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What is Chronic Renal Failure and Its Assessment:Nursing Case Study

Tuesday, 25 March 2014

Chronic renal failure represents a destruction of renal tissue with irreversible sclerosis and loss of nephron function. It can result from chronic illness or from a rapidly progressing disease. Few symptoms develop until less than 25% of glomerular filtration remains. The normal parenchyma deteriorates and symptoms worsen as renal function decreases. This condition is fatal without treatment, but maintenance on dialysis or a kidney transplant can sustain life.


Pathophysiology
Chronic renal failure typically progresses through four stages. Reduced renal reserve shows a glomerular filtration rate (GFR) of 35% to 50% of normal; renal insufficiency has a GFR of 20% to 35% of normal; renal failure has a GFR of 20% to 25% of normal; and end-stage renal disease (ESRD) has a GFR of less than 20% of normal.

Nephron damage is progressive; damaged nephrons can't function and don't recover. The kidneys can maintain relatively normal function until about 75% of the nephrons are nonfunctional. Surviving nephrons hypertrophy and increase their rate of filtration, reabsorption, and secretion. Compensatory excretion continues as the GFR diminishes.

Urine may contain abnormal amounts of protein, red blood cells (RBCs), and white blood cells or casts. The major end products of excretion remain essentially normal, and nephron loss becomes significant. As the GFR decreases, the plasma creatinine level increases proportionately, without regulatory adjustment. As sodium delivery to the nephron increases, less is reabsorbed and sodium deficits and volume depletion follow. The kidney becomes incapable of concentrating and diluting urine.

Complications
■ Anemia
■ Peripheral neuropathy
■ Cardiopulmonary complications
■ GI complications
■ Sexual dysfunction
■ Skeletal defects
■ Paresthesia
■ Motor nerve dysfunction, such as footdrop and flaccid paralysis
■ Pathologic fractures

Assessment
Health perception and management

■ History of decreased urine output, edema, extreme fatigue, depression, loss of interest in environment, impotence, and flank pain
■ History of acute or chronic renal problems, chronic renal insufficiency, hypertension, diabetes mellitus, arteriosclerosis and atherosclerosis, lupus erythematosus, or other systemic diseases involving the kidneys

Nutrition and metabolism
■ Anorexia, nausea, and vomiting
■ Weight loss or gain
■ Unpleasant taste in mouth

Elimination
■ Polyuria and nocturia (early stage)
■ Oliguria (advanced stage)
■ Diarrhea alternating with constipation

Activity and exercise
■ Fatigue
■ Lack of energy to exercise

Cognition and perception
■ Shortened attention span
■ Memory loss
■ Decreased ability to perform abstract reasoning or mathematical calculations
■ Loss of interest in environment

Sleep and rest
■ Extreme somnolence or insomnia and restlessness
■ Sleep commonly interrupted by muscle cramps and leg pain

Self-perception and self-concept
■ Depression or frequent mood swings
■ Altered self‑concept and body image
■ Decreased self‑esteem
■ Reduced level of independence and self‑care
■ Sense of powerlessness and hopelessness

Sexuality and reproduction
■ Amenorrhea, infertility
■ Decreased libido
■ Decreased or absent sexual expression
■ Impotence

Roles and relationships
■ Unable to work effectively
■ Spousal and parental roles impaired
■ Withdrawn from social contacts and activities

Coping and stress management
■ Ineffective individual and family coping patterns
■ Employs defense mechanisms (for example, denial, projection, displacement, or rationalization)

Values and beliefs

■ Loss of confidence in health care providers
■ Questioning or reaffirming lifelong religious and philosophical values and beliefs

Physical examination
General appearance and nutrition
■ Unhealthy appearance
■ Weight loss

Mental status and behavior
■ Listless
■ Depressed

Integumentary
■ Rough, dry skin
■ Bronze‑gray, pallid skin color
■ Pruritus
■ Ecchymoses
■ Poor skin mobility and turgor
■ Excoriation
■ Signs and symptoms of inflammation
■ Thin, brittle nails
■ Coarse, thinning hair

Respiratory
■ Crackles
■ Shortness of breath
■ Coughing
■ Thick, tenacious sputum
■ Deep, rapid respirations (with acidosis)

Cardiovascular
■ Hypertension, or hypotension (uncommon)
■ Orthostatic hypotension
■ Pitting edema of feet, legs, fingers, and hands
■ Periorbital edema
■ Sacral edema
■ Engorged jugular veins
■ Arrhythmias
■ Pericardial friction rub (with pericarditis)
■ Paradoxical pulse (with pericardial effusion or tamponade)
■ Palpitations

Gastrointestinal
■ Smell of urine and ammonia on the breath
■ Gum ulcerations and bleeding
■ Dry, cracked, bleeding mucous membranes and tongue
■ Vomiting
■ GI bleeding
■ Constipation or diarrhea
■ Liver enlargement
■ Ascites

Neurologic
■ Weakness
■ Confusion and disorientation
■ Memory loss
■ Slowing of thought processes
■ Changes in sensorium (somnolence, stupor, or coma)
■ Seizures
■ Changes in behavior (irritability, withdrawal, depression, psychosis, or delusions)
■ Numbness and burning of soles
■ Decreased sensory perception
■ Restlessness of legs
■ Diminished deep tendon reflexes
■ Positive Chvostek's and Trousseau's signs (rare)

Musculoskeletal
■ Muscle cramps (especially in the legs)
■ Loss of muscle strength
■ Limited range of motion (ROM) in joints
■ Bone fractures
■ Lumps (calcium‑phosphate deposits) in skin, soft tissues, and joints
■ Footdrop with motor nerve involvement

Reproductive (includes breasts)
■ Amenorrhea (in females)
■ Atrophy of testicles (in males)
■ Gynecomastia

Diagnostic studies
■ Blood urea nitrogen (BUN) levels are elevated.
■ Serum creatinine levels are elevated.
■ Creatinine clearance is decreased by more than 90% in ESRD.
■ Serum electrolyte levels show hypernatremia (common), hyperkalemia, hyperphosphatemia, hypocalcemia, elevated calcium‑phosphate product, or hypermagnesemia.
■ Venous carbon dioxide (comparable to arterial bicarbonate) levels are decreased.
■ Arterial blood gas levels show an acid‑base imbalance, typically metabolic acidosis.
■ Hemoglobin levels and hematocrit decreased (hemoglobin usually 6 to 8 mg, hematocrit usually 20% to 25%).
■ RBC count is decreased.
■ Electrocardiogram (ECG) may show abnormal rhythms or altered waveform appearance.
■ Renal biopsy indicates the nature and extent of renal disease; it's necessary to diagnose the cause of chronic renal failure.
■ Radionuclide tests (renal scan and renogram) identify abnormal renal structure and function.
■ Renal arteriogram identifies narrowed, stenosed, missing, or misplaced blood vessels.
■ Plain X‑ray of kidneys, ureters, and bladder and ultrasonography identify gross structural abnormalities.
■ Computed tomography scan identifies renal masses, abnormal filling of the collecting system, or vascular disorders.

Teaching checklist
■ Disease process and treatment plan
■ Medications
■ Dietary and fluid modifications
■ Activity restrictions
■ Dialysis schedule and care of the dialysis site
■ Signs and symptoms of complications to report
■ Available community resources
■ How to contact the dialysis nurse or physician

Image: wikimedia.org/wikipedia/commons/
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