Cuizon, Timothy Dimaunahan, Jane Camille Diolata, Rella Quel Domingo, Shirley Fajilan, Mark Lester

Fransisco, Regina Pea, Dianne Angelyn Rojas, Christian Sun, Trixie Rose Tan, Rizalito Jr.

Definition
Chronic renal failure is a renal disorder wherein, it has a

more insidious onset than of acute renal failure. It is a condition where a great number of functioning kidneys are nonfunctional and progresses further to kidney death.
Symptoms occur when 75% of function is lost but considered

chronic if 90-95% of function is lost.

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Etiology & Risk Factors

These conditions/causes may rise to CRF. Systemic diseases:

CV: CVD, hyper/hypotension, polyarteritis nodosa, PVD Hemo: sickle cell anemia, sepsis, ITP NM: rhabdomyolysis, gout Endo/GIT: DM, amyloidosis Chronic pyelonephritis, nephritis, glomerulonephritis Nephrolithiasis, renal CA, CKD Trauma
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Acquired:

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Etiology & Risk Factors

Medications:

Analgesics: salicylates, NSAIDs Antibiotics: tetracyclines, aminoglycosides Other: amphetamine, mannitol, heroin, cisplastin Long-term diuretic tx Heavy metals: Pb, Hg, Cu, Au, Li Poisons: Cortinarius ingestion, insecticides, snake venom Contrast Dyes Organic Solvents: Kerosene, Ethylene Glycol

Nephrotoxins:

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Timeframe
Stages are based on GFR, reflects functioning nephrons Reduced Renal Reserve
(40-70 mL/min)
Renal Insufficiency

(20-40 mL/min)
Renal Failure

(10-20 mL/min)
End-Stage Renal Disease

(<10 mL/min)

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Clinical Manifestations
CV changes HR, arrythmias Chronic BP, weight gain, LV hypertophy, HF, (volume overload, activated RAAS, sympathetic vasoconstriction, absence of prostaglandins) Atherosclerosis (CHO and FAT metabolism, impaired clotting and hyperparathyroidism) Pericardial rub (uremic toxin accumulation)

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Clinical Manifestations
Hematologic changes Normochromic, normocytic anemia ( erythropoietin production, Fe and folate depletion, hemolysis, GI loss) Decrease in RBC survival time (azotemia) Purpura and hemorrhage from body orifices, ecchymoses ( plt adhesion from uremia) Azotemia and uremia (uremic toxin accumulation) Immunologic changes Weak immunity (depressed humoral antibody formation, supressed hypersensitivity, leukocyte chemotaxis)
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Clinical Manifestations
Respiratory changes Crackles (pulmonary edema, fluid overload) Pleuritic rub and effusion (uremic toxin accumulation) breath sounds, dyspnea (uremic lung, pneumonia) RR, Kussmauls respirations (metabolic acidosis) RTI (depressed macrophage activity)

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Clinical Manifestations
Fluid imbalances Hypovolemia (compensatory excretion) Hypervolemia (compensatory fluid retention) pH imbalances Metabolic acidosis ( H+ excretion, HCO3 retention) Metabolic alkalosis (risk from correcting metabolic acidosis)

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Clinical Manifestations
Electrolyte imbalances Hyponatremia (early, H2O retention, pH) Hypernatremia (late, Na+ excretion) Hyperkalemia ( K + excretion, tissue destruction, pH) Hypocalcemia ( Vit. D activation, PO4-3 ) Hypercalcemia (persistent PTH secretion for PO4-3 ) Hyperphospatemia ( PO4-3 excretion) Hypermagnesemia ( Mg+2 excretion, external)

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Clinical Manifestations
Metabolic changes BUN, Crea ( urea compounds and creatinine excretion) CHO intolerance (insulin impairment, secretion, T , erratic levels) Elevated triglyceride ( insulin and CHO levels, lipoprotein lipase activity blockage) Hypoproteinemia (proteinuria, fluid shifts)

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Clinical Manifestations
Gastrointestinal changes N/V, anorexia Metallic, salty taste, uremic fetor, dry mouth Stomatitis, parotitis, gingivitis (poor oral hygiene, NH3 in saliva) Ulcerations ( gastrin secretion) Esophagitis, gastritis, colitis, diarrhea, GI bleeding Constipation (Treatment by PO4-3 binding agents, fluid restriction, constipation diet are contraindicated)

