Renal concepts

Page 1: Alteration in Renal Perfusion from Chronic Renal Failure

Concepts

• Fluid Volume Excess

  • Caused by altered elimination in renal failure

  • Monitoring is crucial; a weight gain of 1 kg (2.2 lbs) equals approximately 1 liter of fluid retained.

  • Nursing Care:

    • Weigh the patient regularly and monitor intake & output (I&O)

    • Assess neurological status and vital signs

    • Limit fluid and sodium intake

    • Refer to the chapter on Fluid Balance for specific interventions.

• Altered Electrolyte Balance

  • Hyponatremia (Dilutional)

  • Hyperkalemia

  • Metabolic Acidosis

  • Other concerns: Immobility, Skin integrity issues, Infection risks, Anemia from decreased erythropoietin production.

  • Look for indications of fluid retention which can lead to pulmonary edema, and heart failure due to fluid overload.

  • Monitor for dysrhythmias related to hyperkalemia and assess for muscle twitching or diarrhea.

  • Avoid salt substitutes due to high potassium content.

Nursing Responsibilities

• Continually assess respiratory rate (RR), arterial blood gases, BUN, creatinine levels, and monitor heart rhythm.

• Consider starting dialysis for patients with severe metabolic acidosis.

• Maintain skin integrity by keeping fingernails clipped and assessing for skin breakdown and pruritus.

• Emotional support for coping with chronic illness.

• Dietary adjustments towards low sodium, potassium, and protein.

• Encourage hydrotherapy for respiratory function; assessment of breath sounds every 4 hours per protocol.

Page 2: Hyperphosphatemia/Hypocalcemia from Chronic Renal Failure

System-Specific Assessments

• Symptoms:

  • TWITCH (muscle spasms): Trousseau's sign, facial twitching (Chvostek's sign), seizures, hypotension, increased deep tendon reflexes (DTR).

  • Monitor for dysrhythmias: prolonged ST segment, prolonged QT interval on ECG.

  • Increased nausea and vomiting.

Priority Interventions - SAFE

• Initiate seizure precautions, reduce environmental stimuli, administer calcium supplements, and phosphate binders with meals.

• Evaluate results for signs of bone disorders and ensure emergency equipment is present during treatment.

Evaluation of Expected Outcomes - TWITCH

• Trousseau's sign should be absent, no dysrhythmias, improved gastrointestinal symptoms, and no signs of tetany. Maintain stable blood pressure and normal DTR.

Page 3: Hyponatremia (Dilutional) from Chronic Renal Failure

System-Specific Assessments

• Symptoms:

  • EDEMA: Pitting edema, decreased hematocrit, elevated weight, increased BP, HR, RR.

  • Monitor serum sodium levels and assess mental status (lethargy, seizures).

Priority Interventions - RESTRICT

• Restrict fluid and sodium intake, monitor I&O, weight checks daily, and implement diuretics/dialysis as needed. Provide stool softeners to counteract constipation risk.

Evaluation of Expected Outcomes - EDEMA

• Fluid overall reduction with continued evaluation of neurological changes. Normal BP and HR monitoring alongside serum sodium within normal limits.

Page 4: Pathophysiology

Respiratory Status

• Metabolic acidosis due to lactic acid accumulation; respiratory compensation involves increased RR and depth to blow off CO2.

• Fluid overload can cause adventitious breath sounds and respiratory complications.

Nutritional Impacts

• Assessment for nutritional intake is crucial in managing chronic renal failure and related anemia.

• Monitor for potential GI bleeding and assess skin integrity.

Emotional and Neurological Status

• Look for signs of anxiety or depression due to physical changes. Monitor CNS reactions to increased waste products.

System-Specific Assessments

• Respiratory evaluations, BP monitoring, anemia assessments, and nutritional intake reviews.

Page 5: Renal Lab Review

Kidney Functions and GFR

• Kidneys are essential for regulating fluid/electrolyte balance and waste removal via glomerular filtration.

  • GFR < 15 mL/min indicates kidney failure.

  • Fluid overload due to inability to excrete profits can lead to complications.

Lab Abnormalities

• Elevated phosphorus (> 4.5 mg/dL) can lead to hypocalcemia.

  • The inverse relationship of calcium and phosphorus levels must be remembered.

  • Hemoglobin and hematocrit may be low due to decreased erythropoietin production.

Page 6: Safety and System-Specific Management

System-Specific Assessment - RENAL

• Monitor for adequate respiratory status and fluid retention leading to imbalance; include emotional support and nutritional needs.

• Look for signs of anemia and manage through appropriate interventions.

Priority Interventions - FAILURE

• Address fluid overload, provide support for anemia and fatigue, active infection management, and ensure thorough assessments for malnutrition.