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Group 3

Group 3

  1. 1. Anatomy: The Renal System <ul><li>Kidneys </li></ul><ul><li>Ureters </li></ul><ul><ul><li>Enter at oblique angle </li></ul></ul><ul><ul><li>Peristalsis </li></ul></ul><ul><ul><ul><li>Both prevent reflux </li></ul></ul></ul><ul><li>Bladder </li></ul><ul><ul><li>Capacity 300–500 ml </li></ul></ul><ul><li>Urethra </li></ul><ul><ul><li>Excretion; outside of body. </li></ul></ul><ul><ul><li>In Males surrounded by prostate </li></ul></ul>
  2. 2. Functions of the Renal System <ul><li>Elimination of Metabolic Wastes </li></ul><ul><li>Regulation of RBC Production </li></ul><ul><li>Regulation of Vitamin D & Calcium </li></ul><ul><li>Regulation of Blood Pressure </li></ul><ul><li>Regulation of Electrolyte, Acid-Base & Fluid Balances </li></ul>
  3. 3. Elimination of Waste Products <ul><li>Urea Nitrogen </li></ul><ul><ul><li>By-product of the protein metabolism. </li></ul></ul><ul><ul><li>Measured clinically via serum BUN </li></ul></ul><ul><ul><ul><li>Some amounts normally found in blood; Not a reliable indicator of renal function alone. </li></ul></ul></ul><ul><li>Creatinine </li></ul><ul><ul><li>A by-product of muscle metabolism. </li></ul></ul><ul><ul><ul><li>Normally, almost completely excreted </li></ul></ul></ul><ul><ul><ul><li>A more reliable as an indicator of renal function than BUN. </li></ul></ul></ul>
  4. 4. RBC Production <ul><li>Erythropoietin is a hormone that prompts bone marrow to produce RBC’s therefore more HgB to carry oxygen to cells. </li></ul><ul><li>Secreted in response to decreased amount of oxygen delivered to kidneys (i.e. anemia or hypoxia). </li></ul>
  5. 5. Vitamin D & Calcium Regulation <ul><li>Vitamin D from food sources must be converted into it’s active form by the kidneys. </li></ul><ul><li>Active Vitamin D increases absorption of calcium by the renal tubules and the intestines. </li></ul><ul><li>Required to maintain normal calcium balances with the body. </li></ul>
  6. 6. Blood Pressure & Fluid Regulation <ul><li>RAAS : Maintenance of blood volume & altering peripheral vascular resistance. </li></ul><ul><ul><li>Specialized JGA cells in the kidneys respond to decreased renal blood flow and pressures by releasing renin…activating angio. I -> lungs -> angio. II: </li></ul></ul><ul><ul><ul><li>Vasoconstriction </li></ul></ul></ul><ul><ul><ul><li>Stimulates aldosterone release from the adrenal cortex = Na & H2O retention (distal tubules). </li></ul></ul></ul><ul><ul><ul><li>Net Result: ↑ BP & ↑ renal blood flow . </li></ul></ul></ul><ul><li>Antidiuretic Hormone (ADH) : release from the posterior pituitary = H20 retention (collecting ducts). </li></ul>
  7. 7. Electrolyte Balances <ul><li>Potassium </li></ul><ul><ul><li>NL: 3.5 – 5.0 mEq /liter </li></ul></ul><ul><li>Sodium </li></ul><ul><ul><li>NL: 135-145 mEq / liter </li></ul></ul><ul><li>Calcium </li></ul><ul><ul><li>Total NL: 8.5 – 10.5 mg/dL </li></ul></ul><ul><ul><li>Ionized Calcium NL: 4.5- 5.1 mg/dL </li></ul></ul><ul><li>Magnesium </li></ul><ul><ul><li>NL: 1.8 – 2.7 mg /dL </li></ul></ul><ul><li>Phosphorous </li></ul><ul><ul><li>NL: 2.5 -4.5 mg/dL </li></ul></ul><ul><ul><li>*See Thalen (pp. 748-749; table 30-2 & 3) </li></ul></ul>
  8. 8. Acid-Base Balance <ul><li>Kidneys regulate day-to-day acid-base balances; not as rapid as lungs. </li></ul><ul><ul><li>Hydrogen: potent organic acidic </li></ul></ul><ul><ul><li>Bicarbonate (HCO3-): principle buffer </li></ul></ul><ul><li>CO2 + H20 ↔ H2CO3 ↔ H + HCO3 </li></ul><ul><li>LUNGS Carbonic Kidneys </li></ul><ul><li> Acid </li></ul>
  9. 9. Anatomy & Physiology: The Nephron <ul><li>Functional unit or the “heart” of the kidney </li></ul><ul><li>One million nephrons per kidney </li></ul><ul><li>Each can perform all individual functions of the kidney </li></ul>
  10. 10. Components of the Nephron See Thalen pp. 720-722
  11. 11. A Closer Look: Urine Formation <ul><li>Excretion of waste products and retention of essential electrolytes and water . </li></ul><ul><li>Three processes involved: </li></ul><ul><ul><li>Glomerular Filtration </li></ul></ul><ul><ul><ul><li>Glomeruli filter blood as it follows through the kidneys; creating filtrate. </li></ul></ul></ul><ul><ul><ul><li>Glomerular blood flow and pressures </li></ul></ul></ul><ul><ul><li>Tubular Reabsorption </li></ul></ul><ul><ul><ul><li>The movement of substances from the filtrate (renal tubules) into plasma (capillaries). </li></ul></ul></ul><ul><ul><li>Tubular Secretion </li></ul></ul><ul><ul><ul><li>The movement of substances from plasma into renal tubules to be excreted. </li></ul></ul></ul>
