Management of Patients with Renal Disorders. Glomerular Diseases Acute Glomerulonephritis Acute...
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Transcript of Management of Patients with Renal Disorders. Glomerular Diseases Acute Glomerulonephritis Acute...
Glomerular DiseasesGlomerular Diseases
Acute GlomerulonephritisAcute Glomerulonephritis Chronic Glomerulonephritis Chronic Glomerulonephritis Nephrotic SyndromeNephrotic Syndrome
Acute Acute GlomerulonephritisGlomerulonephritis
Preceded (10 days) by an infectionPreceded (10 days) by an infection Assess for:Assess for:
LesionsLesions Signs of circulatory overloadSigns of circulatory overload Change in urine color and amountChange in urine color and amount Mild to moderate hypertensionMild to moderate hypertension
Interventions:Interventions: Treat cause: antibiotics, corticosteroids, Treat cause: antibiotics, corticosteroids,
immunosuppressants immunosuppressants Restrict sodium, water, potassium, protein Restrict sodium, water, potassium, protein Dialysis, plasmapheresisDialysis, plasmapheresis Client education Client education
Nursing Management-Nursing Management-Acute Glomerulonephritis Acute Glomerulonephritis
Patient assessmentPatient assessment Maintain fluid balanceMaintain fluid balance Fluid and dietary restrictionsFluid and dietary restrictions Patient educationPatient education Follow-up careFollow-up care
Chronic Chronic GlomerulonephritisGlomerulonephritis
20-30+ years to develop20-30+ years to develop Diagnostics: Diagnostics:
Urine with fixed specific gravity, casts, and Urine with fixed specific gravity, casts, and proteinuriaproteinuria
Electrolyte imbalancesElectrolyte imbalances hypoalbuminemiahypoalbuminemia
Causes:Causes: Repeated episodes of acute Repeated episodes of acute
glomerulonephritis, hypertensive glomerulonephritis, hypertensive nephrosclerosis, hyperlipidemia, nephrosclerosis, hyperlipidemia,
Manifestations:Manifestations: Mild proteinuria and hematuria, Mild proteinuria and hematuria,
hypertension, and occasional edemahypertension, and occasional edema
Nursing Management: Nursing Management: Chronic Glomerulonephritis Chronic Glomerulonephritis AssessmentAssessment Potential fluid and electrolyte Potential fluid and electrolyte
imbalancesimbalances Cardiac statusCardiac status Neurologic statusNeurologic status Emotional supportEmotional support Teaching self-care Teaching self-care
Nephrotic SyndromeNephrotic Syndrome
Increased glomerular permeabilityIncreased glomerular permeability Severe loss of protein into urineSevere loss of protein into urine Treatment:Treatment:
Immunosuppresive agentsImmunosuppresive agents ACE InhibitorsACE Inhibitors HeparinHeparin Diet changesDiet changes Mild diuretics Mild diuretics
NephrosclerosisNephrosclerosis
Narrowing of vessel lumen from Narrowing of vessel lumen from thickening in blood vessels of the thickening in blood vessels of the nephronnephron
Occurs with hypertension, Occurs with hypertension, atherosclerosis and diabetes mellitusatherosclerosis and diabetes mellitus
Collaborative management:Collaborative management: Control hypertensionControl hypertension Preserve renal function Preserve renal function
Renal FailureRenal Failure Results when kidney’s cannot remove Results when kidney’s cannot remove
wastes or perform regulatory functionswastes or perform regulatory functions Systemic disorder resulting from many Systemic disorder resulting from many
different causesdifferent causes Acute renal failure- reversible Acute renal failure- reversible
syndrome that results in decreased syndrome that results in decreased GFR and oliguriaGFR and oliguria
Chronic renal failure- progressive; Chronic renal failure- progressive; irreversible deterioration of renal irreversible deterioration of renal function resulting in azotemia function resulting in azotemia
Acute Renal FailureAcute Renal Failure
PathophysiologyPathophysiology Types of acute renal failure include:Types of acute renal failure include:
Prerenal Prerenal Intrarenal Intrarenal Postrenal Postrenal
Phases of Acute Renal Phases of Acute Renal FailureFailure
Phases of rapid decrease in renal Phases of rapid decrease in renal function lead to the collection of function lead to the collection of metabolic wastes in the body.metabolic wastes in the body.
