Askep

Gagal Ginjal
Ns.Fitrio Deviantony S.Kep
Emergency department
STIKES WIDYAGAMA HUSADA

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Renal Failure
Renal failure is the loss of function in both kidneys

renal failure is associated with multiple

systemic effects.
Renal failure is also categorized as acute renal

failure, which occurs suddenly and is usually

reversible, or chronic renal failure, which is
associated with progressive, irreversible loss of
renal function.
Chronic renal failure usually develops after years

of renal disease or damage, but may occur rapidly

in some situations. Chronic renal failure inevitably
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leads to renal dialysis, transplantation, or death.

Acute Renal Failure (ARF)

Loss function of kidney suddenly

elevated BUN (>15-30 mg/dl) & creatinin

serum (>1-2 mg/dl)
Oliguria and anuria

Acute Renal Failure (ARF)

Causes of acute renal failure have been separated

into three general categories: prerenal, intrarenal,

and postrenal
1. Prerenal failure is the most common cause of
acute renal failure. Prerenal failure occurs as a result
of conditions unrelated to the kidney but that
damage the kidney by affecting renal blood flow.
Causes of prerenal failure include anything that
severely reduces systemic blood pressure, leading to
shock, such as a myocardial infarct, an anaphylactic
reaction, severe blood loss or volume depletion, a
burn, or sepsis, Surgical procedures resulting in a
prolonged decrease in renal blood flow
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Renal autoregulation is unsuccessful with a

mean systemic blood pressure below 80

mmHg.
Interruption of renal blood flow, and
therefore oxygen delivery, can irreversibly
damage the kidneys within 30 minutes.
The tubules are most susceptible to the
effects of hypoxia, and ischemic tubular
necrosis (tubular cell death caused by
decreased oxygenation) frequently
develops.
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2. Intrarenal failure is a type of acute renal

failure that occurs as a result of primary
damage to kidney tissue itself. It has
many causes, including glomerulonephritis,
acute pyelonephritis, and myoglobinuria.
Kidney cell damage usually occurs as a
result of ischemic tubular necrosis.
Tubular necrosis also can result from direct
action of nephrotoxic antibiotics,
contrast, analgetics, NSAID
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3. Postrenal failure is a type of acute renal failure

that occurs as a result of conditions that affect the
flow of urine out of the kidneys and includes injury
to or disease of the ureters, bladder, or urethra.
The usual cause of postrenal failure is
obstruction untreated calculi, a tumor,
repeated infections, prostatic hyperplasia, or a
neurogenic bladder.
Recovery from acute renal failure typically occurs

after a few weeks, but occasionally takes as long

as 6 weeks after the onset of oliguria
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Clinical Manifestations

Oliguria may occur, especially if the failure

is caused by ischemia or by obstruction.

Oliguria results from decreased GFR.
Toxic tubular necrosis may be non-oliguric

(high output) and is associated with the

production of an adequate volume of dilute
urine.

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Diagnostic Tools

A good history identifies precipitating

causes of renal failure.

Laboratory finding of azotemia (increased
nitrogenous compounds in the blood), and
elevated BUN and creatinine confirm
diagnosis.
Laboratory findings of hyperkalemia and
acidosis are common.

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Treatment
Prevention of acute renal failure is essential.
Individuals experiencing shock should be quickly

treated with fluid replacement to support blood

pressure.
Individuals at risk of developing acute renal failure, for
instance, those about to undergo heart surgery, may
be given an osmotic diuretic before surgery to
increase renal function.
Give adequate hydration before nephrotoxic drugs
For patients at high risk of suffering renal failure, the
use of nephrotoxic drugs and intravenous radioactive
dyes must be shown to be essential before they are
employed, and their use may be contraindicated in
some cases
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Chronic Renal Failure (CRF)

Gagal ginjal kronik merupakan penurunan faal

ginjal yang menahun yang umumnya irreversibel

dan cukup lanjut. (Suparman, 1990).
Gagal ginjal kronik merupakan perkembangan

gagal ginjal yang progresif dan lambat, biasanya

berlangsung dalam beberapa tahun (Wilson,
2005).
Gagal Ginjal Kronik (GGK) atau penyakit ginjal

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tahap akhir adalah gangguan fungsi ginjal yang

menahun bersifat progresif dan irreversible
kemampuan tubuh gagal untuk mempertahankan
metabolisme atau keseimbangan cairan dan
elektrolit, menyebabkan uremia (retensi urea dan
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sampah nitrogen lain dalam darah) (Smeltzer &

Penyakit Ginjal Kronik (PGK)

PGK menggantikan istilah gagal ginjal kronik (GGK) atau

insufisiensi yang tidak jelas definisinya KONTROVERSI

LFG yang disebut PGK apabila < 60 ml/min/1,73 m2
atau > 60 ml/min/1,73 m2 ditambah dengan kerusakan
ginjal dan menetap >3 bulan
Kerusakan ginjal didefinisikan sebagai :
Abnormal patologi atau adanya penanda kerusakan ginjal
seperti abnormalitas pada pemeriksaan darah, urine
atau pemeriksaan imaging walaupun LGF turun ringan
(PGK stadium1-2)
PGK stadium 3-5 hanya memerlukan penurunan LFG
dengan atau tanpa bukti kerusakan ginjal .
Penurunan LFG dengan atau tanpa kerusakan ginjal harus
ada > 3 bulan
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Stadium GGK:
Stadium GGK (Wilson, 2005):

I: penurunan fungsi ginjal kadar BUN dan

kreatinin normal, asimtomatik
II: insufisiensi renal 75 % jaringan rusak
( GFR 25 %), BUN mulai meningkat,
azotemia ringan, nokturia dan poliuria
III: ggl ginjal stadium akhir (uremia) 90 %
massa nefron hancur, atau 200.000 nefron
yang masih utuh, GFR 10 %, CCR 5-10
ml/menit, BJ 1,010; oliguria; sindrom uremia
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Lanjut...

