RENAL DISORDERS – finals 4 tubule returns needed substances to your blood and

removes wastes.
Functions of the kidneys

 remove waste products and toxins from the body

 Help in the proper removal of drugs from the body
 Maintain appropriate fluid and electrolyte balance
in the body
 release a hormone called Renin that regulates
blood pressure
 Control the production of red blood cells by the
bone marrow by producing a hormone called
Erythropoietin
 produces the most active form of vitamin D( called
1,25-dihydroxycholecalciferol) that promotes
strong, healthy bone

As Children Grow: Development of the Genitourinary

System  The glomeruli become edematous and are infiltrated
 All nephrons are present at birth, the ureters are short, with polymorphonuclear leukocytes, which occlude the
and tubules have a smaller surface area, resulting in capillary lumen.
diminished water reabsorption. Nephrons grow in size,  This condition results in decreased plasma filtration,
and the kidneys and the tubule system gradually causing excessive accumulation of water and retention
develop during childhood to reach adult size during of sodium.
adolescence.  The resultant plasma and interstitial fluid volumes lead
 Glomerular filtration rate (GFR) in a neonate is one to circulatory congestion and edema.
third to one fourth of adult levels, GFR increases  Hypertension is associated with glomerulonephritis.
progressively and reaches adut levels between 1 and 2 Causes
years of age (Otukesh, Hoseini, Rahimzadeh, et aL,
2012). 1. Autoimmune diseases
 Kidneys are less efficient at regulating electrolyze and 2. Antecedent group A B. hemolytic streptococcal
acid-base balance, and less able to concentrate urine. infection of the pharynx or skin
Diarrhea, infection, and improper feeding may lead to 3. History of pharyngitis or tonsillitis 2 to 3 weeks
severe acidosis and fluid imbalance. Efficiency of the before symptoms
kidneys in regulating electrolytes and acid-base balance Types
increases after 2 years of age. 1. Acute - Occurs 2 to 3 weeks after a streptococcal
 Expected urine output for a neonate and infant is 1-2 infection
mL/kg/, while an adult should have 0,5 mL/kg/hr 2. Chronic - May occur after the acute phase or
(Alarcon & Fink, 2015). Toddler Reproductive system is slowly over time
immature. Reproductive system matures atter puberty. Complications
 Hypertensive encephalopathy (characterized by
GLOMERULONEPHRITIS headache, vomiting, irritability, convulsions, and
 Glomerulonephritis refers to a group of kidney coma)-can result from the chronic hypertension
disorders characterized by inflammatory injury in the  Cardiac failure, possibly a result of an increase in
glomerulus, most of which are caused by an blood volume secondary to retention of sodium
immunological reaction. and water- associated with pulmonary congestion
 The disorder results in proliferative and inflammatory  End-stage renal disease
changes within the glomerular structure. Assessment Findings
 Destruction, inflammation, and sclerosis of the 1. Periorbital and facial edema that is more
glomeruli of the kidneys occur. Inflammation of the prominent in the morning
glomeruli results from an antigen-antibody reaction 2. Anorexia
produced by an infection elsewhere in the body. 3. Decreased urinary output
 Loss of kidney function develops. 4. Cloudy, smoky, brown-colored urine (hematuria)
5. Pallor, irritability, lethargy
Each of your kidneys is made up of about a million filtering 6. In an older child: Headaches, abdominal or flank
units called nephrons. Each nephron includes a filter, called pain, dysuria
the glomerulus, and a tubule. The nephrons work through a 7. Hypertension
two-step process: the glomerulus filters your blood, and the 8. Proteinuria that produces a persistent and
excessive foam in the urine
 9. Azotemia CAUSES:
10. Increased blood urea nitrogen and creatinine  Kidney disease that affects a kidney's filtering
levels system is the most common cause in children,
11. Increased anti-streptolysin O tier (used to diagnose  Other causes can include diseases that affect other
disorders caused by streptococcal infections) parts of the body, infections, some medicines, and
12. Anemia in acute phase genetics.
 glomerutoscierosis- when the inside of the kidney
Priority Nursing Actions: Fluid Volume Overload in a Child becomes scarred.
with Glomerulonephritis  glomerutonephritis - intlammation inside the
 Assess airway patency, vital signs, and weight. kidney.