  12. 12. Factors Affecting Glomerular Filtration <ul><li>Glomerular Blood Flow: </li></ul><ul><ul><li>Plasma Hydrostatic Pressure </li></ul></ul><ul><ul><ul><li>Pushing pressure: result of arterial blood pressure; Favors filtration </li></ul></ul></ul><ul><ul><li>Plasma Oncotic / Osmotic Pressures </li></ul></ul><ul><ul><ul><li>Pulling pressure: result of plasma proteins (i.e. albumin); Opposes filtration </li></ul></ul></ul><ul><li>Pressure within the Bowman Capsule: </li></ul><ul><ul><li>Capsular Hydrostatic Pressures </li></ul></ul><ul><ul><ul><li>Pushing pressures from within the capsule; Opposes filtration </li></ul></ul></ul>
  13. 13. Glomerular Filtration Capsule Hydrostatic Pressure 14mmHg Plasma Hydrostatic Pressure 70 mmHg Plasma Oncotic Pressure 32mmHg <ul><li>70 mmHg </li></ul><ul><li>32 mmHg </li></ul><ul><li>38 mmHg </li></ul>Total Plasma 38 mmHg <ul><li>38 mmHg </li></ul><ul><li>14 mmHg </li></ul><ul><li>24 mmHg </li></ul>Forces Favoring Filtration: Plasma Hydrostatic Pressure Forces Opposing Filtration: Plasma Oncotic Pressure Capsule Hydrostatic Pressure NET FILTRATION PRESSURE = 24 mmHg ( 70 mmHg - 46mmHg ( 32mmHg + 14mmHG ) = 24mmHg )
  14. 14. General Renal Failure Symptoms <ul><li>Subjective </li></ul><ul><ul><li>Metallic taste in mouth </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Pruritis </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>Ammonia (urine) odor to breath </li></ul></ul><ul><ul><li>Oliguria / anuria </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Dysrhythmias </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Rapid weight gain </li></ul></ul><ul><ul><li>Dry, scaly skin </li></ul></ul><ul><ul><li>Peripheral edema </li></ul></ul>
  15. 15. Laboratory Studies <ul><li>Serum Analysis </li></ul><ul><ul><li>BUN (5-20mg/dl) </li></ul></ul><ul><ul><li>Creatinine (0.6 -1.5 mg/dl) </li></ul></ul><ul><ul><li>Osmolarity </li></ul></ul><ul><ul><li>H&H </li></ul></ul><ul><ul><li>Electrolytes (K+, Na+, Mg+, Ca++ & PO4-) </li></ul></ul><ul><li>Combination: Serum/Urine Analysis </li></ul><ul><ul><li>Creatinine Clearance (100-140 ml/min) </li></ul></ul><ul><ul><ul><li>Direct measure of glomerular filtration (GFR) </li></ul></ul></ul>See Thalen pp. 738-742
  16. 16. Renal Failure <ul><li>Is a severe impairment in or a total lack of renal function, which leads to disturbances in all body systems. </li></ul><ul><li>Classification According To Onset: </li></ul><ul><ul><li>Acute Renal Failure (ARF) </li></ul></ul><ul><ul><ul><li>Developing within hours to days with little time to adjust to the biochemical changes, but is potentially reversible with treatment. </li></ul></ul></ul><ul><ul><li>Chronic Renal Failure (CRF) </li></ul></ul><ul><ul><ul><li>Insidious & progressive development over a period of several years; allows for some adjustment to biochemical changes. </li></ul></ul></ul><ul><ul><ul><li>Irreversible; often necessitates some form of dialysis or transplantation for long-term survival. </li></ul></ul></ul>
  17. 17. Acute Renal Failure (ARF) <ul><li>Sudden loss of kidney function over a period of hour or days. </li></ul><ul><ul><li>Characterized by: </li></ul></ul><ul><ul><ul><li>A rapid decrease in GFR </li></ul></ul></ul><ul><ul><ul><li>Retention of metabolic waste </li></ul></ul></ul><ul><ul><ul><ul><li>A progressive ↑ in BUN & Creatinine levels. </li></ul></ul></ul></ul><ul><ul><li>Associated with: </li></ul></ul><ul><ul><ul><li>Classic finding of Oliguria (UO < 400ml/day); but may have normal to increase UO. </li></ul></ul></ul><ul><ul><ul><li>Fluid, electrolyte and acid-base imbalances </li></ul></ul></ul><ul><ul><li>Usually reversible with prompt treatment </li></ul></ul>
  18. 18. ARF: The Clinical Course <ul><li>Involves Four Distinct Phases: </li></ul><ul><ul><li>Onset (Initiation) Phase </li></ul></ul><ul><ul><li>Oliguric Phase </li></ul></ul><ul><ul><li>Diuresis Phase </li></ul></ul><ul><ul><li>Recovery Phase </li></ul></ul>
  19. 19. Chronic Renal Failure <ul><li>A progressive and irreversible loss of renal function over a period of months to years </li></ul><ul><ul><li>The kidneys can loss up to 80% of all nephrons with relatively few overt changes in functioning of the body. </li></ul></ul><ul><ul><li>Nephrons are destroyed and replace with scar tissue; remaining nephrons become hypertrophied and eventually fail to function. </li></ul></ul><ul><ul><ul><li>Resulting in alterations in all of body’s systems. </li></ul></ul></ul>
