Critical care nursing
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| 5. RENAL NURSING
Renal nursing, also known as nephrology nursing, is a specialized field of nursing that focuses on caring for individuals with kidney-related health issues. This area of nursing is essential because the kidney play a crucial role in maintaining overall health by filtering waste and excess fluid from the blood, regulating balance, and producing hormones that control blood pressure. This nursing specialty covers all age groups and encompasses varied care environment , from the home to the intensive care unit. Renal nursing involves both preventing disease and assessing the health needs of patient and families. Care spans the life cycle and involves patients who are experiencing the real or threatened impact of acute or chronic kidney disease, therefore nephrology nurses must be well-educated, highly skilled, and motivated. Nephrology nurses also deal with every organ system in the body, calling for a holistic approach to patient care that is both challenging and rewarding. Nephrology nurses practice in dialysis clinics, hospitals, home settings, long term facilities, transplant programs and many other inpatient and outpatient settings. They work in primary, secondary and tertiary care facilities, wherever individual experiencing or at risk of kidney disease receive healthcare. In acute care settings, patient are often critically ill, and care is fast-paced. In an outpatient settings, the nephrology nurse is an integral member of a interprofessional team that cares for patients with complex needs. IMPORTANCE OF RENAL NURSING IN HEALTHCARE Early detection and intervention: Renal nurses play a crucial role in early detection of kidney disease through monitoring and assessment. This early detection allows for timely intervention, potentially slowing the progression of the disease and preventing complications. Dialysis management: Many patient with kidney disease require dialysis to remove products and excess fluids from the blood. Renal nurses are skilled in managing and producing dialysis treatment, which are life-sustaining for these patients. Education and patient management: Renal nurse educate the family about kidney disease, its management and the importance of adhering to treatment plans. Patient education encourages individuals to actively participate in their care and make informed decision. Preventing complication: By closely monitoring and managing patients with kidney disease, renal nurses help prevent complication that can arise from uncontrolled kidney disease, such as heart disease, bone disease and anaemia. Promoting quality of life: The care provided by these nurses aims to enhance the overall quality of life for patients with kidney disease, helping them lead fulfilling and productive lives. STRUCTURE OF THE KIDNEY ANATOMY OF THE KIDNEY: 1. Location: The kidneys are bean-shaped organs located on each side of the spine in the upper abdominal region. They are situated just below the ribcage, with one on the left side and one on the right side. 2. Size: Each kidney is approximately 4.5 to 5 inches (11-13 cm) in length, 2 to 3 inches (5-7.5 cm) in width, and about 1 inch (2.5 cm) in thickness. 3. Blood Supply: The kidneys have a rich blood supply. The renal arteries deliver oxygenated blood to the kidneys, and each kidney has a single renal artery. Once filtered, deoxygenated blood is carried away from the kidneys by the renal veins. Each kidney has a single renal vein. 4. Venous Drainage: The renal veins from both kidneys connect to the inferior vena cava, a large vein that carries deoxygenated blood back to the heart. 5. Structure: Each kidney is divided into two main regions - the outer renal cortex and the inner renal medulla. Within the medulla are renal pyramids, which are responsible for the concentration of urine. The functional units of the kidney are called nephrons, and there are over a million nephrons in each kidney. FUNCTIONS OF THE NEPHRON The nephron is the functional unit of the kidney responsible for filtering and regulating blood to maintain fluid and electrolyte balance in the body. It consists of several structures and performs various functions. The functions include: Filtration: The process starts at the glomerulus, a cluster of capillaries that filters blood to form an ultrafiltrate. Fenestrations in the capillaries allow small molecules to pass through, while larger ones are retained. Reabsorption: The proximal tubule reabsorbs essential substances such as glucose, ions (e.g., sodium, potassium), and water from the ultrafiltrate back into the bloodstream. Secretion : The nephron secretes waste products like hydrogen ions and certain drugs into the tubular fluid to be excreted. This process contributes to pH regulation and elimination of toxins. Concentration: The loop of Henle establishes an osmotic gradient in the medulla, allowing for water reabsorption in the descending limb and solute reabsorption in the ascending limb. This is crucial for concentrating the urine. Dilution: The distal tubule can further modify the urine by reabsorbing sodium and calcium and secreting potassium, depending on the body's needs. Regulation: The collecting duct fine-tunes urine concentration by responding to hormonal signals (e.g., antidiuretic hormone) to either reabsorb more water or excrete more water, helping to maintain fluid and electrolyte balance. Aldosterone regulation: Principal cells in the collecting duct respond to aldosterone, regulating sodium reabsorption and potassium excretion. Acid-Base balance: Intercalated cells in the collecting duct help control acid-base balance by secreting hydrogen ions or bicarbonate ions based on the body's pH needs. Detoxification: The nephron also plays a role in detoxifying the body by filtering and excreting waste products, drugs, and metabolic byproducts. The kidneys play a vital role in maintaining the body's overall fluid and electrolyte balance, regulating blood pressure, and filtering metabolic waste from the bloodstream. Their complex structure and intricate physiological processes make them essential for homeostasis in the body. FUNCTIONS OF THE KIDNEY The primary function of the kidney is to make urine and purify the blood. Each kidney removes waste materials, and other chemicals which are not required by the body. Most important functions of the kidney