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NURS 2280 (11)


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Dalhousie University
NURS 2280
Shauna Houk

Caring for the Patient with Renal Failure Objectives  Explain the Functions of the Kidney  Define Chronic Kidney Disease (CKD)  Identify Risk Factors for CKD and Common Kidney Diseases  Identify Signs and Symptoms that may indicate Kidney Disease  Discuss the clinical manifestations of End Stage Renal Disease (ESRD)  Discuss measures that can be taken to minimize CKD Progression  Describe Nursing Care for those living with ESRD  Compare/Contrast Hemodialysis and Peritoneal Dialysis  Dialysis: Explain the Role of the Nurse and the Highest Nursing Care Priority(ies)  Explain the Signs and Symptoms of Kidney Transplant Rejection  Identify Factors to include in teaching Self Management to those living with a Kidney Transplant Canadian Statisitcs:  An estimated 2.6 million Canadians have kidney disease, or are at risk.  Each day, an average of 16 Canadians learns that their kidneys have failed.  The number being treated for kidney failure has tripled over the past 20 years  Over half of all new patients are 65 years or older.  39, 352 people being treated for kidney failure in Canada in 2010 Renal Structures  Blood enters through renal artery  Blood travels through tiny blood vessels to reach millions of filtering units called nephrons Enlarged View of a Nephron  In the nephron, blood is filtered through the glomerulus to produce fluid containing waste products  Blood is returned by the renal vein to the rest of the body  Filtered fluids and waste products become urine in the nephron and are excreted through the ureter to the bladder  The kidneys receive ~ 20% of the cardiac output  Every hour the blood supply circulates through the kidneys about 12 times.  Each day the kidneys process around 200 litres of blood, with around 1 - 2 litres of waste leaving the body as urine. Functions of the Kidney Maintains Homeostasis  Cleans the blood by removing excess fluid, minerals, & wastes  Regulates blood pressure  Regulates acid-base balance  Regulates electrolyte balance  Makes 3 important hormones, erythropoietin, renin and active vitamin D. 1. Renin is involved in the control of blood pressure 2. Active vitamin D (calcitriol) controls calcium uptake and helps make strong bones. 3. Erythropoietin stimulates the production of red blood cells Acute Kidney Injury  High risk of mortality  In ICU settings, > 60% developAKI with 70-80% mortality  Prevention through Education andAwareness  Early Recognition and Correction of Precipitating Cause/Factor(s) RIFLE Criteria Chronic Kidney Disease (CKD) 1. Glomerular filtration rate (GFR) of < 60 mL/minute/1.73m2 for > 3 months, with or without kidney damage OR 2. Kidney damage for > 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either:  pathological abnormalities  markers of kidney damage, including abnormalities in  the composition of the blood or urine, or  abnormalities in imaging tests (CSN, 2009) Estimating GFR (eGFR) 1) Cockcroft-Gault equation: Used CPS, Micromedex, and most Clinical Trials CrCl (ml/min)= (140-age) x actual weight (kg) x 1.2 (if male) SCreat (µmol/L) 2) MDRD (Modification of Diet in Renal Disease): Used in NS Lab Reporting 6 variable or abbreviated versions GFR(ml/min/1.73m2)=170 (PCr) -0.99x (Age)-0.17x (0.762 if female) x (1.21 if AfricanAmerican) x (serum urea) -0.17x (Albumin) +0.318 Interpreting eGFR 2 Normal GFR in Men: 130 ml/min/1.73 m up to 2ge 30 Normal GFR in Women: 120 ml/min/1.73 m up to age 30 Rate of Decline afterAge 30 is 1 mL/min/year High Risk for CKD  Diabetes  Hypertension  Family History  Age > 60 years  GFR < 60 ml/min Other Risk Factors  Receiving nephrotoxic medications  Being ofAfrican-Canadian, First Nations, Hispanic,Asian descent  Smoking  Obesity Incidence CKD by Primary Diagnosis in Canada 2010 Diabetes Mellitus 35% CORR 2011 Renal Vascular Pyelonephritis 3% Disease (HTN) 18% Drug Induced 2% Glomerulonephritis 10% Other 13% Polycystic Kidney Disease 4% Unknown 15% Causes of CKD 1. Diabetes – 35% 2. Renal Vascular Disease (high blood pressure) – 18% 3. Glomerulonephritis – 10% Diabetes Hypertension/RVD  2 most common cause CKD  Nephrosclerosis  5% of people with HTN have kidney disease Glomerulonephritis  3 leading cause CKD  Inflammation of glomerulus (capillaries)  Generally immune-mediated  Acute or chronic  Biopsy to confirm (cellular or fibrous crescents):Abnormalities: < 50% glomeruli focal, > 50% diffuse Polycystic Kidney Disease  Most frequent genetic cause of CKD  Accounts for 10% of patients on dialysis  Can involve liver, pancreas  Intracranial and coronary aneurysms Chronic Kidney Disease BODY SYSTEM CLINICAL MANIFESTATIONS Urinary Decreased Output Proteinuria Cardiovascular Volume Overload Heart Failure Hypotension/Hypertension Pericarditis Respiratory Pulmonary Edema Kussmal‟s Respirations Pleural Effusions Gastrointestinal Nausea/Vomiting Anorexia Diarrhea Bleeding Hematological Anemia (within 48 hours) Defect in Platelet Function Increased Infection Susceptibility Neurological Lethargy Memory Impairment Seizures Asterixis Metabolic Increased Urea, Creatinine, Potassium, Phosphate Decreased Sodium, pH, Bicarbonate, Calcium Bone Hyperparathyroidism caused by low calcium & high phosphorus levels Osteomalacia secondary to low 1,25 dihydroxy Vitamin D3 Other Pruritis Cold Intolerance Sleep Disturbances cramps, restless legs, PND, orthopnea Calciphylaxis: Calcium deposits in the blood vessels and skin that prevent blood flow to the area, causing tissue death. Classification of Chronic Kidney Disease Requires 2 or more GFR results MI, CHF, CV Death Stage I Stage II Stage III Stage IV Stage V CKD Risk Mild  Moderate  Severe  Kidney Factors/Damage Kidney Kidney Kidney Failure with preserved Function Function Function ESRD GFR 130 120 110 100 90 80 70 60 50 40 30 20 15 10 0 Kidney Function Glomerular Filtration Rate (ml/min/1.73m) CKD Stages & Complications Description Complications Stage (GFR) (Typically begin at Stage 3 [50%  GFR]) Kidney damage,  Parathyroid hormone (PTH) 2 mild  GFR (60-89 ml/min/1.73 m ) Hypertension possible 2+ Abnormal mineral metabolism ( Ca ,  PO 4 PTH) Kidney damage,  lipoprotein activity 3 moderate  GFR Malnutrition potential (30-59 ml/min/1.73 m ) Onset of LVH Onset of anemia Hypertension Adapted from:Levin A and Mendelssohn D: Care and Referral of Adult Pati
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