jcmendiola_Achievers2013

Care of Clients with Problems In Oxygenation,

Fluids and Electrolytes, Metabolism and Endocrine
(NCM103)
Patients With Fluids and Electrolytes (Renal) Alteration IV

Renal Diseases

RENAL FAILURE
A. Definition:
- A state of total / nearly total loss of the kidneys ability to excrete waste products and
maintain fluid and electrolyte balance
B. Causes:
Pre-Renal
A condition that occurs BEFORE the kidney
Any situation/condition that would bring about a HYPOPERFUSION of the
kidney (Hypoperfusion Any condition that brings blood flow/supply to the
kidney)
Examples: Pressure in the arteries
1. Bleeding
2. Hemorrhage / Stroke
3. Cardiac Output
Intra-Renal
A condition in which occurs
WITHIN the kidney :-o
Brought about by:
1. Infection of the kidney
- Glomerulonephritis
- Pyelonephritis
2. Malignancy
- Cancer of the Kidney
Post-Renal
A condition in which it occurs AFTER the kidney
Brought about by:
= Any obstructive disease
- Presence of STONE FORMATION
- Stagnant urine
C. Assessment of Signs and Symptoms
1. Fluid Imbalance
Impairment of the normal functioning of the kidney
Isotonic Excess
Hypervolemia
Cues:
a. Urine Output
Oliguria (UO: >50 mL/day but <400 mL/day)
For 1 2 years
Anuria (UO: < 50 mL/day)
b. Edema Formation
Periorbital Edema
Observed during waking up at the morning
Peripheral Edema
Lower extremities 1
st
has the edema
Then eventually the stomach gets affected
(Ascites)
Topics Discussed Here Are:
1. Renal Failure
2. Dialysis
a. Peritoneal Dialysis
b. Hemodialysis
LOOKY
HERE


Will eventually become

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c. Body Weight
1 kg = 1 L retained by the body
Abdominal circumference!
2. Electrolyte Imbalance
a. Hyperkalemia ( K+ [Cannot be excreted!])
b. Hyponatremia ( Na+ in relation to H
2
O)
c. Kidney maintains the acid-based balance
= In the last step in urine formation (Excretion / Secretion)


= The kidney is responsible for EXCRETION of metabolites
- Urea, Creatinine, Uric Acid (Used to assess kidney functioning)
- If in the event, the kidney cannot excrete Urea :o










3.
4. Abnormal Vital Signs
O Normally TPR is NORMAL DOI! XD
O There is an abnormal TEMPERATURE if infection is present
O BLOOD PRESSURE is
5. Skin Changes
a. Uremic Frost
+ Accumulation of URIC ACID on the SKIN
+ How to ASSESS UREMIC FROST XD
- USE A MAGNIFIER (LOL) Experience ni MAM
- It is really hard to see the flakes
+ Disadvantages:
- HIGHLY IRRITATING TO THE NERVES
- The patient complains of SEVERE ITCHINESS
b. Ashen Gray Color
+ Usually occurs on the latter part of the disease process
+ For the laymans term it is color talong of the skin
+ The color depends on the melanin pigmentation of the person
+ The ASHEN GRAY COLOR is brought about by the CHRONICALLY
LOW HEMOGLOBIN CONTENT!!!

Secretion HCO
3

(Impaired)
HCO
3
Acidosis
Excretion H
2

(Impaired)
H
2
Acidosis
Normal
Renal
Tubules
PATIENTS WITH
RENAL FAILURE ARE
AT RISK FOR
METABOLIC
ACIDOSIS!!


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Pathophysiology of Ashen Gray Color for Renal Failure