are described below. Removal of waste products Purification of blood by removal of waste products is the most important function of the kidney. The food that we consume contains protein. Protein is necessary for the growth and repair of the body. But as protein is utilized by the body it produces waste products. Accumulation and retention of these waste products is similar to retaining poison inside the body. Each kidney filters blood, and toxic waste products which are eventually excreted in the urine. Creatinine and urea are two important waste products that can easily be measured in the blood. Their “values” in blood tests reflects the function of the kidney. When both the kidneys fail, value of creatinine and urea will be high in blood test. Removal of excess fluid The second most important function of the kidney is the regulation of fluid balance by excreting excess amount of water as urine while retaining the necessary amount of water in the body, that is essential for living .When the kidneys, fail they lose the ability of removing this excess amount of water. Excess water in the body leads to swelling. Balance minerals and chemicals The kidneys play another important role of regulating minerals and chemicals like sodium, potassium, hydrogen, calcium, phosphorus, magnesium and bicarbonate and maintains normal composition of body fluid. Changes in the sodium level can affect person’s mental state, while changes in the potassium level can have serious adverse effects on the rhythm of the heart as well as functioning of the muscles. Maintenance of normal level of the calcium and phosphorus is essential for healthy bones and teeth. Control of blood pressure The kidneys produce different hormones (renin, angiotensin, aldosterone, prostaglandin etc) which help regulate water and salt in the body, which plays vital roles in the maintenance of good blood pressure control. Disturbances in hormone production and regulation of salt and water in a patient with kidney failure can lead to high blood pressure. Red blood cells production Erythropoietin is another hormone produced in the kidneys, it plays an important role in the production of red blood cells (RBC). During kidney failure, production of erythropoietin is decreased, which in turn leads to decreased production of RBC resulting in low hemoglobin (anemia). This is the reason why in patients with kidney failure, the hemoglobin count does not improve despite supplementation with iron and vitamin preparations. To maintain healthy bones The kidneys convert vitamin D into its active form which is essential for the absorption of calcium from food, growth of the bones and teeth, and keep the bones strong and healthy. During kidney failure, decreased active vitamin D leads to decreased, growth of bones and they also become weak. Growth retardation may be sign of kidney failure in children. Reabsorption of nutrients The kidney reabsorb nutrients from the blood using tubules and transport them to where they will best support health. They also reabsorb other products to help maintain homeostasis. The reabsorbed products include: glucose, amino acids, bicarbonate, water, phosphate, chloride, sodium, magnesium, and potassium ions Maintaining PH In humans, the range of acceptable pH levels is 7.35–7.45. At levels below or above this range, the body enters a state of acidemia or alkalemia, respectively. In these states, proteins and enzymes break down and can no longer function. In extreme cases, this can be fatal. The kidneys and lungs help keep the body’s pH stable. The lungs achieve this by moderating the concentration of carbon dioxide in the blood. The kidneys manage the pH by reabsorbing and producing bicarbonate from urine, which helps neutralize acids. Osmolality regulation Osmolality is a measure of the body’s electrolyte -water balance, which is the ratio between fluids and minerals in the body. Dehydration is a primary cause of electrolyte imbalance. If osmolality rises in the blood plasma, the hypothalamus in the brain responds by passing a message to the pituitary gland. This gland releases anti diuretic hormone (ADH). In response to ADH, the kidney makes several changes, including: increasing urine concentration, increasing water reabsorption, reopening portions of the collecting duct that water cannot normally enter, allowing water back into the body, retaining urea in the medulla of the kidney rather than excreting it, as this compound draws in water 10. Secretion of active compounds The kidneys release several important compounds including; Erythropoietin: This controls erythropoiesis, which is the production of red blood cells. The liver also produces erythropoietin, but the kidneys are its main producers in adults. Renin: This enzyme helps manage the expansion of arteries and the volumes of blood plasma, lymph, and interstitial fluid. Lymph is a fluid that contains white blood cells, which support immune activity, and interstitial fluid is the main component of extracellular fluid. Calcitriol: This is the hormonally active metabolite of vitamin D. It increases both the amount of calcium that the intestines can absorb and the reabsorption of phosphate in the kidney. COMMON RENAL DISORDERS 1. Acute Kidney Injury (AKI): This is a sudden loss of kidney function, often caused by factors like severe infections, dehydration, or medications. The kidneys can't filter waste and fluids properly, leading to a buildup of toxins in the body. Treatment involves addressing the underlying cause and supporting kidney function through hydration and medications. 2. Chronic Kidney Disease (CKD): CKD is a long-term condition where the kidneys gradually lose their ability to filter blood and remove waste products. Common causes include high blood pressure and diabetes. It progresses through stages, and management includes controlling underlying conditions, diet changes, and, in severe cases, dialysis or kidney transplant. 3. Nephrolithiasis (Kidney Stones): Kidney stones are hard, crystal-like deposits that form in the urinary tract. They can cause severe pain when they block the flow of urine. Treatment may involve pain relief, increased fluid intake, and in some cases, procedures to remove or break up the stones. 4. Glomerulonephritis: This is inflammation of the glomeruli, the tiny filters in the kidneys. It can be caused by infections, autoimmune disorders, or other factors. Symptoms may include blood in the urine and swelling. Treatment aims to control the inflammation and manage underlying causes. 