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Clinical Manifestations
Genitourinary changes Dilute cloudy urine (pus, bacteria, fat, colloidal particles, crystals, casts, urates) Dirty, brown sediment (RBCs, hemoglobin, myoglobin, porphyrins) Urine output <400 mL/day (oliguria/anuria) Ammenorhea and infertility Psychologic/physical impotence, libido Testicular atrophy Oligospermia, reduced sperm motility
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Clinical Manifestations
Endocrine changes Erratic insulin utilization, PTH (PO4-3 excess) Pituitary hormone secretion, hypothyroidism (blunt response of TRH) Psychologic changes Powerlessness (lack of control over illness and treatment) Role reversal, altered body image, changes in sexuality

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Clinical Manifestations
Neurologic changes Burning feet, restless legs syndrome, gait changes, paraplegia (peripheral neuropathy) Slow nerve conduction, DTR, vibratory senses (progressive paresthesia to motor neuron dysfunction) Forgetfulness, inability to concentrate, short attention span, impaired reasoning, judgement and cognitive functioning EEG changes, apathy, irritablility, nystagmus, twitching, dysarthia, seizures, CNS depression and coma. Bilateral blindness (uremic amanurosis, calcium salts)
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Clinical Manifestations
Musculoskeletalchanges Renal osteodystrophy (PTH-kidney-bone, Vit. D-Ca+2-PO4-3) Pathologic fractures (bone demineralization and tissue calcifications) Muscle twitches, cramps (osmolar changes, hypocalcemia) Bone and muscle pain, weakness Gait abnormality, loss of ambulation Muscle irritability

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Clinical Manifestations
Integumentary changes Dry, scaly skin (sweat gland atrophy) Pruritus (2 hyperparathyroidism, skin calcium deposits) Pallor (erythropoietin-deficient anemia) Bleeding tendency ( platelet abnormalities, bruising, purpura, petechiae) Orange-green discoloration (urochrome pigment retention) Brittle nails, (+) Mueheckes lines, half-and-half nail pattern Hair is brittle, discolored, tends to fall out Uremic frost (late)
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Pathophysiology
Urine Concentration
Na+, Polyuria Electrolyte Imbalances Uremia DEATH
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Nephron Hypertrophy BUN Crea Decreased ability to excrete fluids, electrolytes and toxins
BSN222, Group 86

Aggravating factors

GFR ClCr

(Early) Progressive loss of renal function

(Late) Progressive loss of renal function

(Early) Progressive nephron destruction

GFR ClCr

(Late) Progressive nephron destruction

18

Diagnostic Tools
Blood analysis show: Hgb, Hct BUN (>25 mg/dL), Crea , (<7.2pH) Arterial pH HCO3 ,Na+ (late), , Ca+2 K+ (6.5 mEq/L), PO4-3 Mg+2

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Diagnostic Tools
Urine osmolality is <350 mOsm/kg
Serum osmolality is >285 mOsm/kg Urine/serum ratio is often 1:1 ClCr (<80 mL/min, early), (<10 mL/min, ESRD) serum protein

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Diagnostic Tools
Urine specific gravity fixed at 1.010
Urinalysis may show (depending on the etiology): (3-4+) Protein (+) Glucose (+) Erythrocytes (+) Leukocytes (+) Casts (+) Debris

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Diagnostic Tools
Kidney biopsy shows histologic hypertrophy of nephrons,

necrosis and scarred renal tissue, depending on underlying pathology or timeframe. ECG shows for hyperkalemia
Tall T waves Wide QRS complex

Disappearing P waves

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Diagnostic Tools
Radiographic studies include: KUB excretory urography retrograde pyelogram and arteriogram nephrotomography renal scan Renal or abdominal CT scan, MRI or UTZ indicate changes

associated with chronic renal failure, including abnormally small size in both kidneys.
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Medical Goals
Preserve kidney function
Delay need for dialysis and kidney transplant Alleviate external manifestations Improve blood chemistry levels Provide optimal life to client

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Nursing Diagnosis
Excess fluid volume r/t iimpaired renal function

secondary to CRF.
CRF nephron hyperthrophy ability of the kidney to concentrate urine impaired excretion of fluid oliguria anuria

GFR hydrostatic pressure fluid overload lymph system overload interstitial water retention
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pulmonary congestion

weight HPN edema

25

Nursing Diagnosis
Acute pain r/t to kidney destruction secondary to CRF.
CRF nerve ending stimulation

kidney damage

cytokine and prostaglandin release

trauma

costovertebral area or flank pain

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Nursing Diagnosis
Altered renal tissue perfusion r/t diminished renal

function secondary to CRF.

