RENAL SYSTEM

ACUTE RENAL
FAILURE
 ACUTE RENAL FAILURE
 Is a sudden decline in
renal function, usually
marked by increased
concentrations of blood
nitrogen (BUN;
azotemia) and
creatinine; oliguria (less
than 500ml of urine in
24hours); hyperkalemia;
and sodium retention.
 CLASSIFICATION OF ARF
1. Pre renal failure –results from
conditions that interrupt the renal
blood supply;
2. Post renal failure – results from
obstruction of urine flow.
3. Intra renal failure- results from injury
to the kidneys themselves (ischemia,
toxins, immunologic processes,
systemic and vascular disorders).
 COMPICATIONS
 Dysrhythmias
 Increased susceptibility to infection
 Electrolyte abnormalities
 GI bleeding due to stress ulcers
 Multiple organ failure

*Untreated ARF can also progress to chronic

renal failure, end-stage renal disease, and
death from uremia or related causes.
 ASSESSMENT
• OLIGURIC - ANURIC PHASE: urine volume
less than 400ml per 24 hours; increased in
serum creatinine , uric acid, organic acids,
potassium, and magnesium; last 3 to 5 days in
infants and children, 10 to 14 days in
adolescents and adults.

• DIURETIC PHASE: begins when urine output

exceeds 500ml per 24 hours, end when BUN
and creatinine levels stop rising ; length is
available.
• RECOVERY PHASE: Asymptomatic, last several
months to 1 year, same scar tissue may remain.

• IN PRERENAL DISEASE: Decreased tissue

turgor, dryness od mucous membranes, weight
loss, flat neck veins, hypotension, tachycardia.

• IN POSTRENAL DISEASE: Difficulty in voiding,

changes in urine flow.

• IN TRARENAL FAILURE DISEASE: Presentation

varies, usually have edema, may have fever, skin
rash.

• Nausea, vomiting, diarrhea and lethargy may also

occur.
DIAGNOSTIC EVALUATION:
1.URINALYSIS - shows protenutia, hematuria,
casts. Urine chemistry distinguishes various forms
of ARF (prerenal, postrenal, intrarenal)

2.SERUM CREATININE and BUN LEVELS are

eleveated: ARTERIAL BLOOD GAS LEVELS,
SERUM ELECTROLYTES may be abnormal.

3. RENAL UNTRASONOGRAPHY - estimates

renal size and rules out treatable obstructive
uropathy.
THERAPEUTIC AND
PHARMACOLOGIC INTERVENTIONS:
1.
Surgical relief of obstruction may be necessary.
2.
Correction of underlying fluid excess or deficits.
3.
Correction and control of biochemical imbalances.
4.
Restoration and maintenance of blood pressure
through I.V, fluids and vasopressors.

5.Maintenance of adequate nutrition: low protein

diet with supplemental amino acids and vitamins.

6. Initiations of hemodialysis, peritoneal
dialysis, or continuous renal replacement
therapy for patients with progressive
azotemia and other life-threatening
complications.
 NURSING INTERVENTION
1. Monitor 2-4 hour urine volume to follow
clinical course of the disease.

2. Monitor BUN, creatinine and electrolyte.

3. Monitor ABG levels as necessary to evaluate

acid-base balance.

4. Weigh the patient to provide an index of

fluid balance.

5. Measure blood pressure at various times

during the day with patients in supine,
6.Adjust fluid intake to avoid volume overload

and dehydration.

7.Watch for cardiac dysrhythmias and heart

failure from hyperkalemia, electrolyte

imbalance, or fluid overload. Have resuscitation

equipment available in case of cardiac arrest.

8.Watch for urinary tract infection, and remove

bladder catheter as soon as possible.

9.Employ intensive pulmonary hygiene because

10.Provide meticulous wound care.

11.Offer high- carbohydrate feeding because

carbohydrate have greater protein-sparing power
and additional calories.

12.Institute seizure precautions.

13.Encourage and assist the patient to turn and

move because drowsiness and lethargy may
reduce activity.

14.Explain that the patient may experience

residual defects in kidney function for a long time
15. Encourage that the patient to report
routine urinalysis and follow-up
examinations.