  20. 20. Precipitating / Risk Factors of CRF <ul><li>Environmental Or Occupational Factors </li></ul><ul><li>Systemic Disorders </li></ul><ul><ul><li>Diabetes Mellitus* </li></ul></ul><ul><ul><li>Hypertension* </li></ul></ul><ul><ul><li>Chronic glomerulonephritis or Pyelonephritis </li></ul></ul><ul><ul><li>Frequent obstructions of the urinary tract </li></ul></ul><ul><ul><li>Sickle cell anemia </li></ul></ul><ul><ul><li>Systemic lupus erythematous </li></ul></ul><ul><li>Increased Age </li></ul><ul><ul><li>> 60 years-old </li></ul></ul><ul><li>Race </li></ul><ul><ul><li>African-Americans, Native Americans & Asian Americans at greater risk </li></ul></ul><ul><li>Gender </li></ul><ul><ul><li>Men at slightly greater risk than women </li></ul></ul><ul><li>Positive Family History </li></ul><ul><ul><li>i.e. Polycystic kidney Disease </li></ul></ul><ul><li>Smoking </li></ul>
  21. 21. Stages of CRF <ul><li>Stage 1 </li></ul><ul><ul><li>Reduced Renal Reserve </li></ul></ul><ul><ul><ul><li>Characterized by a loss of 40-75% of nephron function. </li></ul></ul></ul><ul><ul><ul><li>Usually asymptomatic; remaining function nephrons able to rid the body of metabolic wastes. </li></ul></ul></ul>
  22. 22. Stages of CRF Cont., <ul><li>Stage 2 </li></ul><ul><ul><li>Renal Insufficiency </li></ul></ul><ul><ul><ul><li>Characterized by a 75-90% loss of nephron function. </li></ul></ul></ul><ul><ul><ul><li>Clinical Manifestations: </li></ul></ul></ul><ul><ul><ul><ul><li>↑ Serum Creatinine and ↑BUN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Kidneys loose ability to concentrate urine </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Client may report polyuria and nocturia. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Anemia develops </li></ul></ul></ul></ul>
  23. 23. Stages of CRF Cont., <ul><li>Stage 3 </li></ul><ul><ul><li>End-Stage Renal Disease (ESRD) </li></ul></ul><ul><ul><ul><li>Final Stage: Characterized by < 90% loss of nephron function or < 10% of functioning nephrons remain !! </li></ul></ul></ul><ul><ul><ul><li>Clinical Manifestations: </li></ul></ul></ul><ul><ul><ul><ul><li>↑ Serum Creatinine & ↑ BUN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Electrolyte Imbalances </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Uremia Affecting All Body Systems </li></ul></ul></ul></ul><ul><ul><ul><li>Requires life-long dialysis or renal transplant to prolong life !! </li></ul></ul></ul>
  24. 24. Renal Failure: Complications <ul><li>Seizures </li></ul><ul><li>Coma </li></ul><ul><li>Heart Failure </li></ul><ul><li>Pericardial & Pulmonary Effusions </li></ul><ul><li>GI Ulcerations & Bleeding </li></ul><ul><li>Renal Osteodystrophy </li></ul><ul><li>Secondary Hyperparathyroidism </li></ul>
  25. 25. Renal Failure: Conservative Management <ul><li>Fluid Imbalances </li></ul><ul><ul><li>Volume Excess </li></ul></ul><ul><ul><ul><li>Fluid Restriction </li></ul></ul></ul><ul><ul><ul><ul><li>24 hour UO + 500-600ml </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Daily weights & I&O’s are essential !! </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Also, treatment for hyponatremia </li></ul></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><ul><li>Loop: i.e. Furosemide (Lasix) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Osmotic: i.e. Mannitol (Osmitrol) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Both promotes diuresis and increases renal blood flow. </li></ul></ul></ul></ul></ul>
  26. 26. Renal Failure: Conservative Management Cont., <ul><li>Acid-Base Imbalances ( ↓pH & ↓HCO3ˉ) </li></ul><ul><ul><li>Metabolic Acidosis </li></ul></ul><ul><ul><ul><li>I.V. Sodium Bicarbonate </li></ul></ul></ul><ul><li>Hypertensive Management </li></ul><ul><ul><li>ACE Inhibitors </li></ul></ul><ul><ul><li>Angiotensin II Receptor Blockers (ARB’s) </li></ul></ul><ul><ul><li>Calcium Channel Blockers </li></ul></ul><ul><li>Anemia </li></ul><ul><ul><li>RBC transfusions </li></ul></ul><ul><ul><li>Epogen: Stimulates RBC production </li></ul></ul><ul><ul><li>Ferrous sulfate and folic acid supplements </li></ul></ul>
  27. 27. Nursing Diagnoses: Renal Failure <ul><li>Fluid volume excess related to inability of kidneys to produce urine. </li></ul><ul><li>Altered renal perfusion related to damaged nephrons secondary to acute or chronic renal failure. </li></ul><ul><li>Nutrition Altered: less than body requirements related to renal failure or dietary restrictions. </li></ul><ul><li>Skin Integrity, high-risk for impairment related to poor cellular nutrition. </li></ul>
