Chronic Renal Failure

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intgumentary effects renal failure

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pruritis brittle hair, nails, eccymosis, yellow brown discoloration of skin

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musculoskeletal effects renal failure

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cramps and weakneitiesss, long term renal osteodystrophy: bone pain, deform

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hematologic effects renal failure

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anemia, dec. platelets, prolonged clotting times, dec. leukocytes

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endocrine effects renal failure

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glucose intolerance

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reproductive effects renal failure

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dec. libido, infertility

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azotemia

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accumulation of nitrogenous waste in bloodstream

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uremia

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accumulation of urea, azotemia with symptoms

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chronic renal failure risk factors

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> 60, african, native amers. and asian., smoking, + fam. history, HTN, DM, SLE, sickle cell.

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3 stages chronic renal failure

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1. Decr. renal reserve
2. renal insufficiency
3. ESRD

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1st stages chronic renal failure:
decreased renal reserve charactesristic

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loss of 45-75% of nephron function, usually asymptomatic

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2nd stages chronic renal failure:

renal insufficiency

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75-80% loss of nephron fn,
clinical manifestations:
inc serum Cr, Inc. BUN, inc. PO4
cant concentrate urine, polyuria
anemia develops

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3rd stages chronic renal failure:

ESRD

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>90% nephron loss
clinical manifestations:
inc serum Cr, Inc. BUN,elctrolye imbalances, uremia affecting all systems. requires dialysis ir transplant

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renal failure electrolye imbalances

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hyperkalemia
hyperphosphatemia
hypermagnesia
hypocalcemia
hyponatrimia, (dilutional)
Metabolic acidosis

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renal failure fluid effects

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decr urine output causes fluid retention, JVD bounding pulses, inc CVP and Artery pressure

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clinical manifestations of RF on genitourinary system

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oliguria
urine findings: casts, RBC, WBC, protein, spec gravity decreased and fixed at 1.010, urine osmolarity< serum osmolarity. Dec. Cr clearance

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clinical manifestations of RF on neurologic system

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fatigue, confusion, lethargy, changes in LOC, seizures, coma

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clinical manifestations of RF on cardiac system

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dysrhythmias, HTN, Hyperlipidemia, preripheraledema, heart failure, uremic pericarditis

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clinical manifestations of RF on respiratory system

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kussmaul respirations, crackles, uremic pleuritis

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clinical manifestations of RF on GI system

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anorexia, N&V, stomatitis, metallic taste, GI bleed

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Tx for hyperkalemia

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IV glucose: moves K+ into cells
IV sodium bicarbonate: addresses meta acidosis, moves H+ out of cells, allows K+ to move in
IV calcium glutonate: decreases cardiac irritibility
Kayexelate: binds with K+ in GI tract

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Tx for hyperphosphatemia

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Phosphate binders

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Renagel

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phospahte binder, give with meals

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Calcium acetate

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phospahte binder, give with meals

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Tx fo hypocalcemia

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Give Ca+, synthetic activated Vitamin D (calcitrol)

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Renal failure conservative mgt
Acid base imbalances

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IV sodium bicarbonate

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Renal failure conservative mgt
HTN

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ACE I
Angiotensin II receptor blockers(ARB's)
CCB

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Renal failure conservative mgt
anemia

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RBC transfusion
EPO
Ferrous sulfate
folic acid

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Renal failure conservative mgt
pain

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avoid NSAID's demerol and morphine, use dilaidid, percocet

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Nutrition-renal diet: calories

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Met with high carb diet

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Nutrition-renal diet: glucose

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moitoring and control

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Nutrition-renal diet: dietary restrictions

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low protein <6gm/kg/day
ptassium
sodium
phosphorous

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Renal failure Intervenions:
monitoring

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VS, I&O, CBC, urinalysis, C&S
acidbase imbalances, S&S infection

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Renal failure Intervenions:
management

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maintain diet, fluid restrictions, bedrest(semifowler), quiet

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Renal failure Intervenions:
infection

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avoid unnecessary foley, asceptc techinque, pulmonary care, skin and mouth

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hypermagnesia: foods to avoid

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meat, nuts, legumes. limit fish, veg, whole grain

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RF when to notify phyician

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rapid weight gain>2lbs/day, or recurrent N&V

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S&S worsening renal function

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S&S of infection, and hyperkalemia