5. Polycystic Kidney Disease (PKD): PKD is a genetic disorder where fluid-filled cysts form in the kidneys. Over time, these cysts can lead to kidney damage and failure. Treatment focuses on managing symptoms, blood pressure, and, in advanced cases, considering kidney transplantation. ASSESSMENT OF THE KIDNEY AND URINARY SYSTEM: Assessment and diagnosis of renal disorders typically involve a combination of patient history, physical examination, laboratory tests, and diagnostic procedures. 1. Patient History: - Gathering a comprehensive patient history is the first step. This includes asking about symptoms such as changes in urination (frequency, color, pain), swelling, high blood pressure, and any family history of kidney disease. - Information about pre-existing conditions like diabetes, hypertension, and any medications or supplements the patient is taking is crucial. 2. Physical Examination: - A physical examination helps the healthcare provider assess signs of kidney disease. They may check for swelling (edema), high blood pressure, and tenderness in the kidney area. - Examination of the eyes for signs of hypertension-related kidney damage (retinopathy) can also be part of the assessment. 3. Laboratory Tests: - Blood Tests: These include serum creatinine and blood urea nitrogen (BUN) levels, which reflect kidney function. Elevated levels may indicate kidney problems. - Urinalysis: Analyzing a urine sample can reveal the presence of blood, protein, or abnormal cells, all of which are important indicators of kidney function. - Glomerular Filtration Rate (GFR): This is calculated using serum creatinine levels and age. It provides an estimate of how well the kidneys are filtering waste. - Electrolyte Levels: Measuring levels of electrolytes like potassium and sodium can help identify imbalances often associated with kidney disease. 4. Diagnostic Procedures: - Imaging Tests: These may include ultrasound, CT scans, or MRIs to visualize the kidneys and identify structural abnormalities, cysts, or obstructions. - Kidney Biopsy: In some cases, a small sample of kidney tissue may be obtained through a biopsy to diagnose specific kidney diseases, especially if the cause is unclear from other tests. These assessment and diagnostic methods are critical in identifying and understanding renal disorders. The results guide healthcare professionals in making an accurate diagnosis and developing an appropriate treatment plan for patients. Nursing Interventions for Diagnostic Procedures: Nursing interventions for renal diagnostic procedures involve preparing the patient, ensuring their safety, providing support, and monitoring their condition. Here are some key nursing interventions for common renal diagnostic procedures: 1. Urinalysis: - Educate the patient about the procedure and the need to provide a clean midstream urine sample. - Assist the patient in collecting the urine sample in a sterile container. - Label the specimen correctly and ensure proper storage and transport. 2. Blood Tests (Serum Creatinine, BUN, Electrolytes): - Ensure the patient is well-hydrated before the blood draw unless otherwise specified. - Verify the correct patient, prepare the equipment, and draw the blood sample. - Label the samples accurately and send them to the laboratory. - Monitor the patient for any signs of bleeding, hematoma, or fainting after the blood draw. 3. Glomerular Filtration Rate (GFR) Calculation: - Assist in collecting the necessary blood samples for GFR calculation. - Calculate GFR using the patient's age and serum creatinine levels. - Educate the patient about the significance of GFR results and what they indicate about kidney function. 4. Imaging Tests (Ultrasound, CT, MRI): - Explain the procedure to the patient and address any concerns. - Ensure that the patient follows any specific preparation instructions, such as fasting or drinking contrast media. - Monitor the patient for any adverse reactions to contrast media, such as allergic reactions. 5. Kidney Biopsy: - Educate the patient about the purpose of the biopsy and the potential risks and benefits. - Obtain informed consent. - Prepare the patient by establishing intravenous access and administering any necessary medications. - Assist the physician during the procedure by providing necessary instruments. - Monitor the patient closely after the biopsy for signs of bleeding, infection, or other complications. 6. Patient Support: - Provide emotional support to the patient, as these procedures can be anxiety-inducing. - Offer pain management and comfort measures as needed, especially after invasive procedures like kidney biopsy. - Ensure that the patient is well-hydrated and monitor vital signs as appropriate for the specific procedure. 7. Documentation: - Accurately document the patient's response to the procedure, vital signs, and any adverse events or complications. - Record the results of the diagnostic procedure and communicate them to the healthcare team. TREATMENTS MODALITIES FOR KIDNEY CONDITIONS When the kidneys can no longer function properly in removing waste and maintaining fluid and electrolyte balance, renal replacement therapies are essential. These therapies can be needed on a short-term or long-term basis and include dialysis and kidney transplantation. Dialysis: Dialysis is used for patients with acute or chronic kidney conditions. It helps remove toxins, excess water, and medications from the blood. Hemodialysis, which is commonly done in an outpatient setting, uses a machine called a dialyzer to filter the blood through a synthetic membrane. This membrane allows toxins to move from the blood to the dialysate solution. Peritoneal dialysis is another type, which involves introducing dialysate fluid into the peritoneal cavity, allowing waste products to be cleared through the peritoneal membrane. Types of dialysis Hemodialysis: Hemodialysis is used for both short-term and long-term treatment. It involves filtering the blood through a dialyzer to remove toxins and excess water. Hemodialysis is performed multiple times a week, typically in an outpatient setting or at home. The key principles are diffusion, osmosis, and ultrafiltration. Peritoneal Dialysis: Peritoneal dialysis is an option for patients who cannot undergo hemodialysis. It involves