Fluid & Electrolytes - Acute & Chronic Renal Failure

Slide #3
Remember the glomerulus does NOT normally filter blood cells or proteins
(just water, urea, creatinine, and ions).
By measuring creatinine levels in the urine and blood it helps us to
determine the functionality of the kidneys. If your kidneys are not working
like they should, your serum creatinine level goes up
Slide #7
prerenal is an insufficiency in the blood flow getting to the Kidney …blood
clots, tumors, shock or hypovolemic states or hypoperfusion states where
the blood flow is inadequate therefore causing what's called acute tubular
necrosis (ATN) or an insufficiency of the nephron to get the prefusion it
needs. so, things like congestive heart failure, or cardiac issues will over time
cause prerenal issues and an elevation in the waste products because the
blood flow is insufficient. so prerenal before it gets to the kidney.
Slide #8
intrarenal is when the organ is assaulted directly from something it could be
something that's nephrotoxic like nephrotoxic drugs (antibiotics “mycin” like
gentamycin or vancomycin). Also, CT contrast, NSAIDS. Creatinine over 1.3
BUN over 20 and urine output of 30ml or less. As well as metabolic acidosis
or pH less than 7.35
Slide #9
Post renal failure is when there is an injury after urine has already been
formed because of some blockage that's causing backup of the urine that
mechanically injuries the organ itself so it could be a renal stone in the
ureter that causes back up or a foley that's not draining properly and then if
you're backs up and interesting organ itself so that is post renal failure very
avoidable
Slide #10
Normal urine output is about 1500ml/24 hours. During the second or Oliguric
phase you will see less than 400ml/24hours. Urine will be thick with a high
specific gravity. 3rd phase you will see 3-6 liters per day of urine output and
urite with a low specific gravity.
Slide #12
When GFR decreases dramatically it leads to many problems (in the early
stages the patient may be asymptomatic):
Increased waste in the body: Uremia (Increased BUN and Creatinine levels,
neuro changes, itching, metabolic acidosis)
Hypervolemia (edema, HTN, pulmonary and cardiac problems)
Electrolyte Imbalances: hyperkalemia, hypocalcemia, hyperphosphatemia
(high phosphate levels cause low calcium levels, which stimulates the
parathyroid gland to produce PTH. This causes calcium to leak out of the
bones…hence bone problems), hypermagnesemia
Oliguria (less than 400 ml/day) or Anuria (less than 100 mL/day)
Proteinuria and Hematuria: glomerulus is damaged, so it is allowing blood
cells and proteins to leak through. The patient may have lower albumin
levels (more swelling) and further anemia.
Daily weights 1lb of weight gain = 1 liter of fluid retained
Avoid nephrotoxic drugs
Kidneys also produce hormones:
EPO (erythropoietin): helps create RBCs in the bone marrow. In CKD, the EPO
decreases, which leads to anemia.
Renin: plays a role in increasing blood pressure. In CKD the glomerulus is
filtering less water and the kidneys think the blood pressure is low, so it
releases renin, which in turn increases blood pressure even more.
Kidneys activate Vitamin D - Vitamin D: plays a role in helping the body
reabsorb calcium from the food we eat. In CKD, the activation of vitamin D is
diminished, and this leads to lower calcium levels (hypocalcemia).
Slide #13
Early stages with normal GFR:
Controlling blood pressure and glucose level
Medications for hypertension that help protect the kidneys, such as ACE
inhibitors “pril” or ARBs “sartan”
Monitoring GFR and blood pressure regularly
Advanced stages where GFR is abnormal:
Dialysis
Kidney transplant
Diet changes
Slide #15
*High blood pressure (hypertension): constant high pressure on the artery
wall that supplies the kidneys causes damage. Therefore, less blood reaches
the kidneys, and the nephrons can’t function properly.
*Diabetes Mellitus: uncontrolled hyperglycemia causes glucose to stick to
arteries walls, which damages the blood supply to the kidneys.
Acute kidney injury
Polycystic kidney disease: genetic condition where cysts grow in the kidneys
Infection
Nephrotoxic drugs: NSAIDS, aminoglycosides, chemotherapy drugs, contrast
dyes for testing procedures
*most common causes of chronic renal failure

