*Kidneys:2 kidney locate in Retroperitoneal areaStructure: basic functional unit = nephronCortex Medulla 1-3 million nephrons of each kidneyReceives 20% to 25% of cardiac outputPerforms numerous functions

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*Glomerular filtration rate (GFR)Result of pressure gradient80 to 125 mL/minReabsorptionSecretionHormonal controlAldosteroneAntidiuretic hormone

*Reabsorption of filtered bicarbonateProduction of new bicarbonateExcretion of small amounts of hydrogen ions

*Juxtaglomerular apparatusRenin-angiotensin-aldosterone system

*Sudden deterioration of renal functionOliguria: low urine outputAzotemia: accumulation of nitrogenous wastesAcid-base disturbances

*PrerenalRenal: intrinsic; parenchymalPostrenal

*Diminished blood flow; hypoperfusion of the kidneyVolume depletionVasodilationDecreased cardiac outputCan progress to intrarenal damage

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*Obstruction of flow: +Kidney stones+Tumor in side and out side ureters, bladder, urethraIncrease intratubular pressure leading to decreased GFRReverses when obstruction is removed

*Renal tissue damage directly:Glomerulo nephritis, exp: Streptococcalbacterialinfections may damage the glomeruliVascularAcute interstitial nephritis -Medications such as antibiotics, AINS (aspirin,brufen) -Infections and immune-related diseases such aslupus , leukemia,lymphoma, andsarcoidosis.TubulesHematologic problem

*Acute tubular necrosis (ATN)Ischemia: trauma, hemorrhage shockNephrotoxic agentsAntibiotics: aminoglycoside, vancomycinNon-steroidal anti-inflammatory drugs (NSAIDs)Contrast-induced: Rhabdomyolysis: convulsion, intoxication, hemolyse

*Prerenal: decreased blood supplyRenal: failure of nephronsPostrenal: obstruction of outflow

Acute tubular necrosis

*IV. Course of ARF: 3 phases

PHASES OF ARFInitiating phaseOliguric phase Diuretic phase and probably recovery phase

*Initiation phaseTime from event to signs of decreased renal perfusionFew hours to 2 daysPotentially reversible

*Maintenance phase (oliguric/anuric)BUN and creatinine increase dailyOliguria is common: Urine output less than 400 mL/dayUrine output less than 200 mL/day: anuricFluid overload, electrolyte imbalances, and acidosisRenal replacement therapy required

*Recovery phaseReturn of tubular function4 to 6 months for BUN and creatinine to return to normalResidual impairment of GFREarly dialysis may prevent the traditional diuretic phase of ARF

*V. How to assess the renal system(Nursing diagnoses)-Pt history-Clinical presentations-Physical examinations-Labolatory tests: serum, urine-Diagnostic studies

*Predisposing factorsDisease statesHypertensionDiabetes Immunologic diseaseHereditary disordersHypotensive episodesExposure to nephrotoxic agents

*Vital signs may be alteredBlood pressure changes depending on etiologyHyperventilation to compensate for metabolic acidosisBody temperature may be alteredAssess for volume depletion and volume overload

*Skin: edema, dry, petechiaeBody weight (W gain/loss), input, output informationSigns of overload: neck vein distention, BP, HR, dry or wet mucous/membranes, breath soundsSigns of complications: +HF, pulmonary edema +Anemia, +Neuromuscular: drowsiness, confusion, irritability, coma, convulsions +Gastrointestinal signs: anorexia, nausea, vomiting

*Serum creatinineSerum BUNAffected by catabolism, bleeding, and dehydrationBun: creatinine ratioNormal 10:1 to 20:1More than 20:1, suspect nonrenal causes of laboratory abnormalities

*Urine creatinine clearanceNormal 84 to 138 mL/minCan calculate an estimated value with serum lab values (Cockroft and Gault formula)

*Urine electrolytesUrine specific gravityUrine osmolality

*Non-invasive testsX-ray of kidneys, ureter, and bladder (KUB)Size, shape, and position of kidneysCalculi, cysts, and tumorsRenal ultrasoundSize of kidneysObstruction