cyclic exchanges of dialysate fluid in the peritoneal cavity to remove waste and regulate fluid and electrolyte balance. It's especially suitable for patients with certain medical conditions and those at risk for complications with hemodialysis. Kidney Transplantation: Kidney transplantation is the preferred treatment for some patients with end-stage renal disease. It can significantly extend a patient's lifespan compared to dialysis. Transplants can come from living or deceased donors, with living donors providing better success rates. The patient's health and compatibility are assessed before transplantation. After the procedure, medications are given to suppress the immune system to prevent rejection, but they can have side effects. NURSING MANAGEMENT FOR THE TREATMENTS FOR KIDNEY CONDITIONS Nurses play a crucial role in patient care throughout these treatments. This includes assessing patients for transplant rejection, preventing infections, monitoring urinary function, addressing psychological concerns, managing potential complications, and teaching patients self-care. Follow-up care is essential in ensuring the long-term success of kidney treatments. Here are the nursing management interventions for the treatment of kidney conditions in bullet points: Medication Management: - Administer prescribed medications as ordered. - Monitor for medication side effects and educate about adherence. Fluid and Electrolyte Balance: - Monitor and document intake and output (I&O). - Collaborate with the healthcare team on fluid and dietary restrictions. - Educate patients about fluid and dietary guidelines. Blood Pressure Management: - Regularly monitor and record blood pressure. - Administer antihypertensive medications as prescribed. - Educate on lifestyle modifications to control blood pressure. Nutrition and Diet: - Collaborate with a dietitian for a renal-friendly diet. - Monitor nutritional status and educate on dietary restrictions. - Encourage maintaining a healthy weight and managing comorbid conditions. Dialysis Support: - Provide care for dialysis patients, including monitoring, access care, and complications. - Offer emotional support to patients on dialysis. Infection Control: - Ensure aseptic technique for catheter care. - Educate on hygiene and infection prevention. Symptom Management: - Manage symptoms like pain, nausea, and fatigue. - Administer pain relief medications and provide comfort measures. Patient Education: - Educate about the kidney condition, treatment options, and follow-up appointments. - Teach self-care, monitoring, and recognizing complications. - Encourage communication with the healthcare team. Emotional Support: - Provide emotional support to patients and families. - Refer to support groups or counseling if needed. Continuous Assessment and Documentation: - Regularly assess and document vital signs, lab results, and changes in symptoms. - Communicate concerns or changes to the healthcare team. MEDICATIONS MANAGEMENT IN RENAL NURSING Patients with renal impairment often take many drugs of which is not limited to the following; Diuretics, ACEI Blockers and ARBs, Statins, Phosphate Binders, Immunosuppressants, Erythropoietin, Intravenous Iron agents, B-complex complex Vitamin and Folic Acid. Diuretics - These are medications that promote urinary output, thereby reducing the blood volume and consequently lowering blood pressure. Diuretics are broadly classified based on their mechanism of actions as Thiazides, loop diuretics, Potassium sparing diuretics, Osmotic diuretics and Carbonic anhydrase Inhibitors. Thiazides- These diuretics act by preventing sodium ion and chloride reabsorption at the distal convoluted tubules of the kidney, thereby increasing the urinary output of fhus electrolytes including potassium and water. Examples are Chlorothiazides, Hydrochorothiazides. Loop Diuretics - These diuretics act on the loop of Henle of the Nephron and even the Distal convoluted tubules , preventing reabsorption into the blood stream of sodium, chloride, water and potassium, thereby increasing the urinary output and reducing oedema. Examples include Fruosemide, Torsemide, Bumetanide. Potassium Sparing Diuretics- Potassium sparing diuretics produce a mild diuretic effect by blocking the sodium/potassium exchange pump in the distal tubule. This exchanger is highly active in patients with HF who receive both a loop and thiazide diuretic. As potassium sparing diuretics tend to have a weak diuretic effect, they are mainly used in combination with thiazide or loop diuretics to prevent hypokalemia, as they are more effective than potassium replacement. Examples are Amiloride, Sprinolactone, Triamterene. Osmotic Diuretics - This type of diuretic exerts their therapeutic effect by pulling water into the renal tubule without loss of sodium. Only one osmotic diuretic is currently available, mannitol (Osmitrol). Carbonic anhydrase Inhibitors -This acts by Inhibiting the action of the enzyme carbonic anhydrase, the catalyst for the formation of sodium bicarbonate stored as alkaline reserve in the renal tubules and is important for the excretion of hydrogen;It slows down the movement of hydrogen ions which leads to greater amount of sodium and bicarbonate lost in the Urine . Common example is Acetazolamide. Phosphate binders- Phosphate binders are used to decrease the absorption of phosphate from food in the digestive tract.They are used when there is an abnormally high blood phosphate level (hyperphosphatemia) which can be caused by impaired renal phosphate excretion as seen in Chronic Kidney Disease patients undergoing dialysis or increased extracellular fluid phosphate loads. Example include, Calcium Carbonate, Calcium acetate, Sucroferric oxyhydroxide Immunosuppresants- As the word immunosuppressant suggests, the function of these drugs is to suppress the immune system, which is the body’s natural defence system. The aim is to dampen down the immune system enough to stop it rejecting a transplanted kidney while still keeping it active enough to fight infections. Common inmunosuppressants include Cyclosporine Erythropoietin - Nearly all patients with end stage renal disease (ESRD) who are on dialysis, have Anaemia. Erythropoietin is the hormone responsible for keeping a normal red blood cell count, and the kidneys are responsible for making and secreting this hormone. Most patients with renal failure on hemodialysis