 Assess for bounding, increased pulse.  an infection - such as HIV or hepatitis.
 Assess for distended hand and neck veins.  lupus.
 Assess for elevated central venous pressure (CVP)  diabetes.
and for dysrhythmias.  sickle cell anaemia.
 Notify the health care provider (HCP) and carry out  autoimmune diseases.
prescriptions including water and sodium  in very rare cases, certain types of cancer - such as
restriction and administration of diuretics. leukaemia, multiple myeloma or lymphoma.

Nursing Interventions PATHOPHYSIOLOGY

1. Monitor VS, I and 0, and characteristics of urine.
2. Measure daily weights at the same time of day,
using the same scale, and wearing the same
clothing.
3. Limit activity; provide safety measures.
4. Diet restrictions of sodium depend on the stage
and severity of the disease, especially the extent of
the edema; in addition, potassium may be
restricted during periods of oliguria.
5. Monitor for complications (e.g., kidney failure,
hypertensive encephalopathy, seizures, pulmonary
edema, heart failure).
6. Administer diuretics (if significant edema and fluid Assessment Findings
overload are present), antihypertensives (for  Child gains weight
hypertension), and antibiotics (to a child with  Periorbital and facial edema most prominent in the
evidence of persistent streptococcal infections) as morning
prescribed.  Leg, ankle, labial, or scrotal edema
7. Initiate seizure precautions and administer  Urine output decreases: urine dark and frothy
anticonvulsants as prescribed for seizures  Ascites (fluid in abdominal cavity)
associated with hypertensive encephalopathy.  Blood pressure normal or slightly decreased
8. Instruct parents to report signs of bloody urine,  Lethargy, anorexia, and pallor
headache, or edema.  Massive proteinuria
9. Instruct parents that the child needs to obtain  Decreased serum protein (hypoproteinemia) and
appropriate treatment for infections, specifically elevated serum lipid levels
for sore throats, upper respiratory infections, and The classic manifestations of nephrotic syndrome are
skin infections. Measuring the daily weight and massive proteinuria, hypoalbuminemia, and edema
assessing for changes is the most useful and
effective measure for determining fluid balance. COMPLICATIONS:
1. Fluid/electrolyte balance: intravascular volume
NEPHROTIC SYNDROME depletion (hypovolemia), respiratory compromise
 Nephrotic Syndrome Nephrotic syndrome is a kidney (related to fluid retention and abdominal
disorder characterized by massive proteinuria, distention), skin breakdown (from severe edema,
hypoalbuminemia (hypoproteinemia), and edema poor healing)
 The primary objectives of therapeutic management 2. Cardiovascular: hypercoagulability (venous
are to reduce the excretion of urinary protein, thrombosis)
maintain protein-free urine, reduce edema, prevent 3. Immune: infection (especially cellulitis, peritonitis,
infection, and minimize complications. pneumonia, septicemia)
 4. Multiple body systems: untoward side effects of o Immunosuppressive therapy (alkylating agents
medications, growth failure, and muscle wasting [cyclophosphamide, and/or to decrease the
(long-term) frequency of relapses.
LABORATORY AND DIAGNOSTIC TEST o Dietary sodium restriction (no added salt) is used
Nephrotic syndrome is generally diagnosed based on to reduce edema. A high protein diet and/or
clinical presentation and laboratory test results. intravenous albumin infusion are used for protein
replacement and to restore fluid balance.
1. Urinalysis, urine dipstick -to detect protein and blood o Diuretic therapy may be needed to treat severe
in the urine. edema (i.e., when severe fluid retention interferes
a. Proteinuria (urinary protein loss) with respiration and/or causes skin breakdown).
b. Hematuria (may be microscopic) o Diuretics should be used with caution to prevent
2. Urinary protein/ creatine ratio – calculated to monitor intravascular volume depletion, thrombus
persistent proteinuria; best if first void of the morning formation, and/or electrolyte imbalances.
is used; more accurate than 24 hour urine protein o Electrolyte replacement is administered as
collection needed. Antibiotics may be administered to
a. Normal value <0.5 prevent or treat infection.