  28. 28. Nursing Diagnoses: Renal Failure Cont., <ul><li>Infection, high-risk for impairment related to lowered resistance </li></ul><ul><li>Potential for infection related to suppressed immune responses associated with azotemia. </li></ul><ul><li>Anxiety, related to unknown outcomes of disease processes of renal failure </li></ul><ul><li>Potential for altered family processes related to health crisis in family member. </li></ul><ul><li>Knowledge deficit related to renal failure and/or its treatments </li></ul>
  29. 29. Renal Failure: Nursing Education <ul><li>Explain: </li></ul><ul><ul><li>Renal Failure (and its etiology) </li></ul></ul><ul><ul><li>Dietary Restrictions / Supplements </li></ul></ul><ul><ul><li>Fluid Restriction </li></ul></ul><ul><ul><li>Medications (side effects too) </li></ul></ul><ul><ul><li>Signs & Symptoms: </li></ul></ul><ul><ul><ul><li>Worsening renal function; signs and symptoms of infection & hyperkalemia </li></ul></ul></ul><ul><ul><li>When to Notify Physician: </li></ul></ul><ul><ul><ul><li>i.e. Rapid weight gains ( > 2 lbs /day) or recurrent nausea / vomiting </li></ul></ul></ul>
  30. 30. Renal Failure: Nursing Education Cont., <ul><li>Demonstrate how to check daily weights and to assess for edema. </li></ul><ul><li>Stress the Importance of: </li></ul><ul><ul><li>Keeping follow-up appointments </li></ul></ul><ul><ul><li>Importance of good hygiene </li></ul></ul><ul><ul><li>Maintaining an activity-rest balance </li></ul></ul><ul><ul><li>Maintaining a normal weight </li></ul></ul><ul><ul><li>Smoking Cessation </li></ul></ul><ul><ul><li>Avoiding OTC medications i.e. NSAIDs </li></ul></ul>
  31. 31. Renal Dialysis <ul><li>Process of movement of fluid and particles from one fluid compartment to another across a semipermeable membrane. </li></ul><ul><ul><li>Removes excess fluid and metabolic waste products from the body when the kidneys are unable to do so. </li></ul></ul><ul><ul><li>Can be done in-home, in-hospital or in-center </li></ul></ul><ul><ul><li>The need for dialysis maybe acute or chronic in nature. </li></ul></ul>
  32. 32. General Principles of Dialysis <ul><li>Diffusion </li></ul><ul><ul><li>Toxins and waste products are moved from an area higher concentration in the client’s blood to an area of lower concentration the dialysate solution. </li></ul></ul><ul><li>Osmosis </li></ul><ul><ul><li>Excess water is moved from a higher concentration in the client’s blood to a lower concentration in the dialysate solution. </li></ul></ul>
  33. 33. General Principles of Dialysis Cont., <ul><li>Ultrafiltration </li></ul><ul><ul><li>Removal of excess water by creating a pressure gradient between the positive hydrostatic pressure of the client’s blood and the negative hydrostatic pressure (suctioning force) applied to the dialysate solution. </li></ul></ul><ul><ul><li>More efficient water removal than osmosis </li></ul></ul>
  34. 34. Indications For Acute Dialysis <ul><li>Hyperkalemia </li></ul><ul><li>Fluid Overload </li></ul><ul><li>Impending pulmonary edema </li></ul><ul><li>Pericarditis </li></ul><ul><li>Drug overdose or poisoning </li></ul><ul><li>Acidosis </li></ul><ul><li>Severe mental confusion </li></ul>
  35. 35. Indications For Chronic Dialysis <ul><li>End-Stage Renal Disease (ESRD) </li></ul><ul><ul><li>Hyperkalemia </li></ul></ul><ul><ul><li>Nausea / Vomiting </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Mental confusion </li></ul></ul><ul><ul><li>Increasing lethargy </li></ul></ul><ul><ul><li>Fluid overload despite medical therapies </li></ul></ul><ul><ul><li>Pericardial friction rub indicates an urgent need for dialysis </li></ul></ul>
  36. 36. Mnemonic “ AEIOU ” <ul><li>A cid-base Imbalances </li></ul><ul><li>E lectrolyte Disturbances </li></ul><ul><li>I ntoxication </li></ul><ul><li>O verload, Fluid </li></ul><ul><li>U remic Symptoms </li></ul>
  37. 37. Hemodialysis <ul><li>Most common method of dialysis </li></ul><ul><li>Maybe used for short-term therapy (days to weeks) in acutely ill or life-long therapy as in ESRD. </li></ul><ul><ul><li>Life-Long Therapy </li></ul></ul><ul><ul><ul><li>3 times a week for 3-4 hours each session </li></ul></ul></ul><ul><ul><ul><li>Prevents death, but does not cure renal disease </li></ul></ul></ul><ul><li>Dialysis machine removes “dirty” blood, cleanses it and then returns it to the body. </li></ul>