will get erythropoietin during each treatment by intravenous injection into the return dialysis tubing. Intravenous (IV) iron agents- This is usually administered to augment erythropoietin in red blood cell formation. Examples are ferumoxytol, ferric carboxymaltose and iron isomaltoside Statins- Sometimes, Statins are usually recommended to combat high cholesterol levels common in Renal impaired patients.People with chronic kidney disease often have high levels of bad cholesterol, which can increase the risk of heart disease. Examples include Atorvastatin B complex Vitamin & folic acid - The dialysis procedure removes large amounts of water-soluble vitamins, such as vitamin C, B-complex vitamins and folic acid. While a kidney diet can usually keep up with these losses, many people on dialysis don't always have an appetite. Most nephrologists feel that the use of a B-complex vitamin along with folic acid is a good protection for when patients don't have an appetite. RNDAGICS OF SOME MEDICATIONS USED IN RENAL NURSING Fruosemide (Lazix): Group: it is a loop or potent diuretic Mode of action: it acts on loop of henle and even the distal convoluted tubule, preventing reabsorption into the bloodstream of sodium, chlorine, water and potassium, get by increasing the urinary output and reducing the oedema. Dosage: 20 to 80 mg daily in the morning. or 20 to 40 mg for ccf. initially 40 mg twice-daily orally then increasing dosage based on patient response. Route: orally, intramuscularly and intravenously Side effect: deafness, hypokalemia, hypovolemia, hyponatremia, hypocalcemia, severe dehydration, metabolic alkalosis, weakness, dizziness, nausea and prerenal azotemia. Indications: toxicaemia of pregnancy, preeclampsia, congestive cardiac failure, pulmonary edema, nephritic syndrome, ascites in liver cirrhosis, hypertension. Contraindication: renal failure, burns, shock, cholera, gastroenteritis, precomatose states associated with liver cirrhosis. Nursing responibility: monitor the intake and output chart for the patients. give the prescribe potassium supplements to prevent hypokalemia. weigh the patient daily. advice only or restrict salts (sodium) in taking the diets to enable this drug(frusemide) to be effective. Synthetic Erythropoietin: Group: Erythropoietin is classified as a hematopoietic agent. Mode Of Action: Erythropoietin acts on erythroid progenitor cells in the bone marrow, which are immature cells that develop into red blood cells. Erythropoietin stimulates these progenitor cells to proliferate and mature, which leads to an increase in red blood cell production. Dosage: The recommended starting dose for adult patients is 50 to 100 Units/kg 3 times weekly intravenously or subcutaneously Route: Sub cuteneous, intravenous. Side Effect: nausea, vomiting, diarrhea, headache, and high blood pressure. Less common side effects include low blood pressure, dizziness, and skin rash. Rare but serious side effects can include blood clots and seizures. Indication: Erythropoietin is indicated for the treatment of anemia caused by chronic kidney disease, chemotherapy, or certain other conditions. It can also be used to reduce the need for blood transfusions in patients undergoing certain surgeries. Contraindications: Erythropoietin should not be used in patients who have uncontrolled hypertension, a history of blood clots, or iron deficiency anemia that has not been treated. It should also not be used in patients who have cancer that has spread or who are receiving chemotherapy for a type of cancer that is not likely to respond to treatment. Nursing Responibility: Before starting erythropoietin, nurses should make sure the patient is screened for iron deficiency, high blood pressure, and other conditions that may increase the risk of side effects. Nurses who administer erythropoietin should be aware of the drug's potential side effects and should monitor the patient's blood pressure and other vital signs closely. They should also educate the patient about the possible side effects and what to do if they occur. Cyclosporin (Cyclosporine, Neoral, Sandimmun): Group: Cyclosporin is an immunosuppressive and a corticosteroid. Mode of action: As an immunosuppressant, it helps to suppress rejection in organ transplant recipients and also helps to treat a variety of chronic inflammatory and autoimmune diseases. It has an important role in organisation transportation for the prevention of graft rejection following bone marrow, kidney, liver, pancreas, heart lungs and heart long transplantations. It is a calcineurin inhibitor. Dosage: for organ transplantation=adults and children over 3 months=10 to 15 mg per kg body weight by mouth 4-12 hours before transplantation followed by 10 to 15 mg per kg body weight daily for 1 to 2 weeks postoperatively then reduce gradually to 2-6 mg per kg daily for maintenance. Route: Orally in capsule form, intravenous infusion. Side Effect: headache, tremor, hypertension (especially in heart transplant patients), hepatic dysfunction, fatigue, gingival hypertrophy, burning sensation in hands and feet, mild anaemia, hypokalemia, Gout, weight increase, edema, pancreatitis, neuropathy, confusion, convulsion, amenorrhea, cramps, Myayopathy, etc. Indications: Atopic dermatitis, rejection in kidney, flavour, hacks for bone marrow transplantation; graft-versus-host disease. Refractory ulcerative colitis. Contraindication: don't use with Tacrolimus. don't give two patients experiencing above side effects. Nursing Responibility: Monitor the liver function test results, blood pressure, serum potassium, blood lipids before and after treatment. avoid other immunosuppressants due to increased risk of infection and lymphoma. Avoid grapefruit on iTunes for 1 hour before taking this drug. total daily dose should be taken into divided doses. Azathioprine (Imuran) Group: It is an immunosuppressive drug. Mode Of Action: As an immunosuppressant, it helps to suppress rejection in organ transplant recipients and also helps to treat a variety of chronic inflammatory and autoimmune diseases. When Azathioprine has been metabolized by the enzyme thiopurine methyltransferase to Mercaptopurine Dosage: For autoimmune conditions, 1- 3 mg per kg body weight daily. For auto suppression of transplant rejection-initially up 25 mg per kg body weight, then 1-4 mg per kg body weight daily according to response for maintenance. Route: Oral in