Phases include:Phases include: Onset Onset Diuretic Diuretic Oliguric Oliguric Recovery Recovery
Acute syndrome may be reversible Acute syndrome may be reversible with prompt intervention.with prompt intervention.
Assessment Assessment
History History Clinical manifestationsClinical manifestations Laboratory assessmentLaboratory assessment Radiographic assessmentRadiographic assessment Other diagnostic assessments such Other diagnostic assessments such
as renal biopsyas renal biopsy
Drug TherapyDrug Therapy CardioglycidesCardioglycides Vitamins and mineralsVitamins and minerals Biologic response modifiersBiologic response modifiers Phosphate bindersPhosphate binders Stool softeners and laxativesStool softeners and laxatives Monitor fluidsMonitor fluids DiureticsDiuretics Calcium channel blockersCalcium channel blockers
TreatmentTreatment
Diet therapyDiet therapy Dialysis therapiesDialysis therapies
HemodialysisHemodialysis Peritoneal dialysisPeritoneal dialysis
Renal Replacement Renal Replacement TherapyTherapy
Standard treatment Standard treatment Dialysate solutionDialysate solution Vascular accessVascular access Continuous arteriovenous Continuous arteriovenous
hemofiltration hemofiltration Continuous venovenous Continuous venovenous
hemofiltrationhemofiltration
Posthospital CarePosthospital Care
If renal failure is resolving, follow-up If renal failure is resolving, follow-up care may be required.care may be required.
There may be permanent renal There may be permanent renal damage and the need for chronic damage and the need for chronic dialysis or even transplantation.dialysis or even transplantation.
Temporary dialysis is appropriate for Temporary dialysis is appropriate for some clients.some clients.
Chronic Renal FailureChronic Renal Failure
Progressive, irreversible kidney Progressive, irreversible kidney injury; kidney function does not injury; kidney function does not recoverrecover
AzotemiaAzotemia UremiaUremia Uremic syndromeUremic syndrome
Stages of Chronic Renal Stages of Chronic Renal FailureFailure
Diminished renal reserveDiminished renal reserve Renal insufficiencyRenal insufficiency End-stage renal diseaseEnd-stage renal disease
Changes R/T CRFChanges R/T CRF
• Kidney Kidney • Metabolic Metabolic
– Urea and creatinineUrea and creatinine
• ElectrolytesElectrolytes– Sodium Sodium – PotassiumPotassium
• Acid-base balanceAcid-base balance• Calcium and phosphorusCalcium and phosphorus
(Continued)(Continued)
Changes R/T CRFChanges R/T CRF (Continued)(Continued)
• CardiacCardiac– HypertensionHypertension– HyperlipidemiaHyperlipidemia– Congestive heart failureCongestive heart failure– Uremic pericarditisUremic pericarditis
• HematologicHematologic• GastrointestinalGastrointestinal
Clinical ManifestationsClinical Manifestations NeurologicNeurologic CardiovascularCardiovascular RespiratoryRespiratory Hematologic Hematologic GastrointestinalGastrointestinal UrinaryUrinary SkinSkin
Imbalanced Nutrition: Imbalanced Nutrition: Less Than Body Less Than Body RequirementsRequirements Interventions include:Interventions include:
Dietary evaluation for:Dietary evaluation for: ProteinProtein FluidFluid PotassiumPotassium SodiumSodium PhosphorusPhosphorus
Vitamin supplementationVitamin supplementation
Excess Fluid VolumeExcess Fluid Volume Interventions:Interventions:
Monitor client’s intake and output.Monitor client’s intake and output. Promote fluid balance.Promote fluid balance. Assess for manifestations of volume Assess for manifestations of volume
excess:excess: Crackles in the bases of the lungsCrackles in the bases of the lungs EdemaEdema Distended neck veinsDistended neck veins
Drug therapy includes diureticsDrug therapy includes diuretics..
Decreased Cardiac Decreased Cardiac OutputOutput
Interventions:Interventions: Control hypertension with calcium Control hypertension with calcium
channel blockers, ACE inhibitors, alpha- channel blockers, ACE inhibitors, alpha- and beta-adrenergic blockers, and and beta-adrenergic blockers, and vasodilators.vasodilators.
