity balance
• Explain diet and/or FR
• How to check daily weight

44
Chronic Renal Failure

• A progressive and irreversible loss of renal
  function over a period of months to years
• The kidneys can loss up to 80 (overtime) of all
  nephrons with relatively few overt changes in
  functioning of the body
• Nephrons are destroyed and replace with scar
  tissue remaining nephrons become hypertrophied
  and do not function as well.
• Resulting in systemic disease involving all of
  the bodys organs (Uremic syndrome of CRF)

45
Causes of CRF

• Other Considerations
• Sickle cell anemia
• Systemic lupus erythematosus
• Chronic glomerulonephritis
• Pyelonephritis
• Obstructions of the urinary tract
• Polycystic kidney disease

• Diabetes Mellitus
• Hypertension
• Vascular disorders
• Infections
• Nephrotoxic medications
• Toxic agent exposure

46
Three Stages of CRF

• Stage 1
• Reduced renal reserve
• Characterized by a 40-75 loss of nephron
  function
• Usually asymptomatic normal BUN Creatinine
• Stage 2
• Renal Insufficiency
• Characterized by a 75-90 loss of nephron
  function
• ?BUN and ?Creatinine
• Kidneys loose ability to concentrate urine
  client may report polyuria or/and nocturia
  Anemia develops

47
Three Stages of CRF

• Stage 3
• End-stage renal disease (ESRD)
• Final Stage
• Characterized by a gt90 loss of nephron function
• Characterized by ?BUN ?Creatinine and electrolyte
  imbalances
• Uremic symptoms
• Requires Life-long Dialysis

48
Clinical Manifestations

• Retention of Nitrogenous Wastes
• As ? GFR ? BUN ? Creatinine
• Metabolic Acidosis
• ? pH and ?HCO3
• Electrolyte Imbalances
• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia
• Hypermagnesemia
• Hyponatremia

49
Clinical Manifestations

• Genitourinary System
• Renal insufficiency polyuria, kidneys can no
  longer concentrate urine
• Nocturia frequent waking at night to urinate
• Specific gravity fixed at 1.010
• As renal failure progressesOliguria? Anuria
• Urine findings casts, WBC hematuria
• Psychological Changes
• Personality and behavior changes
• Decreased ability to concentrate
• Emotional lability
• Anxiety and Depression

50
Clinical Manifestations Cont.,

• Neurologic System
• General CNS depression
• Lethargy, apathy fatigue ? alterations in
  mental status ? convulsions ? LOC ? coma
• Peripheral Neuropathy
• Restless leg syndrome ?paresthesias ? motor
  involvement foot drop muscle weakness ?
  paralysis
• Need dialysis or transplant should improve CNS
  symptoms

51
Clinical Manifestations Cont.,

• Cardiovascular System
• Hypertension
• Increased sodium and fluid retention
• Peripheral Edema
• Cardiac Dysrhythmias
• Hyperkalemia Hypocalcemia
• Heart failure
• Uremic pericarditis
• Friction rub, chest pain and low-grade fever
• May progress to pericardial effusion tamponade

52
Clinical Manifestations Cont.,

• Respiratory System
• Kussmauls respirations
• Usually less prominent in CRF versus ARF
• Pulmonary edema and dyspnea
• Secondary to heart failure or overload
• Uremic pleuritis
• Pleural effusion
• Predisposed to respiratory infections
• Thick sputum decreased cough reflex

53
Clinical Manifestations Cont.,

• Gastrointestinal System
• Excessive urea causes inflammation of mucosa
  along the entire GI tract
• Anorexia, hiccups, nausea vomiting
• Oral mucosal ulcerations
• Stomatitis
• Metallic taste in mouth
• Ammonia odor to breath (uremic fector)
• Diarrhea
• Constipation

54
Clinical Manifestations Cont.,

• Anemia
• Inadequate erythropoietin production
• Decreased life span of RBC
• Nutritional deficits
• S/SX fatigue, shortness of breath and even
  angina
• Renal Osteodystrophy
• A syndrome of skeletal changes found in CRF from
  alterations in calcium phosphate metabolism and
  elevated PTH levels
• ? PTH reabsorbs calcium phosphorous from bone
  stores in an attempt to increase serum calcium
  levels.
• Long term effects bone deformity and weakness

55
Clinical Manifestations Cont.,

• Integumentary System
• Yellowish-bronze discoloration to skin
• Retention of urinary chromogens (pigment)
• Pallor
• Result of anemia
• Dry, scaly skin
• Decreased oil and sweat glands
• Pruritus
• Calcium-phosphate deposits on skin / dry skin
• Petechiae and ecchymosis
• Abnormal platelet function and coagulation
  factors
• Uremic frost
• White crystals on skin as a result of urea

