Chronic Renal Failure

Prepared by: ALUMBRO, Anna Rose L. SN

COLANO, Afra B. SNGIMPAYAN, Jerica May F. SNTUDAYAN, Ivana Kim G. SNVALERIO, Stephanie Z. SN

(S.Y. 2015-2016)

Learning Objectives:At the end of this case conference, the students/ learners would be able to:

Describe the anatomy and physiology of the renal systems. 

Discuss the types of Renal Failure and its difference. 

Define the Chronic Renal Failure Explain the stages of Chronic Kidney

Disease (CKD) Identify the clients at risk and causes for

development of CRF. 

Learning Objectives: 

Describe the pathophysiology of CRF Identify the signs and symptoms or

clinical manifestations of End-Stage Renal Disease 

Discuss the diagnostic findings of CRF. Compare and contrast the treatment

options or the medical managements Identify the prioritized and common

Nursing Diagnosis

I. Anatomy and Physiology

Kidney/s located @ upper abdominal cavity on either

side of the vertebral column, behind the

peritoneum (retroperitoneal) upper portions of the kidneys rest on the

lower surface of the diaphragm and enclosed and protected by the lower rib cage

left kidney is slightly higher than the right one.

I. Anatomy and Physiology

Kidney/s embedded in adipose tissue that acts as a

cushion and covered by a fibrous connective tissue membrane called the

renal fascia (helps hold the kidneys in place)

each has an indentation called the hilus on its medial side (renal and the renal vein and ureter emerge)

A. Internal Structure of the Kidney

outer tissue layer is called the renal cortex; it is made of renal corpuscles and convoluted tubules

inner tissue layer is the renal medulla, w/c made of loops of Henle and collecting tubules. Renal medulla consists of wedge shaped pieces called renal pyramids (apex or papilla)

A. Internal Structure of the Kidney

renal pelvis; this is not a layer of tissues, but rather a cavity formed by the expansion of the ureter within the kidney at the hilus. Funnel-shaped extensions of the renal pelvis, called calyces, (enclose the papillae of the renal pyramids.

B. The Nephron

structural and functional unit of the kidney.

Each kidney contains approximately 1 million nephrons

Each nephron has two major

portions: a renal corpuscle and a

renal tubule

B. The Nephron

a.Types of NephronCortical Nephron

80-85 % of the total number of nephrons located in the outermost part of the cortex

Juxtamedullary nephrons 15-20% located deeper in the cortex

b. Parts of NephronsRenal Corpuscle

consists of a glomerulus surrounded by

a Bowman’s capsule glomerulus is a capillary network that

arises from an afferent arteriole and empties into an efferent arteriole

efferent arteriole’s diameter is smaller than the afferent arteriole, w/c helps maintain a fairly high blood pressure in the glomerulus

b. Parts of Nephrons Renal Corpuscle

Bowman’s capsule; it encloses the glomerulus. The inner layer of Bowman’s capsule is made of podocytes; means “foot/feet cells,” that are on the surface of the glomerular capillaries w/c creates pores, slits between adjacent “feet,” which make this layer very permeable

b. Parts of Nephrons

Renal Tubuleconsists of the following parts: proximal

convoluted tubule (in the renal cortex), loop of Henle (or loop of the nephron, in the renal medulla), and distal convoluted tubule (in the renal cortex).

distal convoluted tubules from several nephrons empty into a collecting tubule. Several collecting tubules then unite to form a papillary duct that empties urine into a calyx of the renal pelvis

b. Parts of Nephrons

Renal TubuleAll parts of the renal tubule are surrounded

by peritubular capillaries, which arise from

the efferent arteriole. The peritubular

capillaries will receive the materials

reabsorbed by the renal tubules.

Flow of the Urine

C. Blood Vessels of the Kidney

pathway of blood flow through the kidney is an essential part of the process of urine formation

II. Renal Failure refers to temporary or permanent damage

to the kidneys that result in loss of normal kidney function which cannot remove the body’s metabolic wastes (Brunner & Suddarth, 2010).

two different types of renal failure--acute and chronic.

Acute renal failure has an abrupt onset and is potentially reversible.

