CHRONIC

RENAL
FAILURE
CHRONIC RENAL FAILURE
OR IRREVERSIBLE RENAL FAILURE IS A PROGRESSIVE
REDUCTION OF FUNCTIONING RENAL TISSUE SUCH THAT
THE REMAINING KIDNEY MASS CAN NO LONGER MAINTAIN
THE BODYS INTERNAL ENVIRONMENT.
CAN DEVELOP INSISIOUDLY OVER A PERIOD OF MANY
YEARS, OR CAN OCCUR AS RESULT OF A BOUT OF ACUTE
RENAL FAILURE FROM WHICH THE PATIENT FAILS TO
RECOVER.
CHRONIC GLOMERULONEPHRITIS
ETIOLOGY
ACUTE RENAL FAILURE
POLYCYSTIC KIDNEY DISEASE
OBSTRUCTION
REPEATED BOUTS OF PYELONEPHRITIS
NEPHROTOXINS
SYSTEMIC DISEASE
DIABETES MELLITUS
HYPERTENSION
LUPUS ERYTHEMATOSUS
POLYARTERITIS
SICKLE CELL DISEASE AMYLOID DISEASE
PATHOPHYSIOLOGY
SLOW DETERIORATION AND DESTRUCTION OR RENAL
NEPHRONS WITH PROGRESSIVE LOSS OF THEIR FUNCTION
PORTRAYS THE PATHOGENESIS OF CRF
AS THE TOTAL GLOMERULAR FILTRATION RATE FALLS AND
CLEARANCE IS REDUCED, THE SERUM UREA NITROGEN AND
CREATIINNE LEVELS RISE.
REMAINING FUNCTIONING NEPHRONS HYPERTROPHY AS THEY
ARE REQUIRED TO FILTER A LARGER LOAD OF SOLUTES
IN AN ATTEMPT TO CONTINUE EXCRETING THE SOLUTES, A
LARGE VOLUME OF DILUTE URINE IS PASSED, RESULTING TO
FLUID DEPLETION
TUBULES GRADUALLY LOSE THEIR ABILITY TO REABSORB
ELECTROLYTES
SALT WASTING URINE CONTAINS VERY LARGE AMOUNTS OF
SODIUM, WHICH LEADS TO MORE POLYURIA.
AS RENAL DAMAGE ADVANCES AND THE NUMBER OF
FUNCTIONING NEPHRONS DECLINES, THE TOTAL GFR
DECREASES FURTHER
BODY UNABLE TO RID ITSELF OF SALT AND OTHER WASTE
PRODUCTS THROUGH THE KIDNEYS.
BODY BECOMES INCREASINGLY TOXIC UNTIL ITS STATUS IS NO
LONGER COMPATIBLE WITH LIFE.
DEATH
CARDIOVASCULAR CHANGES
HYPERTENSION
LEFT VENTRICULAR HYPERTROPHY AND CHF
ARRHYTHMIAS
ATHEROSCLEROSIS
PERICARDITIS
HEMATOLOGIC
ANEMIA DUE TO REDUCED ERYTHROPOIESIS
BLEEDING TENDENCIES
GASTOINTESTINAL CHANGES
TRANSIENT ANOREXIA,, NAUSEA AND VOMITING
CONSTANT BITTER, METALLIC OR SALTY TASTE
BREATH SMELLS FETID, FISHY OR AMMONIACAL
STOMATITIS, PAROTITIS AND GINGIVITIS
CONSTIPATION
RESPIRATORY CHANGES
PULMONARY EDEMA
PLEURITIS
MUSCULOSKELETAL CHANGES
BONY REABSORPTION
RENAL
FLUID VOLUME EXCESS
Related Factors:
Excess Fluid Intake
Excess Sodium Intake
Compromised Regulatory Mechanisms
ASSESSMENT
Assess Vital Signs
Assess respiratory pattern and work of breathing
Check for distended neck veins
Auscultate for crackles
Assess amount of edema by palpating area over
tibia, at ankles, sacrum, back and assessing
appearance of face
Assess pts compliance with dietary and fluid
restrictions at home
INTERVENTIONS
Weigh at every visit before and after dialysis (weight
gain not to exceed 1 kg between visits)
Restrict fluid intakes as required by the pts condition
Restrict dietary sodium
Advise pt to elevate feet when sitting down to
prevent fluid accumulation in lower extremities
Instruct about necessity to follow prescribed
fluid/dietary restriction
Give antihypertensive medications if prescribed
Maintain optimal positioning for gas exchange. Have
pt sit up if he/she complains of shortness of breath.