*Invasive tests: doctor demandIV pyelogramComputed tomographyStructures, accumulation of fluidRenal angiographyAbnormalities in blood flow; infarction, massesRenal scanRenal uptake of isotopesRenal biopsyHistologic changes

*Each nursing care plan includes:Nursing diagnosisInterventionsRationales

*HyperkalemiaLow excretionHyponatremiaFluid retentionHypocalcemiaLow excretion of phosphorusDecreased level of vitamin DHyperphosphatemiaLow excretionHypermagnesiumLow excretion

*Due to decreased GFRReduced contentKayexalateDiuretics

*Shift intracellularlyGlucose and insulinAlkali (sodium bicarbonate)Antagonize cellular membrane effectCalcium gluconate

*R/t fluid overloadSalt wasting can occur as nephrons damagedTreated with fluid restriction

*Metabolic acidosisTreatment based on severity of imbalanceMay need IV bicarbonateMonitor ionized calcium as hypocalcemia can occur as pH is corrected

*Early recognitionFluid or volume replacementCaution in patients with underlying cardiac diseaseMay require inotropes, antidysrhythmic agents, preload/afterload reducers, intraaortic balloon pumpMay require hemodynamic monitoring to guide treatment

*MedicationsDietary controlProtein and electrolyte restrictionsManagement of fluid/electrolyte imbalancesDialysis or CRRT

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Reduce obstruction: remove, operate the calculous, hyperprostateMay need stent: ureter

*Convert oliguria to nonoliguric stateHypovolemia corrected firstLoop (furosemide); Osmotic (mannitol)Acetylcysteine: prevent contrast-induced ARFEpoetin alfa: treat anemiaMust adjust dosages and timing of medication if patient on dialysis

*Higher than normal basal requirementProvide adequate energy, protein, and micronutrients25 to 35 kcal/kg of ideal body wt per dayRestrictedProteinSodiumPotassiumFluid intake (output + 600-1000 mL)

*Save the pts by RRTClassificationHemodialysisContinuous renal replacement therapy (CRRT)Peritoneal dialysis

Indication: doctorsPlan for access: temporary centre catheter, AVF..Care the incisionWhen use the AVFPlan for IHD: 2-3/weekOther care- BP-Body weight-Nutrition-Hematology-Underly diseases

*Mecanism by two physical principlesDiffusionUltrafiltration

*Fluid overload: big edema, cerebral edema, pulmonary edema..Electrolyte imbalances: hyper K, Hypo NaAcid-base disturbances: acidose metabolism

*Percutaneous cathetersArteriovenous (AV) fistulasGrafts External shunts

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*What are important nursing interventions for the patient with a percutaneous dialysis catheter?Can the dialysis catheter be used to draw blood samples or give medications?What are appropriate interventions if the patient has a graft or shunt?

*Usually done at the bedside in the ICUPre- and post-dialysis labs and weightMonitor for complicationsVolume depletionDysrhythmiasHypoxemiaDisequilibrium syndromeInfection vascular access

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*Which medications should be given before dialysis?Which should be withheld until after dialysis?How can you determine whether to give medications before dialysis?

*Used with patients too unstable for hemodialysisAdvantagesMore gradual solute removalFlexible fluid administrationMinimal heparinCan be done by staff nurses at the bedsideDisadvantagesBed restOne-to-one nursing care

*CAVHcontinuous arteriovenous hemofiltration CVAcontinuous venovenous hemofiltrationCAVHDcontinuous arteriovenous hemodialysisCVVHDcontinuous venovenous hemodialysis

*Removal of solutes and fluids using the peritoneal membrane as a filterRarely used in the critical care setting because it is less efficientHigh risk of peritonitisDescribe the procedure

*-Fever, tachycardia, breath sounds, chest X-ray-Cultures: body fluids, blood, wounds-WBC

*-Signs and manifestations-Monitor, explain, calm, sedative medications-Early recognition of signs and symptoms, inform doctors-Transfer to calm, restful, relaxed environment

*Assess the PtsProvide specific and factual information about the disease process, include the family

*Normal decline owing to agingComorbiditiesDiabetesHypertensionPrescribed medications

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