CRF kidney damage decreased or loss of kidney excretory functions impaired excretion of nitrogenous waste product uric Acid Level

BUN

creatinine

azotemia, uremia, toxin accumulation

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Nursing Diagnosis
Impaired urinary elimination r/t kidney destruction

secondary to CRF.
CRF kidney destruction

accumulation of toxins
oliguria decreased or loss of kidney excretory functions impaired excretion of fluid anuria

GFR

ability of the kidney to concentrate urine

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Nursing Diagnosis
Altered nutrition: less than body requirements r/t diet

restriction and anorexia. Fatigue r/t anemia and metabolic state.

erythropoietin CRF kidney damage ineffective waste filtration waste accumulation diet restriction anorexia and nausea unmaintained IBW insufficient nutrition

anemia fatigue weakness

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Nursing Diagnosis
Other possible nursing care plans includes: Risk for hyperthermia r/t infection and activation of inflammatory process. Impaired skin integrity r/t edema, dry skin and pruritus secondary to CRF. Constipation r/t fluids, medication and dietary restrictions and decreased activity level. Risk for infection r/t presence of therapeutic foreign materials, treatment regimen and immunodepression. Risk for injury r/t dialysis trauma on vascular site altered bone integrity.
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Medical Interventions
PO4-3 binding agents: Al(OH)3 gel (Amphojel); binds PO4-3

to Ca+2 Evaluate need for K+ binding agents: Na+ polystyrene sulfonate (Kayexalate) PO to K+ Insulin with D5W to K+ in ICF, strict monitoring NaHCO3 to correct metabolic acidosis Epoetin- (EPO), erythropoietin to RBC formation FeSO4, B12, folate to complement, BT as necessary Calcium replacements and Vit. D analogs
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Medical Interventions
Anticonvulsants and sedatives for seizures
UVB, IV lidocaine, antihistamines, lotions and emollients

for pruritus Statins for hyperlipidemia Antihypertensives (-andrenergics, ACE inhibitors, 1receptor blockers) for HPN and fluid excess Bulk laxatives (psyllium hydrophilic mucilloid) for constipation

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Surgical Interventions
Dialysis to replace and compensate for the lost kidney

function either temporary of permanently.

Hemodialysis, using an external machine for the filtration,

like continuous arteriovenous hemofiltration Peritoneal dialysis, uses peritoneum as a semi-permeable membrane Prepare for AV fistula and access on peritoneum

Prepare for kidney transplant, assess for clients

compatibility Removal of parathyroid glands for correcting PTH

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Nursing Interventions and Goals

Assess general conditions VS every 1-4 hr Monitor fluid and electrolytes for shifts and extremes, coordinate with therapy Assess for fluid retention, constipation, symptoms of electrolyte imbalance, uremia, pain, turgor, mental clarity Maintain strict I&O: fluid replacement >500600 cc than

24 hr UO Review laboratory results and coordinate with the physician for a collaborative treatment
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Nursing Interventions and Goals

Help the kidney maintain homeostasis Maintain bed rest, semi-Fowler, DBCT, breath sounds Provide neutral temperature, quiet environment Teach to adjust for ADL, get regular exercise, if advised Promote overall health measure Manage pain Allow verbalization of pain, teach pain diversions and relaxation techniques Analgesics and opioids for better management
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Nursing Interventions and Goals

Precaution to medications Adjust to lower doses and lower frequency Consider water-soluble medications and vitamins Care for K+ management, Na+ shifts and CHON ingestion Provide skin care, emphasize on pulmonary toilet, oral and body hygiene Teach management for pruritus Assess for bleeding tendencies, promote safety and security Moisturizing oils, no alcohol/perfume products Assess and avoid pressure on edematous areas
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Nursing Interventions and Goals

Renal diet, foods must be deficient/rich in CHON, K+, CHO, vitamin and Ca+2, Na+, PO4-3 Meals FAT and cholesterol, blood sugar under control Coordination before taking any OTC medicine, vitamin, or herbal supplement Manage constipation, incorporate bran Assess appetite, weight, manage for TPN Fe in diet, pills, erythropoietin, and BT, Ca+2 and Vit. D BT preparations and precautions must be considered Provide support for neurologic symptoms
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Nursing Interventions and Goals

Observe infection control procedures
Boost clients immunity, incorporate vaccinations Impart knowledge for management and holistic care Teach client about the options of treatment, its complications, managements and interventions, with the significant others State importance of treatment compliance Coordinate with HCP and the family for effective coping and psychosocial management Provide and extend emotional support to client and family
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References
Black, Joyce M., and Jane Hokanson Hawks. Medical-

Surgical Nursing. 8th ed. Winsland House I, Singapore: Elsevier, 2008. Lippincott Williams and Wilkins. Fluids and Electrolytes Made Incredibly Easy. 4th ed. USA: Lippincott Williams and Wilkins, 2008. 5 Chronic Renal Failure Nursing Care Plans. http://nurseslabs.com/nursing-care-plans/chronic-renalfailure-nursing-care-plans/

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End

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