b. Values of >2 mg protein/mg creatinine are o Pain (related to edema and invasive therapy) may
associated with nephrotic syndrome be treated with medications and
3. Serum chemistry, lipid panel - to assess electrolytes, nonpharmacologic approaches.
serum protein, renal function, lipids o Anticoagulants maybe used to prevent or treat
a. Serum electrolytes- vary with individual disease thrombosis.
states and treatments o Antihypertensives (i.e., angiotensin-converting
b. Blood urea nitrogen and creatinine -may be enzyme [ACE] inhibitors) may be used as needed
increased if renal impairment has occurred to control blood pressure and decrease urinary
c. Serum albumin -decreased, related to protein protein losses.
loss Nursing Interventions
d. Serum cholesterol and triglycerides -increased 1. Monitor VS, I and O, daily weights, urine for spec
and related to increased lipoprotein synthesis gravity, and edema.
4. Complete blood count -to monitor for 2. Nutrition:
hemoconcentration and infection  A regular diet without added salt if the child is
a. Hemoglobin, hematocrit, and platelets- in remission;
increased (related to hemoconcentration)  Sodium is restricted during periods of massive
b. White blood cell count- may be increased if edema (fluids may also be restricted).
infection is present 3. Corticosteroid therapy as soon as the diagnosis has
5. Renal biopsy -is done to determine the glomerular been determined; monitor the child closely for signs
status, type of nephrotic syndrome, response to of infection and other adverse effects of
medical management, and disease course, most often corticosteroids
used for patients who are steroid resistant and/or 4. Immunosuppressant therapy (cyclophosphamide) to
steroid dependent. Microscopic evaluation shows reduce the relapse rate and induce long-term
abnormal appearance of basement membranes. remission, or, if the child is unresponsive to
corticosteroid therapy, therapy may be administered
MEDICAL MANAGEMENT along with the corticosteroid.
o Vary according to the type of nephrotic syndrome 5. Diuretics to reduce edema.
and as new data are available regarding the 6. Plasma expander such as salt-poor human albumin
efficacy of various treatments. for a severely edematous child.
o Corticosteroids (prednisone, prednisolone) are 7. Instruct parents about testing the urine for protein,
traditionally administered daily until remission is medication administration, side effects of
achieved (cessation ofurinary protein loss). protein medications, and general care of the child.
loss). 8. Instruct parents on the signs of infection and the
o Corticosteroids are usually tapered off by need to avoid contact with other children who may
administering on alternate days and/or with infectious
decreasing doses. ACUTE RENAL FAILURE
o Relapses may be treated with additional courses of  Acute renal failure (ARF) is the abrupt reduction or
corticosteroids. cessation of renal function secondary to a sudden loss
o For children who fail to achieve remission after 8 of functioning nephrons.
weeks of steroids, they are often deemed "steroid  The rapid loss of renal function leads to a reduction in
resistant. the glomerular filtration rate (GFR)
 This causes a build-up of urea and creatinine, fluid-
electrolyte imbalances, and other related problems. Laboratory and Diagnostic Tests
 ARF occurs suddenly and entails multiple problems and 1. Blood tests
potentially threatening complications. A. BUN and serum creatinine -increased; related to
 Children with ARF and their families need ongoing impaired renal excretion of toxins
support and education. B. Serum sodium and calcium- decreased; sodium
 ARF outcomes range from complete recovery to the decreases because of hemodilution from fluid
development of chronic renal failure. retention; calcium is inversely related to increased
phosphorus
INCIDENCE C. Serum potassium, magnesium, phosphorus-
1. Incidence and prognosis vary according to age, increased; related to altered renal filtration and/or
etiology, associated problems, underlying condition, decreased excretion
geographic location and type of treatment D. Serum pH and bicarbonate (HCO3)- decreased;
2. ARF in infants and children is most frequently caused related to impaired renal excretion of acid
by prerenal failure (hypoperfusion). causing metabolic acidosis
3. ARF is a common complication of critical illness. ARF in E. Hemoglobin, hematocrit, platelet count -
critically ill patients has been associated with high decreased due to bleeding, hemolysis,
mortality (>60%). When ARF is combined with hemodilution, decreased production and/or
multisystem organ failure, the risk of death is even decreased life span of blood cells
higher. F. Serum albumin- decreased due to decreased
CAUSES OF ACUTE RENAL FAILURE intake (nausea and vomiting are common with
(3 types of acute renal injury) uremia), fluid shifts, and/or protein loss
G. Serum glucose- -decreased, particularly in infants
related to decreased intake and/or stress, which
initially increases serum glucose
H. Serum uric acid- -increased; related to decreased
renal excretion
I. Blood cultures- positive; related to systemic
infection such as sepsis
2. Urine tests
A. Urinalysis: RBCs and/or casts-indication of renal
damage from various causes
B. Urine electrolytes, osmolality, and specific gravity
- vary with disease process and stage of ARF
C. Uric acid (24 hour)- -decreased; related to
decreased excretion with some types of renal
disease

3. Electrocardiogram (ECG
4. Chest and abdominal x-ray studies
Complications 5. Ultrasonography
 Fluid balance complications: fluid overload, 6. Renal Doppler blood flow
intravascular volume depletion from third-space losses, 7. Radiographic imaging (intravenous pyelography,
pulmonary edema, ascites causing respiratory difficulty radionuclide studies, renal arteriogram)
 Electrolyte imbalances-arrhythmias, cardiac arrest,
seizures Nursing Assessment
 Cardiovascular: congestive heart failure, hypertension, 1. Assess for signs and symptoms of fluid volume excess.