tablet form not well. Note well: when oral administration is not possible then give it intravenously over at least one minute followed by 50 ml sodium chloride by intravenous infusion since interveniens alkaline solution of Azathioprine is very irritant. Side Effect: Hypersensitivity reactions, Malaise, Dizziness, Vomiting, Intestinal Nephritis, Diarrhoea, Fever, Rigor, Arthralgia, Rash Hypertension Alopecia and Nausea Indications: suppression of transplantation rejection in transplant recipients, Rheumatoid arthritis, Auto-immune conditions, when corticosteroid therapy alone provides no cure. Bowel inflammatory disease. Contraindication: Hypersensitivity to Azathioprine, Mercaptopurine, and be ineastfeeding. Nursing Responibility: Blood test and monitoring for vital signs of myelosuppression are essential in prolonged treatment with azathioprine. Don't administer to pregnant women because of the risks of premature birth and low birth-weight babies. Patient should be warned to report immediately any manifestation of bone marrow suppression like inexplicable bruises or bleeding or infection. NB: Azathioprine injection should be used only when the oral route is impractical and should be discontinued as soon as oral therapy is tolerated. NUTRITION AND DIETARY CONSIDERATIONS OF RENAL DISORDERS Renal Diet Guidelines: A renal diet is a critical component of managing kidney conditions like chronic kidney disease (CKD). It aims to reduce the workload on the kidneys and manage symptoms by controlling the intake of specific nutrients. Key Aspects of a Renal Diet: - Protein Intake: Controlled to reduce the buildup of waste products in the blood. Protein may be restricted, and high-quality sources like lean meat and dairy may be encouraged. - Sodium Restriction: Important to manage blood pressure and fluid balance. Patients are advised to limit high-sodium foods and use alternative seasonings. - Potassium Control: Essential to prevent hyperkalemia. High-potassium foods like bananas and oranges should be limited, and portion sizes monitored. - Phosphorus Management: Phosphorus is restricted to prevent hyperphosphatemia. Foods rich in phosphorus, such as dairy and dark sodas, should be limited. - Fluid Intake: Fluid may be restricted based on the individual's clinical state, degree of reduced GFR, and the presence of edema and hypertension. Patients should be educated to monitor their thirst and fluid intake. Fluid and Electrolyte Management: - Managing fluid and electrolyte balance is crucial for patients with kidney conditions. - It helps prevent complications like fluid overload, hypertension, and electrolyte imbalances. Key Aspects of Fluid and Electrolyte Management: - Fluid Intake: Adjusted to the clinical state, taking into account GFR, edema, and hypertension management. Total dietary fluid intake for patients with CKD is typically unrestricted. "Pushing fluids" is not recommended unless medically necessary. - Sodium Restriction: Reducing sodium intake helps control fluid balance and blood pressure. Excessive sodium intake should be addressed through dietary strategies, and patients with hypertension may need stricter sodium limits. - Potassium Control: Patients are educated on dietary potassium restriction once serum potassium levels are elevated (usually over 5.5 mmol/L). - Phosphorus Management: Dietary phosphorus intake should be adjusted to maintain normal serum phosphate levels. Initial education focuses on limiting inorganic phosphorus sources in the diet. NURSING CARE PLAN FOR A RENAL CLIENT S/N NURSING DIAGNOSIS NURSING OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION 1
The patient will verbalize less pain after 1 hour of nursing intervention I. Assess patient's level of pain, location and intensity. II. Assist patient to find position of relief. III. Administer prescribed analgesics indicated by the physician. IV. Encourage relaxation techniques. I. To serve as a baseline information and to know the degree of discomfort. II. This will aid the patient comfort. III. This blocks the pain pathway thereby reducing pain immediately. IV. Promoted relaxation improves quality of life The patient verbalized less pain after 1 hour of nursing intervention 2
The patient will display no signs of kidney or urinary tract infection by the end of 24 hours of nursing intervention. I. Assess for signs and symptoms of infection II. Check temperature, respiration, pulse and blood pressure 4 hourly and White blood count. III. Maintain strict aseptic technique especially in catheterization. IV. Give prescribed antibiotics I & II. To serve as a baseline information to know the degree of infection process. III. To avoid cross infection and introducing pathogens into the body. IV. Antibiotics prevent infections by disrupting their cell wall synthesis, which halts the growth of or kills the microorganism. The patient displayed no evidence of urinary tract infection or kidney infection after 24 hours of nursing intervention 3
Patient will regain and maintain his normal urine elimination pattern within 5 days period of hospitalization I. Assess renal function daily through serum creatinine and blood urea nitrogen levels and urine creatinine clearance tests. II. Monitor intake and output recordings. Adjust the client's daily fluid intake so that it approximates fluid loss plus 300 to 500 ml/day. III. Test and record urine for haematuria and proteinuria as ordered. Note the colour of urine. IV. Distribute fluid intake evenly throughout the entire day and night. I. Early detection of clinical manifestations enables prompt treatment to prevent serious renal dysfunction. II. Intake and output recordings assess therapy. Careful replacement of fluids is necessary to prevent fluid overload. III. Testing and recording of urine for haematuria and proteinuria assesses therapy and progress of the disease. IV. Allowing toxins to accumulate due to poor hydration can cause complications such as nausea and sensorium changes. Patient regained and maintained a normal urine elimination pattern after 5 days of treatment as evidenced by the restoration of normal renal function. 4
The client's skin will remain intact with no sign of pressure ulcers within the period of hospitalization I. Assess the the skin for redness or breakdown II. Turn patient every two hours I. To ensure prevention of skin breakdown. II. To minimize pressure ulcers The client's skin remained intact with no sign of pressure ulcers within the period of hospitalization. 5