  38. 38. The Process of Hemodialysis <ul><li>Blood is removed from the arterial end and pumped through the dialysis machine (extracorporeal circuit) to the dialyzer at 200- 400 ml/min (rapid flow). </li></ul><ul><ul><li>Heparin added to blood to prevent clotting with in the dialysis machine. </li></ul></ul><ul><li>The dialyzer receives arterial blood flow along one side of the semipermeable membrane, with the dialysis solution flowing along the other side, usually in the opposite (countercurrent) direction. </li></ul><ul><ul><li>Osmosis, Diffusion & Ultrafiltration Occur </li></ul></ul><ul><li>The filtered blood then is returned through venous access to the client. </li></ul>
  39. 39. Vascular Access <ul><li>Short-Term Devices </li></ul><ul><ul><li>Venous Catheters </li></ul></ul><ul><ul><li>Arteriovenous (A-V) Shunts </li></ul></ul><ul><li>Long-Term Devices </li></ul><ul><ul><li>Arteriovenous (A-V) Fistulas </li></ul></ul><ul><ul><li>Arteriovenous (A-V) Grafts </li></ul></ul>
  40. 40. Hemodialysis: Nursing Considerations <ul><li>Strict aseptic technique during dialysis </li></ul><ul><li>Universal precautions </li></ul><ul><li>Continuous monitoring of vital signs </li></ul><ul><ul><li>Watch for hypotension from rapid fluid shifts!! </li></ul></ul><ul><li>Monitor Laboratory Results </li></ul><ul><ul><li>i.e. CBC, BUN, Creatinine & PTT levels </li></ul></ul><ul><li>Observe for signs & symptoms of </li></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><li>Monitor Fluid balance </li></ul><ul><ul><li>Daily weights and I & O’s </li></ul></ul>
  41. 41. Hemodialysis: Nursing Considerations Cont., <ul><li>Chronic Access Devices </li></ul><ul><ul><li>Assessment </li></ul></ul><ul><ul><ul><li>Auscultate for bruit & palpate for thrill </li></ul></ul></ul><ul><ul><ul><li>Neurovascular Checks </li></ul></ul></ul><ul><ul><ul><li>Monitor for s/sx of infection </li></ul></ul></ul><ul><ul><ul><li>No blood pressure or venipuncture to the extremity with A-V access. </li></ul></ul></ul><ul><ul><li>Education </li></ul></ul><ul><ul><ul><li>Care of device </li></ul></ul></ul><ul><ul><ul><li>No constrictive clothing, avoid sleeping on arm with access </li></ul></ul></ul><ul><ul><ul><li>Signs and symptoms of infection </li></ul></ul></ul>
  42. 42. Hemodialysis: Pharmacologic Considerations <ul><li>Some medications are removed during hemodialysis. </li></ul><ul><ul><li>Caution with medication administration prior to dialysis </li></ul></ul><ul><ul><li>Daily Medications usually administered after dialysis or at night </li></ul></ul><ul><ul><li>Medication doses often need to be adjusted with the initiation of dialysis </li></ul></ul><ul><li>Protein bound medications or some drug metabolites are not removed </li></ul><ul><ul><li>Tend to remain in system longer; prone to toxicity. </li></ul></ul>
  43. 43. Complications of Hemodialysis <ul><li>Hypotension </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Chest Pain </li></ul><ul><li>Muscle Cramping </li></ul><ul><li>Exsanguination </li></ul><ul><li>Air embolism </li></ul><ul><li>Sleep Disorders </li></ul><ul><li>Hyperlipidemia (esp. triglycerides) </li></ul>
  44. 44. Complications of Hemodialysis Cont., <ul><li>Dialysis Disequilibrium Syndrome </li></ul><ul><ul><li>Acute disorder occurring during or shortly after hemodialysis procedure. </li></ul></ul><ul><ul><ul><li>Results from the faster removal of urea from plasma than brain & cerebrospinal fluid causing water from plasma to be shifted into the brain= cerebral edema. </li></ul></ul></ul><ul><ul><ul><li>S/Sx: HA, N/V, muscle cramps, restlessness, decreased level of consciousness and seizures </li></ul></ul></ul>
  45. 45. Complications of Hemodialysis Cont., <ul><li>Dialysis Encephalopathy </li></ul><ul><ul><li>Occurs in clients on chronic hemodialysis </li></ul></ul><ul><ul><li>Results from aluminum toxicity </li></ul></ul><ul><ul><ul><li>i.e. aluminum containing antacids or dialysate bath </li></ul></ul></ul><ul><ul><ul><li>S/Sx: dementia, muscle uncoordination, speech disturbances, personality changes and later seizures </li></ul></ul></ul>
  46. 46. Peritoneal Dialysis <ul><li>Indications for peritoneal dialysis: </li></ul><ul><ul><li>Acute or Chronic Renal failure </li></ul></ul><ul><ul><li>Young Children & Older Adults </li></ul></ul><ul><ul><li>Severe Cardiovascular Disease </li></ul></ul><ul><ul><li>Diabetes Mellitus </li></ul></ul><ul><ul><li>Client with bleeding disorders and can not tolerate systemic use of heparin. </li></ul></ul><ul><li>Principles of Peritoneal Dialysis </li></ul><ul><ul><li>Osmosis, Diffusion & Ultrafiltration </li></ul></ul><ul><ul><ul><li>Ultrafiltration: pressure gradient established by high dextrose content of dialysate solution. </li></ul></ul></ul>
