Objective 2 Scientific Principles and concepts
ARF
The nursing role in assessing ARF includes monitoring changes in fluid input and output, blood pressure, monitoring urine for color, specific gravity, protein, blood, and sediment seen visually in urine and by urinalysis. It is also important when observing urine to also ask patient about difficulty of urination such as burning, pain, or distention. The skin should be assessed for edema, color changes, neck vein distention and bruising to the skin Lewis et al. (2007, p. 1203). Assessing for other underlying problems associated with ARF should be observed such as changes in mentation, increase in swelling and edema which can also be manifested in the lungs when hearing crackles, rhonchi, or diminished lung sounds. The patient may have dry oral mucosa and may have a sense of dehydration Lewis et al. (2007, p. 1203).
The nurse must be able to monitor and treat hypotension and hypovolemia to prevent ARF from worsening. When administering medications check for nephrotoxicity and find out what is the lowest effective dose that is effective for therapy or if they could be used as short-term therapy. Two groups of medications that can affect kidney function are NSAIDs and ACE inhibitors Lewis et al. (2007, p.1203).
As mentioned before comorbidities affect renal function and must be managed concurrently with treating ARF. Common conditions are diabetes and cardiovascular diseases influencing renal perfusion. In observation of the intake and output, nurse not only looks for more intake than output, but also weight gain associated with fluid retention Lewis et al. (2007, p.1203). If hypervolemia occurs then administration of loop diuretics such as Lasix and monitoring its effectiveness for changes in output on an hourly basis and decrease in patient’s swelling to extremities and shortness of breath. The nurse must take caution on the pharmacodynamics of a diuretic. Checking blood pressure before administration is essential and a follow up reading is recommended, especially when it’s newly prescribed or the dosage is changed. Potassium sparing diuretics such as Aldactone can potentially retain potassium to toxic levels as it is not readily excreted in the urine. Potassium and sodium must be monitored at least daily with chemistry panels until levels have resolved. Hyperkalemia may cause cardiac dysrhythmias and cause muscle weakness by neurologically impairing contractility Lewis et al. (2007, p. 1204)
Infection prevention is vital in using standard precautions and aseptic technique. It is the nurse’s responsibility to not only adhere to this, but also to educate the patient on proper hygiene. Infections that render the kidneys vulnerable are urinary tract infections caused by inadequately maintaining sterility of equipment, such as indwelling catheters or a lack of perineal care provided by the nurse or the patient. It is important to monitor for symptoms such as a fever, foul smelling urination, or burning when urinating. It is also important to culture the organism if a UTI is suspected. To prevent complications the nurse must implement interventions to prevent the UTI from producing ARF. If a UTI is found in urine culture measures to increase fluid intake orally and intravenously must begin as soon as possible. The nurse must obtain orders for antibiotics that the organism found may be susceptible to. Other labs should be read to indicate change in function or potential complications of the infection, such as elevated white blood cell count, an increase in urinalysis bacteria count, and decrease in glomerular filtration rate Lewis et al. (2007, p. 1200). Secondary lab results that may indicate that the kidneys may be compromised may be an increase in blood, urea, and nitrogen and creatinine, meaning clearance or nitrogenous waste is inhibited. More severe conditions related to infection reaching the kidneys is when it becomes systemic and late manifesting symptoms become evident as altered level of consciousness and multiple organ failure. It always important to observe the patient and look for signs in which a UTI may be compromising the kidneys, such as severe radiating flank pain on one or bilateral sides of lower back Lewis et al. (2007, p. 1204).
Nursing assessment of patient skin care must be done to check for secondary complications, such as wound formation due to edematous skin. Skin care would include protecting the skin by using cushioning, preventing cracking of skin by moisturizing the integument, and elevating extremities to promote venous return of edema. An increase in ammonia may cause stomatitis orally. The mouth must be hydrated to prevent cracking or breakdown of oral mucosa. Supplemental oxygen may be essential as difficulty breathing may manifest from hypervolemia which fluid infiltrates the lungs. A patient may have difficulty lying flat in bed. Deep breathing, coughing, and use of incentive spirometry may be used to clear lungs of secretions and prevent atelectasis and pneumonia as secondary complications. The patient should be educated on increasing physical activity as tolerated to stimulate the circulation so it can promote reuptake the stagnant edema and be excreted Lewis et al. (2007, p. 1204).
CKD
A history and physical must be obtained in order to determine the probable cause of renal failure in the patient. Genetic disorders may predispose the patient to CKD. Diabetes, autoimmune disorders such as lupus, and hypertension are large contributing factors to CKD. Long-term use of nephrotoxic medications may have an insidious effect in damaging the kidneys. Intake and output and weight should also be measured as it was previously discussed with ARF. Education on dietary changes should be implemented in teaching and getting an idea per the patient’s report on what kind of food is usually eaten. Lifestyle changes which may require the person to change various aspects of their personal lives may produce stressful situations with their family relationships. CKD will last a lifetime and may affect how the affected person views their life with the illness. Coping with the illness and finding lasting support systems could pose a significant challenge in helping the individual manage their illness effectively Lewis et al. (2007, p. 2013).
The challenge with CKD once diagnosed is to make sure patients understand the importance of complying with therapy, integrating a plan for ADLs with given within limitations, and ways to cope with CKD. As mentioned before, determining the cause of CKD is needed. Early detection is essential to before symptoms worsen. If a genetic predisposition is known, then frequent screening is needed, because symptoms manifested are a late sign that the disease may be progressing to later stages of failure. Some tests include a blood draw to determine UA, BUN and creatinine. Poorly controlled blood glucose levels in diabetes, uncontrolled and persistent hypertension, and recurrent UTIs have the potential cause CKD if they are not controlled for the majority of a person’s life. Kidney function already gradually deteriorates normally into advance age, so age-related considerations for the geriatric populations should be considered when contributing comorbidities compound the deterioration of kidney function Lewis et al. (2007, p.1230).
When preventative treatment is no longer helping to prevent complications causing CKD, more invasive interventions, such as peritoneal dialysis and hemodialysis are become necessary treatment options. If a compatible donor without the high likelihood of rejection is found, kidney transplantation would be needed, but in the meantime the patient will be on dialysis. The patient and family will need to be informed of options available. Returning to dialysis if organ is rejected is still viable and multiple attempts to transplant again is still an option unless there are other factors contraindicating such a procedure Lewis et al. (2007, p. 1216).
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