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Lanjut...
Menurut Baradero, Dayrit dan Siswadi (2005), beberapa

tahap perkembangan penyakit ginjal kronik adalah sebagai

berikut:
1. Penurunan cadangan ginjal
- Sekitar 40 75 % nefron tidak berfungsi
- Laju filtrasi glumerolus 40 50 % normal
- BUN dan kreatinin serum masih normal
- Pasien asimtomatik
2. Gagal ginjal
- 75 -80 % nefron tidak berfungsi
- Laju filtrasi glumerolus 20 -40 normal
- BUN dan kreatinin serum mulai meningkat
- Anemia ringan dan azotemia ringan
- Nokturia dan poliuria
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Lanjut..
3. Gagal ginjal lanjut
- Laju filtrasi glumerolus 10 20 % normal
- BUN dan kreatinin serum meningkat
- Anemia, azotemia dan asidosis metabolic
- Berat jenis urin
- Poliuria dan nokturia
- Gejala gagal ginjal
4. End-stage renal desease (ESRD)
- Lebih dari 85 % nefron tidak berfungsi
- Laju filtasi glumerolus kurang dari 10% normal
- BUN dan kreatinin tinggi
- anemia, azotemia, dan asidosis metabolic
-Berat jenis urin tetap 1,010
-Oliguria
- Gejala gagal ginjal
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Etiologi
Penyakit glumerular (misalnya pielonefritis,

glumerulonefritis, glumerulopati
uropati obstruktif (misalnya refluks
vesikouretral)
hipoplasia atau displasia ginjal
gangguan ginjal yang diturunkan (misalnya
penyakit ginjal polikistik, sindrom nefrotik
kongenital, sindrom Alport)
neuropati vaskular (misalnya sindrom
uremik-hemolitik, trombosis renal)
kerusakan atau kehilangan ginjal (misalnya
trauma ginjal berat, tumor Wilms)
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Patofisiologi gagal ginjal

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Clinical Manifestations
In stage 1 renal failure, no

symptoms may be apparent.

As disease progresses, reduced
production of erythropoietin
causes chronic fatigue, and
early signs of tissue hypoxia
and cardiovascular compromise
may develop.
As disease progresses, polyuria
(increased urine output) occurs
as the kidneys are unable to
concentrate the urine.
During the final stages of renal
failure, urine output decreases
because of low GFR.

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Diagnostic Tools

Radiographs or ultrasound will show small,

atrophied kidneys.
Serum BUN, creatinine, and GFR will be
abnormal.
Hematocrit and hemoglobin are reduced.
Plasma pH is low.
An elevated respiratory rate indicates
respiratory compensation for metabolic
acidosis.
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Nursing Diagnoses
Excess fluid volume related to decreased urine output,

dietary
excesses, and retention of sodium and water
Imbalanced nutrition: less than body requirements related
to anorexia, nausea and vomiting, dietary restrictions, and
altered oral mucous membranes
Deficient knowledge regarding condition and
treatment/regimen
Activity intolerance related to fatigue, anemia, retention of
waste products, and dialysis procedure
Low self-esteem related to dependency, role changes,
changes in body image, and sexual dysfunction

Potential complication
Hyperkalemia due to decreased excretion, metabolic acidosis,

catabolism, and excessive intake (diet, medications,fluids)

Pericarditis, pericardial effusion, and pericardial tamponade
due to retention of uremic waste products and inadequate
dialysis
Hypertension due to sodium and water retention and
malfunction
of the reninangiotensinaldosterone system
Anemia due to decreased erythropoietin production,
decreased RBC life span, bleeding in the GI tract from
irritating toxins, and blood loss during hemodialysis
Bone disease and metastatic calcifications due to retention of
phosphorus, low serum calcium levels, abnormal vitamin D
metabolism, and elevated aluminum levels

Treatment

Prevention of renal failure is the most

important goal.
Prevention includes lifestyle changes and
drugs when necessary to control
hypertension, good glycemic control in
diabetics, and the avoidance of nephrotoxic
drugs whenever possible.
Early diagnosis and treatment of systemic
lupus erythematosus and other diseases
known to damage the kidneys is essential.
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Contd..
Treatments are modified as progression worsens.
For stages 1, 2, and 3 renal failure, the goals are to

slow further nephron loss, primarily by the use of

protein restriction and antihypertensive medications
(ACEI).
RAMP (Renal Anemia Management Period) is defined
as the time following the onset of chronic kidney
disease when early diagnosis and treatment of anemia
will slow kidney disease progression, delay
cardiovascular complications, and improve quality of
life. Treatment of anemia is by administration of
recombinant human erythropoietin (rHuEPO).
Later stages: correcting fluid and electrolyte
imbalances.
ESRD: dialysis or renal transplantation.
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At all stages, prevention of infection is important. 1/13/17

NIC
Fluid monitoring fluid balanced
Nutrition management low sodium, low

protein, low kalium (RPRGRK)

Acid-base management
Health education
Social/psychological Support

Semoga bermanfaat...