  47. 47. Peritoneal Dialysis Cont., <ul><li>Contraindications </li></ul><ul><ul><li>Recent abdominal surgery </li></ul></ul><ul><ul><li>Previous abdominal surgery resulting in scaring and adhesions </li></ul></ul><ul><ul><li>Significant pulmonary disease </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Client that requires rapid fluid removal . </li></ul></ul>
  48. 48. Peritoneal Dialysis Cont., <ul><li>The peritoneum, a serous membrane that covers the abdominal organs functions as the semipermeable membrane to the capillaries below. </li></ul><ul><ul><li>A catheter is inserted into the abdomen for access. (i.e. Tenckhoff catheter) </li></ul></ul><ul><ul><li>Exchanges : Dialysate instilled (over 5-10 min) at body temperature into the peritoneal cavity; left in (dwell time) usually is between 1- 8 hours. Fluid later drained over 10-30 min by gravity </li></ul></ul>
  49. 49. Peritoneal Dialysis Cont., <ul><li>Peritoneal drainage should be clear or straw-colored. </li></ul><ul><ul><li>Fluid maybe blood-tinged or pink the first treatment after new catheter insertion </li></ul></ul><ul><ul><li>Turn client side-to-side to facilitate drainage </li></ul></ul><ul><li>Dialysate composition, amount of dialysate used & dwell time as per MD. </li></ul>
  50. 50. Main Types of Peritoneal Dialysis <ul><li>Continuous Ambulatory Peritoneal Dialysis (CAPD) </li></ul><ul><li>Continuous Cycling Peritoneal Dialysis (CCPD) </li></ul>
  51. 51. Continuous Ambulatory Peritoneal Dialysis (CAPD) <ul><li>Completed in the home; As per MD’s orders </li></ul><ul><ul><li>Exchanges preformed 4-5 times a day, 7 days a week; dwell time from 4-8 hours. </li></ul></ul><ul><li>Advantages </li></ul><ul><ul><li>More consistent, less electrolyte imbalances </li></ul></ul><ul><ul><li>Frees client physically & mentally from dialysis centers </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>More opportunity for infection </li></ul></ul><ul><ul><li>Must be able to complete exchanges at more frequent intervals; less freedom for work and social engagements outside the home. </li></ul></ul>
  52. 52. Continuous Cycling Peritoneal Dialysis (CCPD) <ul><li>Completed in the home; As per MD’s orders </li></ul><ul><ul><li>Peritoneal automated cycler machine 4-5 exchanges completed during sleep, with one prolonged dwell time during the day . </li></ul></ul><ul><li>Advantages: </li></ul><ul><ul><li>Free from exchanges during the day allowing work and social activities outside the home. </li></ul></ul><ul><ul><li>Reduced risk of infection in comparison to CAPD </li></ul></ul><ul><ul><li>Frees client from attending dialysis centers </li></ul></ul><ul><li>Disadvantages: </li></ul><ul><ul><li>Prolonged daytime dwell time </li></ul></ul><ul><ul><li>Requires a peritoneal cycler machine </li></ul></ul><ul><ul><li>Less night-time mobility </li></ul></ul>
  53. 53. Peritoneal Dialysis <ul><li>Nursing Considerations </li></ul><ul><ul><li>Teaching Self-Care </li></ul></ul><ul><ul><ul><li>Stress the importance of proper hand washing </li></ul></ul></ul><ul><ul><ul><li>Explain and Demonstrate </li></ul></ul></ul><ul><ul><ul><ul><li>Basic aseptic technique </li></ul></ul></ul></ul><ul><ul><ul><ul><li>PD procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tenckhoff catheter exit site care </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Daily Weights </li></ul></ul></ul></ul><ul><ul><li>A home health care consult is necessary!! </li></ul></ul>
  54. 54. Complications: Peritoneal Dialysis <ul><li>Peritonitis </li></ul><ul><li>Bleeding </li></ul><ul><li>Abdominal Wall Hernias </li></ul><ul><li>Hyperlipidemia (esp. triglycerides) </li></ul><ul><li>Anorexia </li></ul><ul><li>Low-Back Pain </li></ul><ul><li>Catheter Malfunction </li></ul><ul><ul><li>Leakage </li></ul></ul><ul><ul><li>Occlusion </li></ul></ul>
  55. 55. Dialysis: Dietary Considerations <ul><li>“High” Protein Diet (1.0-1.5 g/kg/day) </li></ul><ul><li>Dietary Restrictions </li></ul><ul><ul><li>Sodium, Potassium & Phosphate </li></ul></ul><ul><ul><ul><li>Likely to continue; may be less severe </li></ul></ul></ul><ul><ul><ul><li>Use of phosphate binders likely to continue </li></ul></ul></ul><ul><li>Fluid Restrictions </li></ul><ul><ul><li>24 Hour UO + 500-600 ml </li></ul></ul><ul><li>Dietary Supplements </li></ul><ul><ul><li>Calcium </li></ul></ul><ul><ul><li>Active Vitamin D i.e. calcitrol (Rocaltrol) </li></ul></ul>