Slide #16
the nurse should identify potential risk factors for AKI or CKD. This includes
obtaining a thorough medical history, medication history, and performing a
physical examination. evaluate the patient's symptoms and perform
diagnostic tests such as measuring creatinine, blood urea nitrogen, and
electrolyte levels. AKI patients may present with decreased urine output,
edema, and altered mental status, while CKD patients might exhibit
symptoms such as hypertension, fluid and electrolyte imbalances, anemia,
and bone fragility.
Slide #17
What is going on with this patient? Remember waste build up (uremia and
metabolic acidosis), anemia, electrolyte imbalances, low urinary output, and
fluid overload.
Uremia (buildup of waste in the blood) Low protein diet: urea is a waste
product of protein breakdown (patient doesn’t need any more urea).
However, patient needs some protein to prevent muscle wasting.
Itching: due to deposits of urea crystals on the skin via the sweat glands. It
looks like frost on the skin and is called “uremic frost”
Assess for kussmaul breathing which is deep/rapid breaths from the acid
building up in the blood (metabolic acidosis). This type of breathing is a
compensatory mechanism by the respiratory system to increase the blood’s
pH.
Anemia: low red blood cells in the blood. RBCs help transport oxygen
throughout the body so it can function.
Why is anemia presenting? Due to low amounts of EPO being produced by
the kidneys and possible deficiency in other minerals that help with
hemoglobin production (which acts a transporter for RBCs). These minerals
include iron, folic acid, and vitamin B12
Patient signs and symptoms: pale, extremely tired, dyspnea, confused
Safety: patient may be confused, assess neuro status
Treatment: Supplements of Iron (IV form if patient on dialysis rather than
PO), Erythropoietin (subq injections), or blood transfusions per MD order

Hyperkalemia (>5.1 mEq/L): (normal level 3.5 – 5.1 mEq/L) at risk for
significant cardiac event due to the nephrons decreased ability to excrete
potassium.
Nursing Role:
restrict potassium-rich foods (potatoes, avocados, strawberries, tomatoes,
spinach, oranges, bananas), monitor EKG for changes (tall, peaked T-waves,
Wide QRS and prolonged PR interval)
monitor lab values
may be ordered to give Kayexalate orally or rectally to remove extra
potassium out of the blood
place on cardiac monitor to watch rhythm
Hyperphosphatemia (>4.5 mg/dL): normal level 2.7-4.5 mg/dL

Hypocalcemia (<8.6 mg/dL): normal level 8.6-10 mg/dL

Phosphate builds up in the blood because it cannot be excreted out of the
kidney due to a damaged nephron, which leads to the decrease of calcium
“hypocalcemia”. WHY? Because phosphate binds to the calcium and when
there are high amounts of phosphate in the blood it depletes calcium from
the blood due to this binding. In addition, calcium levels decrease due to the
inactivation of vitamin d by the kidneys.
In addition, high phosphate levels stimulate the parathyroid gland to release
PTH (parathyroid hormone), which causes the bones to leak calcium in the
blood stream to increase the level. This can cause bone problems.
Nursing Role:
Administer phosphate binders, such as calcium carbonate or “PhosLo
(calcium acetate)” to decrease phosphate levels. These medications work by
excreting phosphate in the stool found in food. Give with meals or
immediately after eating.
Diet low in phosphate: Restrict foods high is phosphate: poultry, fish, dairy,
nuts, sodas, oatmeal.
Safety due to weak bones.

Hypermagnesemia (>2.6 mg/dL): normal 1.6-2.6 mg/dL

Patient is at risk for EKG changes, tendon reflexes diminished or absent,
lethargy.
Nursing role:
Avoid administering magnesium-based antacids or laxatives
Low magnesium foods
MD may order IV calcium to help decrease level
LOW UOP and Fluid Overload:

Monitor intake and output (strict)

Daily weights
Assess swelling and lung sounds “crackles”
Monitor blood pressure
Low sodium diet

Slide #19
What is the normal range for BUN?
The normal result is generally 6 to 20 mg/dL
What is normal creatinine level?
A normal result is 0.7 to 1.3 mg/dL (61.9 to 114.9 µmol/L) for men and 0.6 to
1.1 mg/dL (53 to 97.2 µmol/L) for women. Women often have a lower
creatinine level than men. This is because women often have less muscle
mass than men. Creatinine level varies based on a person's size and muscle
mass.
Slide #20