HIGH RISK FOR DECREASED CARDIAC OUTPUT
Risk Factors:
Fluid Volume overload
Electrolyte imbalances
Hypoxia
Accumulated toxins
ASSESSMENT
Monitor vital signs with frequent monitoring of BP
Assess skin warmth and peripheral pulses
Assess level of consciousness
Monitor for dysrhythmias
Assess for presence of fluid volume overload
Monitor lab study findings for serum K, BUN,
creatinine, etc
Auscultate heart sounds for presence of third heart
sound
Assess for jugular venous distention, distant or
muffled heart sounds, and hypotension.
INTERVENTIONS
Administer oral and IV fluids as prescribed. Use fluid
restriction as appropriate
Administer medications as prescribed. Note pts
response
Adminster inotropic agents
Administer oxygen as needed
Provide a calm environment with minimal stressors
and restrict activity
Prepare pt for dialysis or ultrafiltration when
indicated
HIGH RISK FOR INJURY: HYPOCALCEMIA
Risk Factors:
Increased Phosphorus level
Renal Failure
ASSESSMENT
Assess for signs/symptoms of hypocalcemia: tingling
sensations at ends of fingers, muscle cramps and
carpopedal spasms, tetany, convulsion
Observe for signs/symptoms of calcium-phosphorus
levels every week/month
Assess for signs/symptoms of extremity pain and
joint swelling
Observe pts gait, ambulation, and movement of
extremities
Assess history for tendency to fracture easily
INTERVENTIONS
Administer phosphate-binding medications as
prescribed
Apply lotion for itchiness; recommend use of
scratcher rather than fingernails
Provide safety measures: side rails, uncluttered
room, orientation to surroundings, proper lighting
Refer to rehabilitation medicine department as
indicated for use of crutches, transport from wheelchair
to chair or vice versa
HIGH RISK FOR INJURY: ANEMIA
Risk Factors:
Bone marrow suppression
Increased hemolysis
Bleeding tendencies
ASSESSMENT
Observe, document signs of fatigue, pallor, bleeding
from puncture sites and incisions, and bruising
tendencies
Observe, document signs of fatigue, pallor, bleeding
from puncture sites and incisions, and bruising
tendencies
> check for guaiac in all stools and emesis
> observe for signs of fluid overload and
adverse reactions during transfusion
INTERVENTIONS
Administer oxygen as prescribed
Administer transfusion as prescribed
If fluid overload is a problem after transfusion,
administer diuretics as prescribed
Administer erythropoietein as prescribed
Institute precautionary measures for pts with a
tendency to bleed: use only compressible vessels for IV
sites; avoid IM injections
HIGH RISK FOR IMPAIRED SKIN INTEGRITY
Risk Factors:
Edema related to end-stage renal disease
Peripheral neuropathy from end-stage renal
disease
ASSESSMENT
Assess skin integrity for pitting of extremities on
manipulation, demarcation of clothing and shoes on
pts body
Assess for presence of peripheral neuropathy
INTERVENTIONS
Instruct the pt to wear loose-fitting clothing when
edema is present
Teach factors important to skin integrity: nutrition,
mobility, hygiene, early recognition of skin breakdown
Use caution when heating or cooling devices are
applied to the pt and also instruct the pt.
HIGH-RISK FOR SELF-ESTEEM
DISTURBANCE
SEXUAL DYSFUNCTION
HIGH-RISK FOR NONCOMPLIANCE
KNOWLEDGE DEFICIT