Instruct client and family to monitor Instruct client and family to monitor blood pressure, client’s weight, diet, blood pressure, client’s weight, diet, and drug therapyand drug therapy..
Risk for InfectionRisk for Infection
Interventions include:Interventions include: Meticulous skin careMeticulous skin care Preventive skin carePreventive skin care Inspection of vascular access site for Inspection of vascular access site for
infectioninfection Monitoring of vital signs for Monitoring of vital signs for
manifestations of infectionmanifestations of infection
Risk for InjuryRisk for Injury
Interventions include:Interventions include: Drug therapyDrug therapy Education to prevent fall or injury, Education to prevent fall or injury,
pathologic fractures, bleeding, and pathologic fractures, bleeding, and toxic effects of prescribed drugstoxic effects of prescribed drugs
FatigueFatigue
Interventions:Interventions: Assess for vitamin deficiency, anemia, Assess for vitamin deficiency, anemia,
and buildup of urea.and buildup of urea. Administer vitamin and mineral Administer vitamin and mineral
supplements.supplements. Administer erythropoietin therapy for Administer erythropoietin therapy for
bone marrow production.bone marrow production. Give iron supplements as neededGive iron supplements as needed..
AnxietyAnxiety
Interventions include:Interventions include: Health care team involvementHealth care team involvement Client and family educationClient and family education Continuity of careContinuity of care Encouragement of client to ask Encouragement of client to ask
questions and discuss fears about the questions and discuss fears about the diagnosis of renal failurediagnosis of renal failure
Potential for Pulmonary Potential for Pulmonary EdemaEdema
Interventions:Interventions: Assess the client for early signs of Assess the client for early signs of
pulmonary edema.pulmonary edema. Monitor serum electrolyte levels, vital Monitor serum electrolyte levels, vital
signs, oxygen saturation levels, signs, oxygen saturation levels, hypertensionhypertension..
HemodialysisHemodialysis
Client selectionClient selection Dialysis settingsDialysis settings Works using Works using
passive transfer of passive transfer of toxins by diffusiontoxins by diffusion
Anticoagulation Anticoagulation needed, usually needed, usually heparin treatmentheparin treatment
Vascular AccessVascular Access
Arteriovenous fistula, or Arteriovenous fistula, or arteriovenous graft for long-term arteriovenous graft for long-term permanent accesspermanent access
Hemodialysis catheter, dual or triple Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for lumen, or arteriovenous shunt for temporary accesstemporary access
PrecautionsPrecautions ComplicationsComplications
Hemodialysis Nursing Hemodialysis Nursing CareCare
Postdialysis care:Postdialysis care: Monitor for complications such as Monitor for complications such as
hypotension, headache, nausea, hypotension, headache, nausea, malaise, vomiting, dizziness, and malaise, vomiting, dizziness, and muscle cramps.muscle cramps.
Monitor vital signs and weight.Monitor vital signs and weight. Avoid invasive procedures 4 to 6 hours Avoid invasive procedures 4 to 6 hours
after dialysis.after dialysis. Continually monitor for hemorrhage.Continually monitor for hemorrhage.
Complications of Complications of HemodialysisHemodialysis
Dialysis disequilibrium syndromeDialysis disequilibrium syndrome Infectious diseasesInfectious diseases Hepatitis B and C infectionsHepatitis B and C infections HIV exposure—poses some risk for HIV exposure—poses some risk for
clients undergoing dialysisclients undergoing dialysis
Peritoneal DialysisPeritoneal Dialysis
Procedure involves siliconized Procedure involves siliconized rubber catheter placed into the rubber catheter placed into the abdominal cavity for infusion of abdominal cavity for infusion of dialysate.dialysate.
Types of peritoneal dialysis:Types of peritoneal dialysis: Continuous ambulatory peritonealContinuous ambulatory peritoneal Automated peritonealAutomated peritoneal Intermittent peritonealIntermittent peritoneal Continuous-cycle peritonealContinuous-cycle peritoneal
ComplicationsComplications
PeritonitisPeritonitis PainPain Exit site and tunnel infectionsExit site and tunnel infections Poor dialysate flowPoor dialysate flow Dialysate leakageDialysate leakage Other complicationsOther complications
Nursing Care During Nursing Care During Peritoneal DialysisPeritoneal Dialysis
Before treating, evaluate baseline vital Before treating, evaluate baseline vital signs, weight, and laboratory tests.signs, weight, and laboratory tests.