Slide #21
The concern is MI, stroke and kidney damage…..watch for hypertensive crisis
headache, N’V and change in cognition (report these).
Metabolic Acidosis – caused by an overload of Hydrogen Ions in the blood pH
below 7.35
Urea develops into uremic frost on the skin, this causes the itching
High Na+ above 145 leads to hypertensive crisis
Phosphorus above 4.5 leads to decrease in Ca and osteoporosis SAFETY
High K+ above 5.0 watch the heart (tele) spiked T (6-7) waves and ST
elevation (7-8), wide QRS over 8meq/L this leads to bradycardia, weakness
and lethargy due to decreased cardiac output.
PRIORITY treatment….lower the potassium!!!!
[Link] calcium gluconate for dysrhythmias
[Link] 50% dextrose (to combat hypoglycemia caused by sugar moving into
cells) and regular insulin if no dysrhythmias (moves K+ and sugar into the
cell ….very fast!)
[Link] (polystyrene sulfonate) takes longer to work
[Link] takes a while to set up
Slide #22
To preserve renal function….low phosphorus and low protein
Slide #23
with urinalysis the most specific finding for CRF is the presence of broad
casts in the urinary sediment. The wide diameter of these casts reflects
compensatory hypertrophy and dilation of the surviving nephrons.
proteinuria does not always indicate renal disease.
Serum Creatinine test – over 1.3 (blood and all urine are collected in 24
hours), discard 1st specimen then save all urine for 24 hours, keep on ice
Serum Sodium: Normal Range: 135 to 145 mmol/L. ...
Serum Potassium: Normal Range: 3.6 to 5.5 mmol/L. ...
Serum Calcium: Normal Range: 8.8 to 10.7 mg/dl. ...
Serum Magnesium: Normal Range: 1.46 to 2.68 mg/dl. ...
Bicarbonate: Normal Range: 23 to 30 mmol/L. ...
Phosphorus: Normal Range: 3.4 to 4.5 mg/dl.
An arterial blood gas (ABG) test is a blood test that requires a sample from
an artery in your body to measure the levels of oxygen and carbon dioxide in
your blood. The test also checks the balance of acids and bases, known as
the pH balance, in your blood
A kidney ultrasound may be used to assess the size, location, and shape of
the kidneys and related structures, such as the ureters and bladder.
Ultrasound can detect cysts, tumors, abscesses, obstructions, fluid collection,
and infection within or around the kidneys.
CT scans of the kidneys can help your healthcare provider find problems
such as tumors or other lesions, obstructive conditions, such as kidney
stones, congenital anomalies, polycystic kidney disease, buildup of fluid
around the kidneys, and the location of abscesses.
MRI has the advantage of superior soft-tissue contrast, which provides a
powerful tool in the detection and characterization of renal lesions. The MRI
features of common and less common renal lesions are discussed as well as
the evaluation of the spread of malignant lesions and preoperative
assessment
with renal biopsy, a small sample of kidney tissue is removed with a needle.
The test is sometimes used to evaluate a transplanted kidney. It is also used
to evaluate an unexplained decrease in kidney function, persistent blood in
the urine, or protein in the urine.
Slide #24
To preserve renal function….low phosphorus and low protein
Low phosphorus – no dairy! Yogurt, pudding, milk
low protein diets. Eggs, chicken etc…
No NA+ processed meats, canned foods, packaged foods and NO salt
substitutes
No K+ leafy green like spinach, avocadoes, carrots or tomatoes,
strawberries, oranges or bananas (apples are the best choice in the fresh
fruits)
To help protect your kidneys. When your body uses protein, it produces
waste. Your kidneys remove this waste. Eating more protein than you need
may make your kidneys work harder.
Eat small portions of protein foods. Plant-protein foods: Beans, Nuts, Grains
Low Fat - To help keep fat from building up in your blood vessels, heart, and
kidneys.
Grill, broil, bake, roast, or stir-fry foods, instead of deep frying.
Cook with nonstick cooking spray or a small amount of olive oil instead of
butter.
Trim fat from meat and remove skin from poultry before eating.
Try to limit saturated and trans fats. Read the food label.
Dietitians encourage most people on peritoneal dialysis to eat high-quality
protein because it produces less waste, which has to be removed during
dialysis. High-quality protein comes from meat, poultry, fish, and eggs.
Slide #25
Medications play a significant role in the nursing management of kidney
disease. ACE inhibitors and angiotensin receptor blockers (ARBs) may be
used to reduce proteinuria and slow the progression of CKD.
Nursing assessments for ACE inhibitors and ARBs include checking the
patient's blood pressure, monitoring serum potassium levels, and assessing
renal function. These medications can cause hyperkalemia, especially in
patients with renal impairment, and can worsen kidney function if already
weak. Angiotensin-converting enzyme inhibitors can cause a dry cough,
while angiotensin II receptor blockers are better tolerated.
Loop diuretics may aid in managing fluid retention and hypertension in
patients with CKD. Nursing assessments for loop diuretics include monitoring
urine output, determining the patient's electrolyte levels, and assessing the
patient for dehydration. These medications can cause hypokalemia, which
can lead to cardiac arrhythmias and muscle weakness.
Erythropoietin may be given to CKD patients with anemia to increase red
blood cell production. Nursing assessments for erythropoietin include
monitoring for blood pressure changes and assessing the patient for
potential medication interactions.
mannitol for rhabdomyolysis-induced renal failure, especially as seen with
crush injury victims as mannitol decreases osmotic swelling and edema in
the injured muscle cells and helps restore the skeletal muscle function
How does mannitol cause renal failure?
The increase in renal blood flow after mannitol administration is
accompanied by a redistribution of renal blood flow, which leads to reduced
oxygen delivery to the medulla
Slide #26
Peritoneal Dialysis:
Peritoneal dialysis (PD) is a type of dialysis that uses the peritoneal
membrane within the patient's abdomen as a filter to remove toxins and
waste products from the body. This process involves the insertion of a
catheter into the peritoneal cavity, which allows for the delivery of dialysis
solution.
Assessment and Implementation:
As with all forms of dialysis, monitoring fluid, and electrolyte balance is
important for patients undergoing PD. Nurses should monitor the patient's
weight, intake and output, electrolytes, and blood pressure.
Nursing interventions for PD involve assisting patients in maintaining a
sterile environment when handling the catheter and performing proper
handwashing. Nurses should also ensure that the dialysis solution is
delivered at the prescribed pace and that the solution is warmed to body
temperature before being infused into the peritoneal cavity. Additionally,
nurses should assist patients with repositioning, ambulation, and activities of
daily living to support patient comfort and safety.