hypotension, arrhythmias, shock, cardiac arrest a) Local edema (periorbital, facial, extremities,
 Respiratory: tachypnea, pulmonary edema, respiratory dependent edema, external genitalia swelling,
failure facial edema) progressing to generalized
 Neurologic: altered level of consciousness, seizures, edema
intracranial bleeding in neonates b) Pulmonary congestion progressing to
 Infection can occur since the child is pulmonary edema
immunocompromised c) Ascites (abdominal distention progressing to
 Skin breakdown due to poor healing, malnutrition, the extent that skin is taut and shiny over the
pruritus abdomen)
 Malnutrition from decreased caloric intake, nausea, d) Intake greater than output e. Weight gain
vomiting, diarrhea, and protein loss
2. Assess for signs of electrolyte imbalance. Frequently 4. Assess for signs of decreased cardiovascular
monitor serum electrolytes for range values. functioning (hypotension, hypertension, shock,
a) Hyperkalemia: levels above 6 mEq/L can lead to life- congestive heart failure, cardiac arrhythmias, fluid
threatening arrhythmias (bradycardia, heart blocks, volume deficit).
asystole and/or other arrhythmias), severe  Blood pressure (hypotension or hypertension)
hemodynamic instability, and cardiorespiratory  Central venous pressure (increased or
arrest. decreased)
o ECG: "tented" or peaked T waves,  Heart rate and rhythm (monitor for
progressing to widening PR interval with tachycardia and signs of arrhythmias related
flattening and then disappearance of the to hyperkalemia as described above)
P wave, progressing to widened ORS, and  Distal perfusion (pulses, capillary refill,
finally leading to merging of QRST temperature, color)
complex and cardiac arrest. 5. Assess for signs of ineffective breathing pattern.
o Other signs: muscle cramping, decreased  Respiratory rate and pattern (tachypnea,
muscle tone, abdominal pain, and abdominal breathing, shallow breathing, apnea)
neuromuscular irritability (twitching,  Use of accessory muscles (retractions, shoulder
tingling in lips or fingertips). Severe shrugging) and nasal flaring
hyperkalemia can lead to muscle and/or  Grunting (infants)
respiratory paralysis.  Cyanosis and/or decreased oxygen saturations
b) Hypocalcemia e. Respiratory acidosis
 Central nervous system (CNS): tetany, anxiety, 6. Assess for signs of hematologic dysfunction (anemia,
seizures bleeding, thrombocytopenia, platelet dysfunction).
 Cardiovascular: hypotension  Anemia: pallor, tachycardia, lethargy, weakness,
 Neuromuscular: Trousseau's sign, Chvostek's shortness of breath
sign, muscle cramping  Bleeding: occult blood, intracranial hemorrhage,
c) Hyponatremia other signs of bleeding
 CNS: apathy, weakness, dizziness, lethargy,  Laboratory: decreased hemoglobin and
encephalopathy, seizures hematocrit, decreased platelet count, increased
 Cardiovascular: hypotension bleeding time
 Gl: nausea, abdominal cramping 7. Assess for signs of infection (fever, increased white
d) Hypermagnesemia blood cell count, septic shock).
