Renal and Urinary Tract Care Plans

Chapter 11


Renal and Urinary Tract Care Plans



Acute Renal Failure


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Acute Tubular Necrosis (ATN); Renal Insufficiency; Acute Kidney Injury


In acute renal failure (ARF), the kidneys are incapable of clearing the blood of the waste products of metabolism. ARF may occur as a single event, with return of normal renal function, or may progress to chronic kidney disease or kidney failure. The causes of acute renal failure can be divided into three major types: prerenal, resulting from a decrease in renal perfusion; intrarenal, caused by a direct injury to the nephrons from ischemia or renal toxins; and postrenal, as a result of urinary tract obstruction that leads to the backflow of urine into the kidney. Hospital-acquired renal failure is most likely a result of acute tubular necrosis (ATN), which results from the administration of nephrotoxins or an acute ischemic episode. Because of declines in renal function as part of the normal aging process, older patients are more at risk when receiving nephrotoxic agents such as IV contrast media or certain medications. During the period of loss of renal function, hemodialysis, peritoneal dialysis, or continuous renal replacement therapy may be required to clear the accumulated toxins from the blood. This care plan focuses on the patient with ARF during hospitalization.




Hemodialysis


Internal Arteriovenous Fistula; Graft; Central Venous Catheter; Renal Replacement Therapy


Hemodialysis is one of the renal replacement therapies that is necessary to sustain life in people with no or very little kidney function. In general, dialysis is the diffusion of solute molecules and fluids across a semipermeable membrane. Dialysis may be a short-term therapy in situations such as acute renal failure (ARF) or long-term therapy for the patient with chronic renal failure. Hemodialysis may be used to remove drugs from the circulatory system as part of the treatment for drug overdoses. The purpose of dialysis is to remove excess fluids, toxins, and metabolic wastes from the blood. The primary mechanisms of dialysis are diffusion, osmosis, and ultrafiltration. The composition of the dialysis solution establishes a concentration and/or osmotic gradient to promote diffusion and osmosis of urea, creatinine, and electrolytes from the blood to the dialysate. Ultrafiltration is used to remove excess fluid by adjusting pressures in the blood compartment and the dialysate compartment. Rapid changes in vascular volume and electrolyte concentrations during hemodialysis can result in complications such as hypotension, muscle cramping, and cerebral edema. Hemodialysis increases the patient’s risk for infection. The most common source for infection is through vascular access sites. The incidence of blood borne infections such as human immunodeficiency virus (HIV) infection and hepatitis B and C has decreased with improved screening of patients and use of dedicated equipment for patients with these infections.


Hemodialysis requires a vascular access. This can be accomplished by surgically creating an arteriovenous (AV) fistula or graft (synthetic material used to connect an artery and a vein); or by insertion of an external catheter into a large central vein. The internal AV fistula is made by surgically creating an anastomosis between an artery and a vein, thus allowing arterial blood to flow through the vein, causing engorgement and enlargement. Placement may be in either forearm, using the radial artery and cephalic vein or brachial artery and cephalic vein. The internal AV fistula is the preferred access for long-term hemodialysis and must heal and mature before it may be used for access in hemodialysis. The central venous catheter may be either single or double lumen. A single-lumen catheter serves as the arterial source, and the venous return is made through a peripheral vein or by the use of an alternating flow device. A double-lumen catheter is used for both the arterial source and the venous return. Because of their location and low durability, femoral catheters are usually used only with inpatients on a short-term basis. Central venous catheters are considered a temporary access device but may be used for weeks or even months on an outpatient basis. The settings for hemodialysis include inpatient dialysis units in hospitals, outpatient dialysis centers, and the patient’s home.




Peritoneal Dialysis


Intermittent Peritoneal Dialysis; Continuous Ambulatory Peritoneal Dialysis; Continuous Cyclic Peritoneal Dialysis; Renal Replacement Therapy


Peritoneal dialysis is indicated for patients with kidney failure who have vascular access problems, who cannot tolerate the hemodynamic alterations of hemodialysis, or who prefer the independence of managing their own therapy in their home environment. A peritoneal catheter is placed through the anterior abdominal wall to achieve access into the peritoneum. During peritoneal dialysis, the peritoneum functions as the semi-permeable membrane by which molecules flow from the side of higher concentration to the side of lower concentration. This procedure removes excess fluid and waste products from the body. Peritoneal dialysis may be performed as intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, or continuous cyclic peritoneal dialysis. Peritoneal dialysis provides more gradual physiological changes than hemodialysis and is appropriate for the older adult patient with diabetes and cardiovascular disease. It is contraindicated in patients with peritonitis, recent abdominal surgery, or respiratory insufficiency because the fluid in the peritoneum decreases lung volume. This care plan focuses on peritoneal dialysis in the acute care setting with teaching for the ambulatory and home care setting.


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Dec 3, 2016 | Posted by in NURSING | Comments Off on Renal and Urinary Tract Care Plans

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