  56. 56. Long-Term Dialysis: Psychosocial Considerations <ul><li>Client’s and their significant others constantly vulnerable to medical, social and emotional crisis. </li></ul><ul><ul><li>In-center and in-hospital dialysis schedule according to the convenience of others. </li></ul></ul><ul><ul><ul><li>May affect work, schooling or leisure activities </li></ul></ul></ul><ul><ul><li>In-home dialysis may increase a client’s dependence. </li></ul></ul><ul><ul><ul><li>Sick Role </li></ul></ul></ul><ul><ul><ul><li>Often leads to caregiver strain </li></ul></ul></ul><ul><ul><li>Family roles and responsibilities change </li></ul></ul><ul><ul><ul><li>Creating tension, feelings of guilt or inadequacy </li></ul></ul></ul>
  57. 57. Long-Term Dialysis: Psychosocial Considerations Cont., <ul><ul><li>Financial burdens of treatment, medications and transportation </li></ul></ul><ul><ul><li>Changes in sexual function </li></ul></ul><ul><ul><ul><li>i.e. decreasing libido and impotence </li></ul></ul></ul><ul><ul><li>Body image disturbances </li></ul></ul><ul><ul><li>Fear, depression and anger are common and permissible </li></ul></ul><ul><ul><ul><li>Suicide rates increased in dialysis clients </li></ul></ul></ul><ul><ul><ul><li>Some act-out depression with non-compliance </li></ul></ul></ul><ul><ul><ul><li>Fear is common related to medications, infection and contracting HBV and/or HIV </li></ul></ul></ul>
  58. 58. Kidney Transplantation <ul><li>The treatment of choice of ESRD </li></ul><ul><ul><li>The average cost of maintaining a successful kidney transplant is 1/3 the cost of dialysis. </li></ul></ul><ul><ul><li>Medicare will cover 80% of the cost of transplant surgery </li></ul></ul><ul><ul><li>As of October 1, 2005 there are 63,301 individuals wait-listed to receive a kidney transplant ( </li></ul></ul><ul><ul><li>Lack of donors is a major problem!! </li></ul></ul><ul><li>Two main types of human donors </li></ul><ul><ul><li>Living (related or non-related) </li></ul></ul><ul><ul><li>Cadaver </li></ul></ul>
  59. 59. Kidney Transplantation Cont., <ul><li>Regulatory Agencies: </li></ul><ul><ul><li>United Network for Organ Sharing (UNOS) </li></ul></ul><ul><li>Regional Support Agencies: </li></ul><ul><ul><li>Gift of Life Program </li></ul></ul><ul><ul><li>Coalition on Donation (Southern NJ) </li></ul></ul><ul><li>Legislation: </li></ul><ul><ul><li>Uniform Anatomical Gift Act (1968) </li></ul></ul><ul><ul><li>End Stage Renal Disease Act (1972) </li></ul></ul><ul><ul><li>The National Organ Transplant Act (1984) </li></ul></ul><ul><ul><li>Organ Donation Leave Act (1999) </li></ul></ul>
  60. 60. Preoperative Considerations <ul><li>Informed Consent </li></ul><ul><li>Dialyzed within 24 hours of procedure to ensure best metabolic state as possible. </li></ul><ul><li>Donor Compatibility </li></ul><ul><ul><li>ABO (blood type) & cross-match antigens and HLA (human leukocyte antigens). </li></ul></ul><ul><li>Lower urinary tract studies to ensure proper functioning prior to transplant. </li></ul><ul><li>Screening for infection; must be infection free to proceed. </li></ul>
  61. 61. Preoperative Considerations Cont., <ul><li>Psychosocial Considerations: </li></ul><ul><ul><li>Some welcome transplant as freedom </li></ul></ul><ul><ul><li>Some anxious about the procedure, possible rejection or the need to return to dialysis or dietary restrictions. </li></ul></ul>
  62. 62. Intraoperative Considerations <ul><li>The donor kidney is placed in the iliac fossa, anterior to iliac crest. </li></ul><ul><li>The native kidney is usually left in for hormones unless cancer or prone to chronic infection. </li></ul>
  63. 63. Postoperative Considerations <ul><li>Standard Postoperative Care </li></ul><ul><ul><li>Monitor </li></ul></ul><ul><ul><ul><li>Vital Signs </li></ul></ul></ul><ul><ul><ul><li>Daily Weight and I&O’s </li></ul></ul></ul><ul><ul><ul><li>Strict aspesis with invasive lines and catheters </li></ul></ul></ul><ul><ul><li>Provide Pain Control </li></ul></ul><ul><ul><li>Prevent Infection </li></ul></ul><ul><ul><ul><li>Early Ambulation </li></ul></ul></ul><ul><ul><ul><li>Pulmonary Toileting </li></ul></ul></ul><ul><ul><ul><li>Incisional Care </li></ul></ul></ul><ul><ul><li>Administer medications as ordered </li></ul></ul><ul><ul><li>Advance diet with return of bowel sounds; encourage protein for healing </li></ul></ul>