Chronic renal failure progresses slowly over at least three months and can lead to permanent renal failure. (hopkinsmedicine.org)

III. Chronic Renal FailureTermed as an End-Stage Renal

Disease (ESRD).A progressive and irreversible

deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia.

Usually end result of gradual tissue destruction

III. Chronic Renal Failure

incidence of ESRD has increased by almost 8% per year from the past 5 years.

In the US, more than 280,000 patients with CRF (65%) are receiving hemodialysis, more than 120,000 (28%) have functioning renal transplants, and more than 24,000 (7%) are receiving peritoneal dialysis (United States Renal Data System [USRD], 2004)

IV. Stages of Chronic Kidney Disease

Stages are based on the GFR. Normal GFR: 90 - 125 mL/min/1.73 m2

(According to National Kidney Foundation)

V. Risk Factors and Causes of CRF/ ESRD

Injury or trauma to the kidneys

Major blood loss Diabetes Mellitus Hypertension Chronic

Glomerulonephritis Pyelonephritis Obstruction of the

Urinary tract

Hereditary Lesion (Polycystic Kidney Disease)

Vascular Disorders Infections Medications Exposure to toxic

agents (lead, cadmium, mercury, and chromium)

Chronic kidney disease (CKD)

VI. Pathophysiology of CKD and CRF/ESRD

VII. SIGNS/SYMPTOMS/ Clinical Manifestations

1.Neurologic Weakness and

fatigue Confusion Inability to

concentrate Disorientation Tremors Seizures Asterixis Restlessness of

legs Burning of soles of

feet Behavior changes

2. Integumentary Gray-bronze skin

color Dry, flaky skin Pruritus Ecchymosis Purpura Thin brittle nails Coarse thinning

hair

VII. SIGNS/SYMPTOMS/ Clinical Manifestations

3. Cardiovascular Hypertension Pitting edema

(feet, hand, sacrum)

Periorbital edema Pericardial friction

rub Engorged neck vein Hyperkalemia

Hyperlipidemia

4. Pulmonary Crackles Depress cough

reflex Pleuritic pain Shortness of breath

tachypnea

VII. SIGNS/SYMPTOMS/ Clinical Manifestations

5. Gastrointestinal Ammonia odor of

breath ( “uremic fetor”)

Metallic taste Mouth ulceration

and bleeding Nausea and

vomiting

Constipation and diarrhea

6. Hematologic Anemia Thrombocytopeni

a

VII. SIGNS/SYMPTOMS/ Clinical Manifestations

7. Reproductive Amenorrhea Testicular

atrophy Infertility Decrease libido

8.

Musculoskeletal Muscle cramps Loss of

muscles strength

Renal osteodystrophy

Bone pain Bone fractures Foot drop

VIII. Diagnostic Findings

A.Laboratory AssessmentGlomerular Filtration Rateglomerular filtration (d/t

nonfunctioning glomeruli)creatinine clearance value serum creatinine and BUN

levels

VIII. Diagnostic Findings

A.Laboratory AssessmentSodium and Water

retention/excretion (altered urine output)

AcidosisMetabolic acidosisDecreased acid secretion

Anemiainadequate erythropoietin production

VIII. Diagnostic Findings

A.Laboratory AssessmentCalcium and Phosphorus Imbalance

Activation of Vit. D Hypocalcemia PTH Hyperphosphatemia

B. Radiographic Assessment

renal osteodystrophy kidneys are atrophic and may

be 8 to 9 cm or smaller

IX. Medical Management The goal of management is to maintain

kidney function and homeostasis for as long as possible

A.Pharmacological TherapyCalcium and Phosphorus Binders

Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract

Calcium Carbonate or Calcium Acetate

IX. Medical Management

A.Pharmacological TherapyAntihypertensive and

Cardiovascular AgentsHypertension is managed by

intravascular volume control and a variety of antihypertensive agents.

