Chronic Renal Failure (ESRF)
Chronic Renal Failure (ESRF)
Chronic Renal Failure (ESRF)
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<strong>Chronic</strong> <strong>Renal</strong> <strong>Failure</strong><br />
(<strong>ESRF</strong>)
Definition<br />
• Progressive irreversible destruction of the nephrons in both<br />
kidneys<br />
• Almost 300,000 ESRD<br />
• 34% above 65 y<br />
• Federal law – all are eligible for Medicare (80%)
Etiology/Causes<br />
• DM (31%)<br />
• Uncontrolled HTN (25%)<br />
• <strong>Chronic</strong> glomerulonephritis (18%)<br />
• Polycystic kidney disease (5%)<br />
• Others (21%)<br />
• Pyelonephritis<br />
• Infection<br />
• Medication<br />
• Toxins
Stages<br />
• Stage I<br />
• Diminished renal reserve<br />
• inability to concentrate urine/increased output<br />
• Stage II - <strong>Renal</strong> insufficiency<br />
• GRE less than 25%- urinary output decreases<br />
• BUN rises - metabolic wastes accumulate<br />
• Stage III-End Stage – uremia<br />
• Every system affected<br />
• GRE less than 10%
Patient History<br />
• Patient may complain of:<br />
• weight gain<br />
• dyspnea<br />
• mental cloudiness<br />
• muscle cramps, numbness<br />
• itching<br />
• weakness, fatigue, decreased endurance
Clinical Manifestations<br />
• Chem Regs:<br />
• Uremia<br />
• Metabolic Acidosis<br />
• Kussmauls<br />
• Hypervolemia<br />
• Hyperlipidemia<br />
• Electrolyte Imbalance<br />
• Na/H2O<br />
• Ca/Ph<br />
• Hyperkalemia
Clinical Manifestations (con’t.)<br />
• Gaseous Transfer<br />
• HTN<br />
• CHF<br />
• Uremic pericarditis<br />
• Edema<br />
• Uremic<br />
• Thick secretions<br />
• Kussmaul’s Respiration
Clinical Manifestations (con’t.)<br />
• Body Defense<br />
• Anemia<br />
• Bleeding tendencies<br />
• Infection - impaired neutrophils<br />
• Severe itching -Pruritis<br />
• Pallor<br />
• Brittle nails<br />
• Coarse thinning hair
Clinical Manifestations (con’t.)<br />
• Mobility<br />
• Osteodystrophy - Loss of Ca from the bone<br />
• Muscle cramps/foot drop<br />
• Neurologic depression<br />
• Lethargy, apathy, confusion seizures, coma<br />
• Dialysis encephalopathy<br />
• Peripheral neuropathy, muscle weakness<br />
• Seizures<br />
• Reproductive<br />
• Infertility/decreased libido/impotence<br />
• Nutrition<br />
• Mucosal ulcerations<br />
• Anorexia/n/v/d<br />
• Ammonia halitosis<br />
• GI bleeding
Diagnostic<br />
• Urinalysis<br />
• Electrolytes<br />
• CBC<br />
• Biopsy<br />
• <strong>Renal</strong> ultrasonography
Medical Management<br />
• Treatment goals:<br />
• stabilization<br />
• fluid /electrolytes/BP<br />
• absence of<br />
• infection, bleeding, toxicity<br />
• sufficient nutrition intake<br />
• control N/V<br />
• control itching
Medical Management<br />
• Dialysis<br />
• Dietary<br />
• fluid restriction<br />
• reduction of:<br />
• proteins- 40 - 80 g/d<br />
• K – 40 mEq<br />
• Na - 2000 mg/d<br />
• Phosphorus/Ca - 500 - 600 mg/d<br />
• carbohydrates – unlimited sugars
Dietary Sources Potassium to Avoid<br />
• Chocolate<br />
• Dried fruit, nuts and seeds<br />
• Oranges, bananas, apricots and cantaloupe<br />
• Meat<br />
• Beans, potatoes<br />
• Tomatoes<br />
• Celery<br />
• Mushrooms
• Medications<br />
• Antihypertensives (vasodilators / beta blockers/ACE inhibitors)<br />
• Erythropoietin (Epogen) / Iron<br />
• Phosphate Binders(PhosLo/Renagel /Aluminum hydroxide)<br />
• Calcium (Rocaltrol) Supplements<br />
• Vitamin (Vit C)<br />
• Diuretics; Stool Softeners(Senokot)<br />
• Potassium Binding (Kayexalate)<br />
• Itching meds
Pain r/t peripheral neuropathies associated with<br />
electrolyte imbalance<br />
• Expected Outcome<br />
• Patient denies muscle cramps...<br />
• Nursing Interventions<br />
• Observe patient’s reaction to<br />
discomfort<br />
• Provide footboard<br />
• Instruct patient to move legs in bed<br />
• Keep linens off extremities<br />
• Apply cold packs<br />
• Administer pain meds
Impaired Skin Intregrity r/t atrophy of<br />
skin glands, accumulation of waste products….<br />
• Expected Outcomes<br />
• Patient refrains from scratching<br />
• Clean intact skin<br />
• Nursing Intervention<br />
• Assess Skin<br />
• pruritus<br />
• Bruises<br />
• Signs of Infection<br />
• Apply cool moist packs<br />
• Apply creams/bath oil<br />
• Discourage bathing<br />
• Provide diversions
Nursing Dx<br />
• Risk for injury: fracture<br />
• Activity Intolerance<br />
• Constipation/Diarrhea<br />
• Anticipatory grieving<br />
• Self Esteem Disturbance<br />
• Sensory perceptual Alteration<br />
• Risk for sexual dysfunction<br />
• Risk for infection
Complications<br />
• Hypertension<br />
• Hyperkalemia<br />
• Peripheral neuropathy<br />
• Seizures<br />
• Cardiac dysrhythmias<br />
• Pulmonary edema<br />
• Infection<br />
• Metabolic acidosis<br />
• Uremia
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