D. Plan of Care
1. Conservative Management
a. Diet:
Low Na Diet (2g Na Diet)
Low K Diet
Protein Content
RESTRICT fluid intake
b. Intake and Output
For an unconscious client, use a DIAPER
c. Weight and Abdominal Circumference
Weigh in the MORNING, BEFORE BREAKFAST and AFTER
VOIDING
Use the same weighing scale
Control the type of clothing
Get the abdominal circumference
- Get the abdominal circumference upon WAKING UP in the
morning, AFTER voiding, and BEFORE breakfast
- Put the tape measure at the HIGHEST POINT of the abdomen
- Put a mark on the AREA!
Strict REVERSED ISOLATION technique!
- Isolate the clean case! (Use a mask, and people should be free
from URTI)
- To prevent infection
2. Dialysis
a. Definition:
^ Process of SEPARATING CRYSTALLOIDS and COLLOIDS in a
solution through a DIFFERENCE in the rate of DIFFUSION!
b. Purpose:
1. To treat the signs and symptoms of RENAL FAILURE
2. To prepare the client for a MORE definite management
(Renal Transplantation)
3. To take the place of the kidneys temporarily!
c. Types:
1. Peritoneal Dialysis
a. Intermittent (On and Off)
Very seldom used
Done at the HOSPITAL
Catheter is inserted on the client, between the umbilicus
and the symphysis pubis 2 3 finger breadths away
Introduction to the peritoneum

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Only a portion of the catheter is exposed on the
abdomen (About 1 inch)
Peritoneum = Space between the large intestine and
skin
Attaches a Y-Tube which is connected to the dialysate
Then has a drainage tube which is connected to a
drainage bag

3 Steps in Peritoneal and Hemodialysis
1. Introduction of Dialysate
+ Open the regulator for the infusion tube, but make sure that the regulator is OFF
+ Occurs for about 10 15 minutes
+ Close the regulator
+ Fluid is inside the peritoneum
2. Retain the Fluid / Dialysate
+ Dialysate is in the peritoneum for about 20 30 minutes
+ Dwell Time The amount of time the dialysate remains in the peritoneum
Also known as: Retention Time, Equilibrium Time and Perfusion Time
+ This is done so that we will allow diffusion to take place
+ Then regulator is opened up
3. Drain the Dialysate
+ Drain then change the dialysate

The WHOLE PROCESS is called ONE EXCHANGE
One type of intermittent dialysis will account for 30 32 or 35 exchanges
o Duration is about 2 3 days XD
Drawback:
o Done in the HOSPITAL
o Patient may acquire Nosocomial infection!
o IT IS VERY EXPENSIVE

b. Continuous Ambulatory Peritoneal Dialysis (CAPD)
Patient wears a mask
Patient performs it himself / herself
Steps are almost the same, differs only on DWELL
TIME

3 Steps in Peritoneal and Hemodialysis
1. Introduction of Dialysate
+ Hang the dialysate on an IV stand
+ Open the regulator
+ Close it then fold the tube neatly
2. Retain the Fluid / Dialysate
+ Dialysate is in the peritoneum for about 4 5 or 6 hours
+ Dwell Time is 5 6 hours (ANG GULO XD)
3. Drain the Dialysate
+ Drain the fluid in the comfort room and then change the dialysate~

2. Hemodialysis
Blood of the client is propelled out which will pass out to a dialysis
machine
This is done to remove bad ELEMENTS and return the blood



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PICTURE A PICTURE B (Not the actual pic na meron si mam)

Mga Sinabi ni Mam sa Pic na to (PICTURE A)
Vascular Access This is in between the client and the machine
Catheter (Has to wait 2 3 weeks before the patient can be attached)
o AV Shunt / Canula
Arteriovenous Shunt
Makes an artificial connection between the artery and the vein
Uses the RADIAL ARTERY
Uses the median cephalic vein
Done on the arm not commonly used
MINOR type of surgery
o AV Graft Catheter

Hooking Up Process
o Process of connecting the client!
Hook Up Attach
Hook Down Detach
The NURSE puts the machine ON THE CLIENT
The TECHNICIAN SETS UP the machine

MGA IBA PANG SINABI NI MAM (PICTURE B)
- Arterial shunt FIRST is connected
o There is a BLOOD PRESSURE DETECTOR on the machine
- Blood passes through a BLOOD PUMP (Spinning)
o To assist the clients heart on the pumping
- The machine is made up of membranes / cellophane-like (semi permeable) membrane
o Cleanses the blood
o Blood comes out to the venous blood line
o Before returning, the blood passes a device that removes clotted blood
o Then the blood is returned to the venous shunt
o This process has a duration of 2 4 hours and is done 3 times in a week

Nursing Responsibilities:
- Get a baseline vital sign
- Get the ABGs of the client
- Get the Creatinine and urea results
- Check the CBC and blood sugar levels and the hemoglobin level