Continually monitor the client for Continually monitor the client for respiratory distress, pain, and respiratory distress, pain, and discomfort.discomfort.
Monitor prescribed dwell time and Monitor prescribed dwell time and initiate outflow.initiate outflow.
Observe the outflow amount and Observe the outflow amount and pattern of fluid.pattern of fluid.
Nursing Management of Nursing Management of Hospitalized Client on Hospitalized Client on
Dialysis Dialysis Protect vascular Protect vascular
accessaccess Monitor fluid Monitor fluid
balance indicatorsbalance indicators Monitor IV carefullyMonitor IV carefully Assess for s/s Assess for s/s
uremiauremia Monitor Monitor
cardiopulmonary cardiopulmonary status carefullystatus carefully
Monitor BPMonitor BP
Monitor Monitor medicationsmedications
Address pain and Address pain and discomfortdiscomfort
Infection control Infection control measuresmeasures
Monitor dietary e-Monitor dietary e-lytes and fluidslytes and fluids
Skin careSkin care CAPD catheter care CAPD catheter care
if appropriate if appropriate
Renal TransplantationRenal Transplantation
Candidate selection criteriaCandidate selection criteria DonorsDonors Preoperative carePreoperative care Immunologic studiesImmunologic studies Surgical teamSurgical team Operative procedureOperative procedure
Postoperative CarePostoperative Care
AssessmentAssessment all body systemsall body systems PainPain Fluid and electrolyte Fluid and electrolyte
statusstatus Urologic Urologic
managementmanagement Assessment of system Assessment of system
patencypatency Assessment of urine Assessment of urine
output hourly for 48 output hourly for 48 hours.hours.
ComplicationsComplications RejectionRejection Acute tubular Acute tubular
necrosisnecrosis ThrombosisThrombosis Renal artery stenosis Renal artery stenosis Other complicationsOther complications Immunosuppressive Immunosuppressive
drug therapydrug therapy Psychosocial Psychosocial
preparationpreparation
Post-transplantation Post-transplantation IntervetionsIntervetions
Pain relief measures and analgesicsPain relief measures and analgesics Promote airway clearance and Promote airway clearance and
effective breathing patterneffective breathing pattern Strict asepsis Strict asepsis Monitor for signs/symptoms of Monitor for signs/symptoms of
bleedingbleeding Encourage leg exercises, early Encourage leg exercises, early
ambulation, and monitor for signs of ambulation, and monitor for signs of DVTDVT
Renal Cell CarcinomaRenal Cell Carcinoma
Healthy kidney tissue damaged and Healthy kidney tissue damaged and replaced by cancer cellsreplaced by cancer cells
Paraneoplastic syndrome: Paraneoplastic syndrome: AnemiaAnemia ErythrocytosisErythrocytosis HypercalcemiaHypercalcemia Liver dysfuntionLiver dysfuntion Hormonal effectsHormonal effects Increased sedimentation rateIncreased sedimentation rate Hypertension Hypertension
Renal Cell Carcinoma Renal Cell Carcinoma Management Management
NonsurgicalNonsurgical Radiofrequency Radiofrequency
ablationablation ChemotherapyChemotherapy Biological response Biological response
modifiers and modifiers and tumor necrosis tumor necrosis factor lengthen factor lengthen survival timesurvival time
Renal artery Renal artery embolization embolization
SurgicalSurgical Pre-op carePre-op care NephrectomyNephrectomy Post-op care:Post-op care:
Monitoring for Monitoring for hemorrhage and hemorrhage and adrenal adrenal insufficiencyinsufficiency
Pain Pain managementmanagement
Prevention of Prevention of complicationscomplications
Renal TraumaRenal Trauma
Minor injuries:Minor injuries: Contusions, small lacerationsContusions, small lacerations
Major injuries:Major injuries: Lacerations to cortex, medulla, or Lacerations to cortex, medulla, or
branches or renal arterybranches or renal artery Nonsurgical management:Nonsurgical management:
Drug and fluid therapyDrug and fluid therapy Surgical management:Surgical management:
Nephrectomy or partial nephrectomyNephrectomy or partial nephrectomy