Arterial Dialysis:
Arterial dialysis (AD) is a form of hemodialysis that involves the placement of
an arteriovenous (AV) graft or fistula for blood access. Blood is then diverted
from the graft or fistula, through a dialyzer in a dialysis machine, and then
returned to the patient.
Assessment and Implementation:
Nursing assessments for AD involve continuous monitoring of vital signs,
blood pressure, and electrolyte levels. Nurses should also check for the
presence of palpable pulses and assess the patency of the AV graft or fistula,
ensuring that the dialysis machine is functioning properly.
Nursing interventions for AD focus on maximizing blood flow through the AV
fistula or graft. Patients may be instructed to perform exercises to promote
blood flow or wear compression sleeves to prevent clotting. Access site care
is also critical, with nurses responsible for properly cleaning and dressing
access sites, assessing for signs of infection, and communicating with the
healthcare team if there are any signs of complications.
Slide #30
Created by connecting an artery and a vein in the wrist or forearm area
allows high pressure arterial flow to go through a normally low-pressure vein.
The patient will need to squeeze a ball or exercise to increase blood flow and
strengthen. Also pitting edema is normal while it is healing.
Not normal pale skin, paresthesia’s, diminished pulses, poor cap refill,
pain that is distal to the shunt. Patient can lose their arm due to poor
circulation
Slide #31
Teach patients to Monitor for infection, bleeding, clotting feel a thrill
vibration means blood flow is adequate.
Assess – fluid and fistula status, edema, VS, heart and lung sounds
No thrill felt or Bruit heard report to HCP immediately (decreased blood flow
by a possible clot)
Hold these meds
A aces and arbs cause K+ retention
B beta blockers lol hr &bp too low
C ca channel blockers to low BP
D diuretics – too dry
D Dilators like nitroglycerin (low BP)
Certain meds are dialyzed out of the body which makes them ineffective
antibiotics like cephalosporines and penicillin’s, digoxin which is given to
heart failure patients to help the heart have a deeper contraction.
Hold water soluble vitamins B, C, and folic acid. Calcium supplements are ok
to give because they will help reduce phosphorus levels, insulin is also ok to
give since it is typically absorbed fast so give with breakfast.
During dialysis IV heparin is given to help reduce clotting so no subq is
needed prior or during dialysis.
Dialysis disequilibrium syndrome – watch for restlessness and disorientation,
vomiting and HA assess for DDS during and after caused by solutes being
removed to quickly and causing brain cells to swell with fluid and leads to ICP
then leading to coma and death. Key signs…. restless and disoriented!!!!
Action – stop or slow infusion and contact the HCP. Any infusion causing a
problem we would stop or slow it immediately and contact HCP.
Slide #32
They must avoid jewelry, no BP, no sleeping no creams/lotions and nothing
more than 5lbs (purse)
Slide #33
Warm the solution, infection risk so sterile technique is imperative to avoid
infection report s/s of infection. Pruritis and oliguria are normal and expected
findings with renal failure. Respiratory distress due to rapid infusion of
overfilling the abdomen – crackles in the lung bases, high RR, dyspnea first
action is to raise the HOB!!! ABCs
Insufficient outflow – assess patient first (abdomen for distension and
constipation) and then the equipment (kinks or obstruction). Reposition to a
side lying position will usually fix the problem
Slide #38 Questions…..
1. D
2. C
3. A
4. A
5. B