Patient will maintain a normal kidney function and normal fluid balance within 2 days of hospitalization I. Assess for signs and symptoms of excess fluid volume or deficient fluid volume. II. Maintain a strict intake and output recordings, monitoring urine specific gravity, serum and urine electrolyte concentrations. III. Give prescribed medications IV. Encourage to drink atleast 2L of fluid daily if not contradicted I. Early recognition of signs and symptoms allow for proper intervention. II. To detect increasing or decreasing fluid in the body and allow day to day comparison of the patient's overall state of dehydration and response to treatment. III. To help reduce extracellular fluid overload or underload. IV. To prevent dehydration Patient regained and maintained a normal kidney function and normal fluid balance within 2 days of hospitalization. INFECTION CONTROL Infection control is an important aspect of nursing care in any setting, including renal nursing. Patients with renal disease are often immunocompromised and more susceptible to infections. Here are some infection control measures to follow in renal nursing: 1. Hand hygiene: Wash hands with soap and water or use an alcohol-based hand sanitizer before and after every patient contact. This is the most effective way to prevent the spread of infections. 2. Personal protective equipment (PPE): Wear gloves, masks, gowns, and eye protection as necessary to prevent transmission of infection. Use PPE when coming into contact with bodily fluids, performing procedures, or handling contaminated equipment. 3. Standard precautions: Follow standard precautions at all times, which include wearing gloves when handling bodily fluids, using proper techniques for disposing of sharps, and using appropriate disinfectants for cleaning surfaces and equipment. 4. Clean environment: Keep the patient's environment clean and free from clutter. Regularly clean surfaces, equipment, and patient care areas using appropriate disinfectants. 5. Transmission-based precautions: Use transmission-based precautions when necessary, depending on the specific infection being treated. This may involve wearing additional PPE or isolating the patient in a separate room. 6. Safe handling of blood and body fluids: Use proper techniques for handling and disposing of blood and body fluids. Use appropriate personal protective equipment when handling these materials to prevent exposure. 7. Vaccination: Ensure that all healthcare workers involved in renal nursing are up to date on their vaccinations, including influenza, hepatitis B, and any other recommended vaccines. 8. Education and training: Provide education and training to patients, families, and healthcare workers about infection control practices. This includes proper hand hygiene, safe handling of equipment, and recognizing signs of infection. 9. Regular monitoring and surveillance: Implement monitoring and surveillance protocols to identify and prevent infections in renal care settings. This may involve tracking infection rates, implementing quality improvement measures, and ensuring staff compliance with infection control protocols. 10. Adherence to guidelines: Follow the guidelines and recommendations of relevant health organizations, such as the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO), to ensure the best practices for infection control are being followed. Vascular Access Care Vascular access care in renal nursing is essential for maintaining access sites used in hemodialysis for patients with kidney disease. The primary goal is to ensure proper functioning and prevent complications like infection or clotting. Three main types of vascular access are utilized: arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs), and central venous catheters (CVCs). AVFs and AVGs are preferred due to better long-term outcomes. Care involves regular assessment, monitoring for infection, assessing blood flow, and proper cleaning for AVFs and AVGs. CVC care includes dressing changes, monitoring for infection or clotting, and flushing with saline or heparin. Patient education is crucial, with nurses teaching proper care, hand hygiene, dressing changes, and recognizing signs of complications. TECHNOLOGICAL ADVANCEMENT IN RENAL NURSING Two of the most recent advancements in kidney replacement technology are the implantable bioartificial kidney and kidney regeneration technology. Improved value in dialysis care can only happen through patient-centered, innovative kidney care. Advances in Dialysis End-stage renal disease (ESRD) is characterized as a disease with a high hospitalization and mortality rate. Hemodialysis remains the most broadly used treatment for ESRD, with kidney transplants being the only alternative to kidney replacement therapy (KRT). Technical, economic, and regulatory challenges faced in renal dialysis technology innovation have resulted in a standstill over the last 50 years. To promote increased cooperation and encourage innovation, the Kidney Health Initiative developed an international roadmap for new approaches to renal replacement therapy. Recent innovations in hemodialysis have focused on portability and total replacement, not just replacing the kidney’s filtration function (clearance). Several enterprises and organizations, including The Advancing American Kidney Health Initiative, The Kidney Health Initiative, and Kidney X: The Kidney Accelerator, are collaborating to develop innovative technologies that may transform the treatment of ESRD. Advances in hemodialysis include: - Hemodiafiltration Hemodiafiltration is a form of KRT that makes use of convection in tandem with diffusive clearance. In the process of hemodiafiltration, the small to middle-sized solutes are carried through the membrane pores by convection. Convection allows a higher clearance rate of larger solutes compared to hemodialysis. Despite the advantages of hemodiafiltration, it has yet to gain acceptability in the U.S. due to regulatory and cost issues. - Portable hemodialysis machines Recently portable and compact machines have been developed to reduce the size of dialysis machines. These devices make it easier for kidney disease patients to perform dialysis at home, resulting in increased flexibility and freedom. - Wearable artificial kidney (WAK) Wearable and portable