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Protein restriction

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early protein restriction can preserve some renal function
Renal failure: 0.6 gm/kg/day
on dialysis: 1-1.5 g/kg/day
peritoneal dialysis, a little more

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ACE I and renal failure

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causes hyperK+. decreased excretion can cause ototoxicity

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uremic halitosis

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causes stomatitis

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assessing protein intake

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decr. serum albumin: not enough intake
incr. Serum BUN: to much protein

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dietary protein restriction

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60-70 mEq/day

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dietary PO4 restriction

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700 mg/day

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Anemia in RF

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decr. RBC, fatigue, pallor, tachycardia

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high K+ serum levels symptoms

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weakness, cramps,numbness,achy muscles, peaked T waves

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Tx serum K+ 6.0

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K+ restritive diets, monitor, kayexelate with D10 and insulin

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Tx serum K+ 6.5

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dialysis

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water soluable vitamins in dialysis

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removed, edd replaced

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low serum Ca++ symptoms

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muscle twitch, tetany, seizures, bone demineralization

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symptom High PO4 levels

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renal osteodystrophy

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Tx low serum Ca++

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oral Ca++, may give vitamin D

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Tx High PO4 levels

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PO4 binders, low protein diet, ROM, encourage mobiltiy

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Vitamin D

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Kidney produce hormone to create active form of Vitamin D, ergo, vit D deficiency and hosphate retention.

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bone changes

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occr due to resorbtion(calcium loss) and excess phosphate

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red eye syndrome and TX

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Ca++ deposit in conjunctiva, Tx comtrol phos, use artificial tears

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metastatic calcification

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calcium phosphate deposits on lungs, heart vessels.

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calcium acetate

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phosphate binder phos-lo, phos-ex, take WITH meals, start 0.5 to 1 gm/meal. monitor for hypercalcemia

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calcium carbonate

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phosphate binder tums, os-cal, Take STAT with meal, no more than 5 minutes before. 300-700 mg/meal. monitor for hypercalcemia

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aluminum carbonate

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phosphate binder baseljel, use only as necessary then switch to calcium based. Incr aluminum levels

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excess aluminum

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osteomalacia, proximal myopathy, encephalopathy, microcytic anemia

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proximal myopathy

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muscle wasting of the shoulders, upper arms, thighs, and pelvis

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osteomalacia,

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softening of the bones

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Kayexelate Oral

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K+ binder
given wit 2-100 mg sorbitol. do not mix with food containig K+. works in 2-12 hours

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Kayexelate rectal

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K+ binder
cleansing enema first, give as retention enema. hold for several hours if possible. Give with 50-100 cc H2O. Takes hours to days to work.

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hypertonic glucose + insulin

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Tx for hyperK+. works fast. K+ moves out of serum into cells. lasts 2-4 hours.

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b12

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once per day

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renal multivitamin

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2x per day after dialysis

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folic acid

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PO daily

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calcitrol

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Vitamin D

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Taking Iron

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do not take w/other Rx or food.
Empty stomach
Take after dialysis
if nausea, take w/small amt. of food or more water.

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Acute renal failure nutrition

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hi calorie, hi CHO/fat, restrict protein, restrict K+ during oliguria

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chronic renal failure nutrition

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decr. Na, K, PO4
CHO=100 mg/day
protein=.5g/kg/day

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uremic breath

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ammonia

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Increase PO4 causes pruitis

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Tx is benadryl

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Rtention of wastes

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H/A lethargy, perpheral nephropathy, pallid grey complexion, moutht lesions, decreased saliva, GI tract ulcers, incr. bleeding, blurred vision, itching, kussmaul, cramps, insomnia.

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Dialysis access flow rates

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best fistula
2nd graft,
3rd cahteter

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digoxin and dialysis

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hold before dialysis

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side effects of renal failure

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anemia, pallor, fatigue, SOB, dizzy

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dysequilibrium syndrome

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rapid removal of urea causing reverse osmosis/cerebral edema. H/A n&V seizures

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dysequilibrium syndrome Tx

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anticonvulsants

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AV fistula capacity

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250-400 ml/hr. artery and vein sewn together. requires two venipunctures

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first use syndrome

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allergic reaction can occur.

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peritoneal dietary restrictions

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not like hemodialysis, not as restrictive

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peritonela dialysis-heparin

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heparin not absorbed systemically ego no problems with clotting