Digoxin or Dobutamine

IX. Medical Management

A.Pharmacological TherapyAntiseizure Agents

Neurologic abnormalities might occurIV Diazepam (Valium) or Phenytoin (Dilantin)

ErythropoietinTreatment for AnemiaEpogen

IX. Medical Management B.Nutritional Therapy

Dietary Intervention is necessary with deterioration of renal function and includes:

Careful regulation of protein intake

Fluid intakes to balance fluid losses

Sodium intake to balance sodium losses

And some restriction of potassiumAdequate caloric intakeVitamins supplementation

IX. Medical Management

C. Dialysis• used to remove fluid and uremic waste

products from the body when the kidneys are unable to do so

• Indicated also to treat patients with edema that does not respond to other treatment, hepatic coma, hyperkalemia, hypercalcemia, hypertension, and uremia.

IX. Medical Management

C. DialysisMethods of therapy includes:

HemodialysisMost common method of dialysis. It used for

patient who are acutely ill and require short-term dialysis (days to weeks) and for patients with ESRD who require long term or permanent therapy. A dialyzer (also referred to as an artificial kidney)serves as a synthetic semipermeable membrane , replacing the renal glomeruli and tubules as the filter for the impaired kidneys

IX. Medical Management

C. DialysisMethods of therapy includes:

CRRT (Continuous Renal Replacement therapies)Indicated for patients with acute or chronic

renal failure who are too clinically unstable for traditional hemodialysis, for patients with fluid overload secondary to oliguria, renal failure, and for patients whose kidney cannot handle their acutely high metabolic or nutritional needs

IX. Medical Management

C. DialysisMethods of therapy includes:

Peritoneal DialysisGoal is to remove toxic substances and

metabolic wastes and to re-establish normal fluid and electrolyte balance. The treatment of choice for patient with renal failure who are unable or unwilling to undergo hemodialysis or renal transplant.

IX. Medical Management

D. Renal/ Kidney TransplantKidney transplantation has become the

treatment of choice for most patients with ESRD.

Patients choose kidney transplantation for various reasons: desire to avoid dialysis or to improve their sense of well-being and the wish to lead a more normal life.

IX. Medical Management

D. Renal/ Kidney TransplantCriteria for Candidate in Kidney

Transplantation Free of medical problems that might increase the risk from the procedure

2 to 7 years old Advanced and uncorrectable cardiac disease are excluded

Metastatic Cancer (-)

IX. Medical Management

A.Renal/ Kidney TransplantCriteria for Candidate in Kidney

Transplantation Chronic Infection (-)Severe Psychosocial problems (chemical

dependency) (-)Long-standing pulmonary disease-

respiratory infections (-)GIT problems (Peptic Ulcer, Diverticulosis)-

made worse by the large doses of steroid used after transplantation (-)

IX. Medical Management

D. Renal/ Kidney TransplantDonors

Usually 18 years old above and are seldom older than 65 years of age

Absence of systemic Disease and infection

No history of cancerNo hypertension or renal diseaseAdequate renal function as determined by diagnostic studies

X. Nursing Diagnosis for CRF/ End-Stage Renal Disease

Excess fluid volume related to decreased urine output, dietary excessive and retention of sodium and water.

Imbalance nutrition; less than body requirements related to anorexia, nausea, vomiting, dietary restrictions and altered oral mucous membranes.

X. Nursing Diagnosis for CRF/ End-Stage Renal Disease

Risk for infection related to inadequate primary defenses (broken skin), chronic disease and malnutrition.

Risk for injury related to internal biochemical risk factor associated with renal failure (increased susceptible to bleeding, falls and fractures)

Deficient knowledge regarding condition and treatment

X. Nursing Diagnosis for CRF/ End-Stage Renal Disease

Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure

Risk for situational low self-esteem related to dependency, role changes, change in body image and change in sexual function

Reference:Scanlon, V. and Sacnders, T. (2011). Essentials of Anatomy and

Physiology (7th Edition)

LaCharity, Linda A. Interventions for Clients with Acute and Chronic Renal Failure

Smeltzer, Bare, Hinkle, Cheever, (2008). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (11th Edition)

Ignatavicus & Workman (2006) Medical Surgical Nursing: Critical Thinking for Collaborative Care (5th Edition)

Pathophysiology an Incredibly Easy (Pocket Guide)

Doenges, Moorhouse & Murr, (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span (9th Edition)

http://www.hopkinsmedicine.org/ 

http://www.kidneyfund.org/

http://www.netwellness.org/

THANK YOU