CHRONIC RENAL FAILURE
Chronic Renal Failure or End stage renal disease is a progressive, irreversible deterioration in renal function in which the body's ability to maintain metabolic and fluid and electrolyte balance fails, resulting fatally in uraemia.
Causes
Chronic glomerulonephritis, pyelonephritis) in uncontrolled HT, obstruction of the urinary tract/hereditary lesions such as polycystic kidney disease, drugs, toxic agents or infection (streptococcal infection); vascular disorders e.g. Atherosclerosis systemic disease e.g. DM. Drug intoxication.
Risk Factors
HT and DM are the most common cause of CRF! Men and Women are equally affected; middle-aged people are mainly affected.
Pathophysiology
Etiological Factors
↓
Decreased glomerular filtration
↓
Hypertrophy of nephrons
↓
Inability to concentrate urine
↓
Further loss of nephron function
[Decrease in GFR → Stimulates Renin-Angiotensin Mechanism causing increased aldosterone secretion leads to Increased Blood Pressure → Sodium & Water Retention, Increased Serum Phosphate, Decreased Serum Calcium levels, Hyperkalaemia, Increased Serum Urea, creatinine levels → Uraemia]
Clinical Manifestations
1. Urinary system- polyuria, nocturia, As renal failure progresses, oliguria develop and later anuria.
2. Cardiovascular system- HT, pitting edema, periorbital edema, engorged neck veins
3. Integumentary system- Gray bronze skin colour, dry flaky skin, pruritus, ecchymoses; thin, brittle nails, coarse, thinning hair.
4. Pulmonary system- thick, tenacious sputum; shortness of breath; Kussmaul type respiration.
5. Gastro-intestinal system - ammonia Odor breath, mouth ulcerations and bleeding; anorexia, nausea and vomiting, constipation bleeding from GIT.
6. Neurological system- weakness a fatigue; confusion; disorientation; seizures; restlessness of legs, burning soles of feet; [behaviour changes].
7. Musculoskeletal system- muscle cramps; loss of muscle strength; bone fracture, foot drop.
8. Metabolic and endocrine- glucose intolerance, Hyperlipidemia, sex hormone disturbances causing Wed libido, impotence and amenorrhea.
9. Psychosocial function- personality of behaviour changes, alteration in cognitive processes.
Diagnostic Evaluation
1. Complete blood count - anaemia.
2. Elevated serum creatinine, BUN, Phosphorus.
3. Increased serum calcium, bicarbonate and protein especially albumin.
4. ABG-low blood Ph, low Co2, low bicarbonate (HCO3)
5. 24-hour urine for creatinine, protein creatinine clearance.
Medical Management
1. Detection of Treatment of reversible causes of RF (e.g. Bring diabetes under control; treat HT)
2. Dietary regulation low protein diet supplemented with essential amino acids [or their keto analogues] to minimize uremic toxicity and to prevent wasting and malnutrition.
3. Treatment of associated condition of improve renal dynamics.
a. Anaemia- recombinant human erythropoietin, a synthetic hormone.
b. Acidosis- replacement of bicarbonate stores by infusion or oral administration of NaCHO3.
c. Hyperkalaemia- restriction of dietary K; administration of cation exchange of resin
d. Phosphate retention- dietary phosphorus (chicken, milk, legumes, carbonate beverages) administer Phosphate binding agents because they bind phosphorus in the intestinal tract.
e. Maintenance- dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management.
Complications
1. [End-stage renal disease)
2. Pul. Oedema.
3. UTI.
4. Pneumonia due to volume overload or uraemia.
5. Death.
Nursing Management
1. Assess fluid and electrolyte status - serum electrolyte levels, daily Wt, 1/0, skin turgor and edema, neck veins distention, B.P. HR, signs of calcium imbalance (chvostek's and trousseau's signs), Respiratory rate.
2. Fluid restriction give only enough fluids to replace losses. Fluid allowance should be distributed through out the day.
3. Restrict salt and H2O intake. [if there is evidence of extra cellular excess].
4. Evaluate for s/s of hyperkalaemia and monitor ser. K. levels.
5. Adm. NaHCO3 or glucose and insulin to shift K. into the cells.
6. Adm. Kayexalate to provide more prolonged correction of elevated K.
7. Adm. Antacids as prescribed antacids promote binding of phosphate in intestinal tract and normal calcium and phosphorus levels.
8. Asses nutritional status encourage a high calorie, low protein, low sodium and low K snacks between meals.
9. Provide oral hygiene before meals and pleasant surroundings at meal time to improve the Patient sense of taste [ by eliminating waste products and moistens mucous membranes].
10. Keep skin clear to relieve itching and dryness with soap; NaHCO3 added to bath H2O; bath oil added to bath H2O.
11. Apply ointments or creams for comfort and to relieve itching.
12. keep nails short and trimmed to prevent excoriation.
13. Keep hair clean and moisturized.
14. Adm. Drugs for relief of itching if indicated.
15. Encourage. High-fibre diet, bearing in mind the K content of some fruits and vegetables. Use stool softness as prescribed. Avoid laxatives and cathartics that cause electrolyte toxicities (compounds containing magnesium or phosphorus). Activity as tolerated to prevent constipation.
16. Inspect Patients gait, ROM and muscle strength.
17. Adm. Analgesics as ordered and provide massage for severe muscle cramps (electrolyte imbalance).
18. Monitor x-rays and bone scan results for number, fracture bone demineralization and it deposits.
19. Activity as tolerated avoid immobilization, because it leads to bone demineralization.
20. Administer Medications as ordered.
a. Phosphate binding medication such as sevelamer (Renagel) or calcium carbonate (Oscal) with meals and snacks to lower serum phosphorus.
b. Calcium supplements between meals to increase serum calcium.
c. Vit. D to absorption and utilization of calcium.
21. Prepare Pt for dialysis or kidney transplantation.
22. Assess Patients understanding of treatment regimen as well as concerns and fears
23. Encourage Strengthening of social support system and coping mechanisms to lessen the impact of the stress of chronic kidney disease.