  64. 64. Postoperative Considerations Cont., <ul><li>Immunosuppressive Therapy </li></ul><ul><ul><li>The survival of the kidney depends on blocking the body’s immune response. </li></ul></ul><ul><ul><ul><li>Neoral (cyclosporine) </li></ul></ul></ul><ul><ul><ul><li>Prograf (tracrolimus) </li></ul></ul></ul><ul><ul><ul><li>CellCept (mycophenolate) </li></ul></ul></ul><ul><ul><ul><li>Rapamune (Sirolimus) </li></ul></ul></ul><ul><ul><li>Doses gradually decreased over a period over several weeks, but will need to be on immunosuppressants for life !! </li></ul></ul><ul><ul><li>Complications: nephrotoxicity, decreased platelets and leukocytes and malignancies. </li></ul></ul>
  65. 65. Postoperative Considerations Cont., <ul><li>Immunosuppressive Therapy Cont., </li></ul><ul><ul><li>Corticosteroids </li></ul></ul><ul><ul><ul><li>i.e. Oral: Prednisone / I.V. Solu-Medrol </li></ul></ul></ul><ul><ul><ul><li>Doses gradually decreased, but require a life-long maintenance dose !! </li></ul></ul></ul><ul><ul><ul><li>Many Long-Term Adverse Effects: </li></ul></ul></ul><ul><ul><ul><ul><li>Glucose Intolerance; Monitor Closely !! </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Weight Gain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>GI Ulcerations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Osteoporosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increased Susceptibility to Infections </li></ul></ul></ul></ul><ul><ul><ul><li>Dietary Considerations: </li></ul></ul></ul><ul><ul><ul><ul><li>Glucose Intolerance: No concentrated sweets </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Weight Gain: Reduced caloric intake </li></ul></ul></ul></ul>
  66. 66. Kidney Transplantation: Complications <ul><li>Cardiovascular Disease </li></ul><ul><ul><li>Most common overall cause of mortality; occurs most often in the later stages of transplantation </li></ul></ul><ul><ul><li>3-5x more likely to have CV disease than normal population. </li></ul></ul><ul><li>Infection </li></ul><ul><ul><li>Common cause of mortality within the first year of transplantation. </li></ul></ul><ul><ul><li>Sources: urine, lung, operative site, catheters or drains. </li></ul></ul><ul><ul><li>S/Sx: shaking chills, fever, tachycardia, tachypnea, changes in WBC’s counts </li></ul></ul>
  67. 67. Kidney Transplantation: Complications Cont., <ul><li>Graft Rejection </li></ul><ul><ul><li>Three Types </li></ul></ul><ul><ul><ul><li>Hyperacute : </li></ul></ul></ul><ul><ul><ul><ul><li>Occurs within 24 hours of transplantation; usually within minutes. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>This type of rejection is rare due to advances in compatibility screening. </li></ul></ul></ul></ul><ul><ul><ul><li>Acute : </li></ul></ul></ul><ul><ul><ul><ul><li>Usually occurs in 6 weeks to 3 months, but can occur for up to 2 years after transplant. </li></ul></ul></ul></ul><ul><ul><ul><li>Chronic : </li></ul></ul></ul><ul><ul><ul><ul><li>Occurs slowly over months to years; often occurs more than 1 year of transplantation . </li></ul></ul></ul></ul>
  68. 68. Kidney Transplantation: Complications Cont., <ul><li>Graft Rejection Cont., </li></ul><ul><ul><li>Acute Rejection: </li></ul></ul><ul><ul><ul><li>Signs/Symptoms: </li></ul></ul></ul><ul><ul><ul><ul><li>Lethargy, fever, edema, weight gain, oliguria, HTN, tenderness & swelling of the graft site. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>An elevation in serum creatinine > 20% </li></ul></ul></ul></ul><ul><ul><ul><li>Management: </li></ul></ul></ul><ul><ul><ul><ul><li>Increased doses of Corticosteroids and other immunosuppressant agents </li></ul></ul></ul></ul>
  69. 69. Kidney Transplantation: Complications Cont., <ul><li>Graft Rejection Cont., </li></ul><ul><ul><li>Chronic Rejection: </li></ul></ul><ul><ul><ul><li>Signs/Symptoms (mimic CRF): </li></ul></ul></ul><ul><ul><ul><ul><li>Fatigue </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gradual increase in serum BUN and creatinine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Electrolyte imbalances . </li></ul></ul></ul></ul><ul><ul><ul><li>Management: </li></ul></ul></ul><ul><ul><ul><ul><li>Conservative therapies until dialysis required or a another transplant can be performed. </li></ul></ul></ul></ul>
  70. 70. Kidney Transplantation: Nursing Considerations Cont., <ul><li>Promoting Organ Donation: </li></ul><ul><ul><li>Stress to client the importance of sharing wishes to be an organ donor with significant others. </li></ul></ul><ul><ul><li>Provide information to the client and/or significant others; clarify any misconceptions. </li></ul></ul><ul><ul><li>Provide support and understanding the client and / or significant other during the decision making process. </li></ul></ul><ul><ul><li>Lead by example; become an organ donor. </li></ul></ul>
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