physiologic events that directly affect the kidney tissue structure and fxn
Describe 3 ways to get to Intrarenal ARF
untreated prerenal ARF/ischemia
exposure to nephrotoxic substances
Example of nephrotoxic substances
anything with a "mycin"-vanco, genta,
iodine contrast medium
What really happens with postrenal ARF?
the kidneys lose their ability to excrete nitrogen waste produced by protein metabolism
any obstruction in urine outflow from the collection ducts of the kidneys to the external urethral orifice
What is really going on with Postrenal ARF?
increased pressure in the kidneys, and they cant fxn.....
blockage makes urine back up in to the kidneys, increasing pressure causing a decrease in GFR
Examples of problems that can cause Postrenal ARF
Strictures/Adhesion-multiple abdominal surgeries
How do you know a persons ARF is getting better?
UO is increasing
Labs are back to normal
Edema is down
No more crackles in the lungs
What do you give a person to increase their BP to increase renal perfusion, which will increase their UO?
Multiple antibiotics =
What do you give a person with ARF who has low volume?
Clinical manifestations of Prerenal ARF
Oliguria <400mL/24 hours
Increased urine specific gravity
Collaborative Management of Prerenal ARF
ID cause and re establish renal perfusion
*Fenoldopam to increase blood flow to kidneys
Albumin to expand intrav. volume
Diuretics to encourage urine production
Dopamine to increase BP
Intrarenal ARF has 2 types
Ischemic and Nephrotoxic
Clinical Manifestations of Intrarenal ARF
Oliguria -<400mL in 24 hours or anuria
S/S of volume overload
Collaborative management for Intrarenal ARF
ID and treat cause
Clinical Manifestations of Post Renal ARF
Decreased GFR and excretion
*no actual impairment in kidney fxn??
Collaborative management of Post renal ARF
ID and remove the obstruction
Post obstruction diuresis will occur, so replace hourly urine output
Monitor electrolytes and acid base balance
Describe Oliguric ARF
gradual accumulation of nitrogenous wastes
lasts hours to days
Why metabolic acidosis with oliguric phase?
kidneys cant synthesize ammonia which is needed for H excretion, so unable to excrete acid metabolites
Why does the K increase during the oliguric phase?
they kidneys are unable to excrete 80-90% of the bodys K
What will show up in a patients EKG who has high K?
tall peaked T waves
Interventions for increases in K.....
5.5 and less=dietary changes
6 and above=dialysis
BUN at this level = a problem
During the diuretic phase what determines the amount of urine excreted?
it is related to how fluid volume overloaded the patient is...can be 4-5L/day
What is a big problem during the diuretic phase?
dumping lots of fluid volume, but the kidneys aren't healed, so they don't concentrate electrolytes.
What do I need to monitor a patient for in the diuretic phase?
What is normal UO?
1-2L/day...with the same for input
With a high K you can give....
diuretics to dump K
Describe the recovery phase...
begins when the GFR is stable
BUN and Creatinine levels are starting to stabilize, then they decrease to normal
*majority of improvements can occur in the first 2 weeks...but can continue for up to 12 months
Collaborative management of ARF
PREVENTION-ID patients at risk
Maintain fluid balance
Decrease further damage
Renal dosing of meds for clients with impaired renal fxn
Who is at risk to get ARF?
Look at patient hx
patients on nephrotoxic meds
patients with cardiovascular disease
increases renal perfusion
What is given to excrete K
phosphate binders....give with meals
How do we solve the problem of a person who needs to have a CT with contrast, but has renal issues?
give dye plus fluids
then after the procedure give Fenoldopam again to protect the kidneys
Platelets decreased adhesiveness....bleed easily
WBC increased...with infection
Serum pH low....acidic
Serum bicarb <22...low
Serum calcium low
Serum phos high
BUN increased...but not radically
Creatinine increased...but not radically
Creatinine Clearance is decreased WITH low GFR
How do you get a creatinine clearance?
it is a 24 hour urine collection
dump first collection
collect all urine for next 24 hours and store it in a ice bucket.
some time during that period have serum creatinine drawn
What is a normal Creatinine Clearance
Creatinine Clearance will tell you the extent of renal failure...what are the numbers?
If a persons creatinine clearance is at this level they will need renal replacement therapy....
What is a lab that is equal to and will tell you the same thing as creatinine clearance?
Key intervention for a person who has ARF
don't stop drinking water....may be a fluid max of 1500 cc, but don't stop drinking!
Diet for a person with ARF
low protein, K and na
passage of patient blood through an artificial kidney in order to remove fluid and waste products, then restores the fluid and electrolytes
Who is contraindicated to have hemodialysis?
severe cardiac disease
What is used to do hemodialysis
AV fistula or graft or
Central line...Quinton, or Perma Cath
How much fluid is removed during hemodialysis? Possible complication?
1000-3000 cc of fluid
BP can drop and MAP can be low
surgically created anastomosis btwn an artery and a vein.
*takes 6 weeks for this to be usable
surgically imposed graft btwn an artery and a vein
can use right away
dual lumen catheter capable of tolerating blood flow of 300cc/min
When will you use an AV line vs. a central line?
AV is used when you know the person is in ESRD...so have to wait 90 days after ARF.
Central lines are used more for temporary dialysis, or while you are waiting for the AV fistula to heal and be ready to use
Care for the patient with a fistula or graft
This is their life line....
no BP on that side
no blood draws from that extremity
no injections on in that extremity
no IV's in that extremity
watch for s/s of infection
watch for clotting
watch for signs of bleeding after dialysis
Nursing care of the patient pre dialysis
Hold the following meds:
Nursing care of the patient post dialysis
Observe for fluid volume deficit
Complete physical assessment
WATCH FOR NEURO CHANGES
Complication that can occur post hemodialysis. What does it present like?
Disequilibrium Syndrome-it is from movement of Na in to the brain. Pt. goes from hemodiluted to increase levels of Na post hemodialysis causing an increase in ICP
How does peritoneal dialysis work?
it uses the peritoneum as the semi permeable membrane. A diasylate is infused in to the peritoneal cavity thru and implanted catheter. Waste diffuses thru the membrane in to the dialysate, which is drained from the peritoneum thru the catheter
Peritoneal hemodialysis is best for....
people with severe cardiac disease
patients who cant tolerate systemic anticoagulation
patients who lack vascular access
Who cant have peritoneal dialysis?
anybody who has had multiple abd surgeries, or has known adhesions
How does peritoneal dialysis work?
1-2 L of dialysate is infused by gravity in to the peritoneal space over 10-20 min, and then it drains by gravity. The outflow contains the dialysate in addition to nitrogenous waste, excess water and electrolytes
Intermittent peritoneal dialysis
takes place over a prescribed time and is interrupted for a prescribed time before it resumes again
usually lasts about 40hrs a week....10hrs a day, 4 days a week
Major complication of peritoneal dialysis? S/S?
cloudy dialysate....should be clear, pale, yellow
Complications from peritoneal dialysis
People who also cant have peritoneal dialysis...and why?
cuz wont be able to take deep breaths with all of that dialysate in their abdomen
Nursing care for the person receiving peritoneal dialsysis
*Strict aseptic technique
Biggest nursing dx for ARF
potential for injury r/t hyperkalemia
Ways to decrease serum K
insulin/glucose admin IV
calcium gluconate IV
How much K should be consumed when you have too much?