16. Recommended resuming activity

gradually because muscle weakness will
be present from excessive catabolism.
CHRONIC RENAL
FAILURE
 CHRONIC KIDNEY DISEASE

• is a gradual process occurring over

time with a resulting decline in renal
function. 
• Over time, chronic renal failure can
lead to a permanent and irreversible
loss of renal functioning, known as
end stage renal disease (ESRD).
Causes of Chronic Kidney Disease

Anyone can get CKD. Some people are

more at risk than others. Some things that
increase your risk for CKD include:
– Diabetes
– High blood pressure (hypertension)
– Heart disease
– Having a family member with kidney disease
– Being African-American, Hispanic, Native
American or Asian
– Being over 60 years old
 Other Causes of ESRD
– Environmental/Occupational Agents
– SLE (Lupus nephritis)
– Systemic diseases
– Remember that it can also be
IDIOPATHIC
 STAGES OF CKD
Staging CKD is a way of quantifying its severity.
CKD has been classified into 5 stages.
• Stage 1: Normal GFR (≥ 90 mL/min/1.73 m 2)
plus either persistent albuminuria or known
structural or hereditary renal disease
• Stage 2: GFR 60 to 89 mL/min/1.73 m 2
• Stage 3a: 45 to 59 mL/min/1.73 m 2
• Stage 3b: 30 to 44 mL/min/1.73 m 2
• Stage 4: GFR 15 to 29 mL/min/1.73 m 2
• Stage 5: GFR < 15 mL/min/1.73 m 2
SYMPTOMS OF CHRONIC KIDNEY
DISEASE
You may notice one or more of the following
symptoms if your kidneys are beginning to
fail:
– Itching
– Muscle cramps
– Nausea and vomiting
– Not feeling hungry
– Swelling in your feet and ankles
– Too much urine (pee) or not enough
urine
– Trouble catching your breath
– Trouble sleeping
 SYMPTOMS IN ADVANCE
STAGES
• Anorexia • Decreased mental
acuity
• Nausea • Muscle twitches and
• Vomiting cramps
• • Water retention
Stomatitis,
• Undernutrition
• Dysgeusia • Peripheral neuropathies
• Nocturia • Seizures
• Lassitude • Uremic Frost
• Fatigue • Uremic Fetor
• Hyperkalemia
• Pruritus
• Altered LOC
• Metabolic Acidosis
 ASSESSMENT
• Once life-threatening conditions are addressed, the
EMS provider should turn to gathering a complete
patient history and performing a detailed
examination.
• Use the SAMPLE (signs/symptoms, allergies,
medications, past medical history, last oral intake
and events preceding the call for help) mnemonic as
a guide to asking basic questions.
• While patient questioning is occurring, ensure that
other providers are assessing vital signs. Pulse
oximetry, blood pressure, pulse, respirations and
temperature should all be assessed and recorded.
 ASSESSMENT
• Check for jugular venous distention, and assess
the breath sounds for any abnormalities. 
• Assess the extremities for signs of edema.
• A patient with chronic renal failure may have
uremic frost on the skin, which is a powdery
deposit of urea and uric acid salts resulting from
severe uremia.
• Question the patient about the ability to void
normally.
• The patient may report a change in color or
report the presence of blood in the urine.
 ASSESSMENT
• Perform an ECG to determine if there
are any dysrhythmias or
abnormalities and when there’s
known or suspected hyperkalemia.
 DIAGNOSIS
• Electrolytes, BUN, creatinine,
phosphate, calcium, CBC
• Urinalysis (including urinary sediment
examination)
• Quantitative urine protein (24-h urine
protein collection or spot urine protein
to creatinine ratio)
• Ultrasonography
• Sometimes renal biopsy
 TREATMENT
• Control of underlying disorders
• Possible restriction of dietary protein,
phosphate, and potassium
• Vitamin D supplements
• Treatment of anemia
• Treatment of contributing comorbidities
(eg, heart failure, diabetes mellitus,
nephrolithiasis, prostatic hypertrophy)
• Doses of all drugs adjusted as needed
• Dialysis for severely decreased GFR if
symptoms and signs not adequately
managed by medical interventions
 TREATMENT
• Dialysis is usually initiated at the onset of
either of the following:
• Uremic symptoms (eg, anorexia,
nausea, vomiting, weight loss,
pericarditis, pleuritis)
• Difficulty controlling fluid overload,
hyperkalemia, or acidosis with drugs
and lifestyle interventions
• Transplantation
If a living kidney donor is available, better
long-term outcomes occur when a patient
receives the transplanted kidney early,
even before beginning dialysis.
 POSSIBLE NDX
 Fluid volume excess
 Impaired Skin Integrity
 Decreased Cardiac Output
 Imbalanced Nutrition
 Risk for Infection
 Activity Intolerance
THANK YOU !