56
Clinical Manifestations Cont.,

• Other Considerations
• Increased triglyceride levels
• Occurs in 30-70 in CFR
• Increased blood sugars
• Usually moderate alterations cellular use of
  glucose
• Increased tendency to bleed
• Altered platelet function and coagulation factors
• Increased risk of Infection
• Impaired leukocyte function and immune responses
• Reproductive Dysfunction
• Infertility and decreased libido

57
Medical Management

• Goals of Conservative Medical Management
• Preserve existing renal function
• Treatment of symptoms
• Prevent Complications
• Comfort
• Conservative Medical Management
• Pharmacologic
• Nutrition
• Support

58
Parmacologic Management

• Conservative Therapies
• Severe Hyperkalemia
• I.V. Glucose Regular Insulin
• I.V. Calcium Gluconate
• I.V. Sodium Bicarbonate
• Kayexalate
• Dietary Restrictions
• Hypertension
• Na and fluid restrictions
• Antihypertensive medications
• Ace Inhibitors Calcium Channel Blockers

59
Medical Management Cont.,

• Renal Osteodystrophy
• Treatment of Increased Phosphate
• Dietary Restrictions
• Phosphate binders with daily meals
• Often accompanied by stool softeners
• Avoid magnesium containing antacids
• Magnesium toxicity and anemia
• Treatment of Decreased Calcium
• Supplements
• Active form of Vitamin D i.e. Calcitrol
  (Rocaltrol)
• Calcium and Vitamin D
• Parathyroid (PTH) Management
• Possible partial- parathyroidectomy

60
Medical Management Cont.,

• Metabolic Acidosis
• Sodium bicarbonate
• Anemia
• Epogen
• Ferrous Sulfate
• Folic Acid
• Other Pharmacologic Considerations
• Anti-seizure medications
• Anti-emetic medications
• Anti-ulcer / GI protectors

61
Management Considerations

• Pharmacologic Therapies
• Drug toxicity
• Increased effects
• Nephrotoxic agents
• Renal Dosing
• Medications eliminated by kidneys may be given
  in lower doses and/or with longer time intervals
  between doses
• When conservative management is no longer
  effective
• Some form of dialysis or renal transplant is
  required to prolong life.

62
Medical Management Cont.,

• Nutrition (Conservative Management)
• High-carbohydrate, Low-protein Diet
• Dietary Restrictions
• Protein
• 0.6-0.8 g/kg with dialysis may increase to 1-1.5
  g/kg
• Sodium, Potassium Phosphate
• Fluid Restriction
• All measurable output 500-600ml/day (insensible
  losses)
• Manage
• Glucose levels if necessary
• Supplements
• Vitamins

63
CRF Possible Complications

• Cardiac dysrhythmias
• Heart Failure
• HTN
• Pericardial Effusion
• Pulmonary Effusion

• Hyperparathyroidism
• GI Bleed
• Uremia
• Anemia
• Renal Osteodystrophy

64
Nursing Management

• Maintain
• Dietary Fluid Restrictions
• Dietician consult
• Administer
• Medications as prescribed
• Monitor/Assess
• Fluid / electrolyte balances
• Vital signs
• Bruising /bleeding
• Laboratory results

• Provide
• Skin care and mouth care
• Pulmonary Toileting
• Protect from infection
• Quiet environment
• Provide support
• To client and significant others

65
Nursing Education

• Keep follow-up appointments
• Avoid OTC medications
• Magnesium cont. laxatives or antacids
• NSAIDS etc.
• S/Sx of worsening renal function
• Edema, hyperkalemia and other electrolyte
  imbalances
• When to notify doctor
• n/v more than once
• Rapid weight gains

• Smoking Cessation
• Maintain normal weight
• Medications use, dose, and side effects
• Diet
• Avoid infection
• Importance of good hygiene
• Rest-activity balance
• Follow
• Diet
• Fluid restrictions
• How to check
• Pulse, BP weight

66
Nursing Diagnoses for Renal Failure

• Fluid volume deficit related to hypovolemia
• Fluid volume excess related to inability of
  kidneys to produce urine (2nd to RF)
• Altered renal perfusion related to damaged
  nephrons related to underlying insult
• Potential for alterations in nutrition related to
  anorexia and/or dietary restrictions
• Skin Integrity, high-risk for impairment related
  to poor cellular nutrition

67
Nursing Diagnoses for Renal Failure Cont.,

• Potential for infection related to suppressed
  immune responses associated with azotemia
• Anxiety, related to unknown outcomes of disease
  processes of renal failure
• Potential for altered family processes related to
  health crisis in family member
• Knowledge deficit, related to renal failure and
  treatment regimes