dialysis systems (artificial kidneys) perform the same functions as dialysis. However, these systems are housed in smaller and less intrusive packages. For hemodialysis patients, WAK devices integrate a dual-channel battery-operated pump for driving dialysate and blood together with dialysate regenerative technology. For peritoneal dialysis, a model of WAK is commercialized as an automated wearable kidney device. This device recycles peritoneal dialysate through a system made up of urease enzymes. These enzymes convert urea to ammonia, with sorbents such as zirconium which absorbs the ammonia. - Sorbent devices in dialysis therapy Sorbent devices work by direct retention or absorption of specific molecules. In recent years, there has been progress in developing biocompatible sorbents. Current sorbent particles can remove toxins and impurities from the dialysate during dialysis. Sorbents aid in the reuse and regeneration of dialysate fluids. Prospective studies have examined adding sorbent cartridges to conventional hemodialysis to improve the quality of life and survival rate. - Bioartificial Kidney Bio-engineering artificial kidneys has been a research and innovation topic for the last 30 years. The basics of the technology used to develop bioartificial kidneys are based on cell-based therapeutics, specifically the principle that damaged or dysfunctional cells in multiple disease states can be replaced. Like a human kidney, the bioartificial kidney produces ultrafiltrate that undergoes processing, resulting in the reabsorption of water and electrolytes back into the bloodstream. Examples of bioartificial kidneys include: - The implantable kidney (The Kidney Project). - The renal assist device (RAD). - The human nephron filter. - The bioartificial renal epithelial cell system (BRECS). New Diagnostic Methods New diagnostic methods would allow healthcare professionals to diagnose CKD earlier, as most patients are only diagnosed in stage 3. Novel diagnostic methods may be used to identify CKD in earlier stages. - Imaging: Imaging techniques are non-invasive and can safely be repeated to evaluate changes in disease status. Advancements in imaging relate to overall kidney function, estimation of nephron numbers, fibrosis, and new functional MRIS and ultrasound techniques such as diffusion-weighted MRI. - Biological fluid biomarkers: In nephrology, metabolomics and proteomics have been tested, in some cases being used as biomarkers or as tools used to identify individual biomarkers that are then further assessed. Furthermore, both DNA and RNA in biological fluids may also act as biomarkers. Biological fluid biomarkers should correspond with kidney disease, progression, early disease, and outcomes, allowing for non-invasive, rapid, and specific measurements. Additional Advances in Kidney Disease Treatment The main objective of these kidney disease treatments is to avoid dialysis care centers, prevent CKD progression, or treat CKD complications in advanced stages. Current advances in kidney disease treatment that have not already been discussed include the following: - Xenotransplantation Xenotransplantation is an old concept of transplanting organs from animals such as pigs into humans. Due to the increased waiting list for kidney transplants, this concept has regained clinical and research attention. The field of biotechnology and CRISPR/Cas9 has allowed xenotransplantation across non-human species to have lower complications and higher success rates. Medications New drugs that have promising results in clinical trials and have recently been approved for the treatment of CKD complications, kidney protection, and specific causes of CKD include: - Nonsteroidal MRA: This medication is used for kidney protection and has been shown to decrease hospitalization rates for strokes, Myocardial infarction, and heart failure. It may reduce CKD progression by reducing proteinuria. - Endothelin receptor antagonists: This medicine may be used to decrease proteinuria and kidney disease progression in CKD patients with scleroderma. - HIF stabilizers: These are oral agents used to treat CKD-associated anemia. Some HIF stabilizers are currently in clinical use in Japan and China, with the EMA recently approving roxadustat. - Voclosporin: This drug is showing promising results in phase 3 clinical trials for patients with active lupus nephritis. So far, Voclosporin has provided better kidney outcomes, including urine protein to creatine ratio and eGRF. Future Direction In Renal Nursing In the future, kidney care will become highly personalized and customized based on the genetic makeup and body tissue of each patient. Tissue will be used to grow a new kidney to replace a diseased one, such as in the case of polycystic kidney disease. Right now, rudimentary stem cells can be replicated, but in time, researchers will develop more complex, architecturally relevant models that are fully functional with a patient’s body, thereby eliminating the need for the immunosuppressive medication. NURSING RECOMMENDATION OF RENAL NURSING Prioritize patient-centered care and continuous education in renal nursing. Possess knowledge of common renal disorders, diagnostic findings, and treatment options (pharmacologic and non-pharmacologic) for each condition. Understand appropriate nutrition and dietary considerations for renal patients. Implement various nursing management strategies as needed for renal patients. Diligently monitor vital signs, fluid balance, and laboratory results for early detection and management of renal issues. Collaborate with a multidisciplinary team, including nephrologists and dietitians, for comprehensive patient care. Stay updated on new technological advancements to enhance the quality of care in renal nursing. Familiarize oneself with the care of patients undergoing dialysis or kidney transplant. Emphasize patient education on self-care and the management of renal conditions. Develop effective communication skills for interacting with patients, families, and the healthcare team. Understand the psychological and emotional aspects of renal disease in patients and provide appropriate support. Promote a culture of safety and infection control in renal care settings. Ensure adherence to ethical and legal standards in renal nursing practice. Download 98.49 Kb. Share with your friends:
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