 CNS: depressed CNS, peripheral 8. Assess for signs of failure to thrive (FTT) and
neuromuscular function, and deep tendon malnutrition (lethargy, weakness, poor feeding,
reflexes decreased appetite, vomiting, failure to gain weight,
 Cardiovascular: hypotension, cardiac inadequate caloric intake, loss of developmental
arrhythmias, depressed cardiac functioning milestones).
e) Hyperphosphatemia 9. Assess for skin breakdown.
 Monitor serum magnesium levels 10. Assess child's comfort level,
 Usually asymptomatic until levels are very high 11. Assess child's level of activity and developmental needs
(>10 mEq/L) 12. Assess child and family's coping response, caregiver
Hypocalcemia roles, knowledge level, and ability to manage the
Trousseau's Sign child's long-term care
 Induction of carpopedal spasm by inflation of a Treatment
sphygmomanometer above SBP for 3 minutes  Treatment depends on the underlying cause of the
 Response: Carpopedal spasm characterized by renal failure.
o Adduction of the thumb  The goal is to minimize or prevent permanent renal
o Flexion of the metacarpophalangeal joints damage while maintaining fluid and electrolyte
o Extension of the interphalangeal joints balance and managing complications.
o Flexion of the wrist  Initial emergency treatment of children with fluid
Chvostek's sign depletion focuses on rapid fluid replacement of
 Contraction of the ipsilateral facial muscles elicited saline or lactated Ringer solution at 20 mL/kg given
by tapping the facial nerve just anterior to the ear rapidly over 5 to 10minutes and repeated as
 Response: Twitching of the lip to spasm of all facial needed to ensure renal perfusion and stabilize
muscles blood pressure.
3. Assess for signs of uremia.  Albumin may also be administered when blood loss
 CNS: lethargy, confusion, seizures is the cause of circulatory depletion.
 Cardiovascular: hypotension  If oliguria persists after restoration of adequate
 Gl: nausea, vomiting, anorexia fluid volume, intrinsic renal damage is suspected.
  Children with fluid overload, such as those with c. Provide cardiac support through
pulmonary edema, require diuretic therapy, and medication administration and decreasing
dialysis if they respond poorly to diuretics. myocardial workload (i.e., sedation,
 Once the child is stabilized, fluid requirements are assistance with ventilation, etc.) as
calculated to maintain zero water balance (intake needed.
should equal urine output and insensible fluid 4. Monitor neurologic functioning, and promptly report
loss). deterioration in status. Promptly respond to seizure
 All potential sources of potassium should be activity.
eliminated until hyperkalemia is controlled. Other 5. Assess for signs of bleeding, and implement bleeding
electrolyte imbalances are treated. precautions (soft toothbrush, minimize needle sticks,
 Nutrition must be maintained with extra avoid invasive procedures).
carbohydrate intake during the catabolic state. 6. Monitor for signs of anemia, and implement corrective
 Antibiotics are prescribed for infection if applicable. measures as indicated (blood transfusion, medication);
Nephrotoxic antibiotics such as aminoglycosides use minimum volumes for blood draws
(e.g., gentamicin, vancomycin) should be avoided. 7. Assess for signs of infection and implement
 Dialysis if unresponsive to correct severe preventive measures.
electrolyte imbalances, manage fluid overload, and a. Use proper handwashing techniques and/or
cleanse the blood of waste products. antiseptic gel.
 The clinical situation and age of the child b. Perform appropriate care for all invasive
determine whether hemodialysis or peritoneal catheters and lines.
dialysis is used. c. Protect from infectious contacts.
 Prognosis depends on the cause of ARF. When renal 8. Assess for signs of malnutrition and provide
failure results from drug toxicity or dehydration, nutritional support.
the prognosis is generally good. a. Administer parenteral nutrition as indicated.
 However, AF that results from diseases such as b. Assess tolerance of enteral feeds via oral,
hemolytic-uremic syndrome or acute nasogastric, or nasojejunal route.
glomerulonephritis may be associated with c. Oral feedings: offer appetizing foods while
residual kidney damage. implementing dietary restrictions.
 Nursing care focuses on preventing complications, d. Monitor caloric intake.
maintaining fluid balance, administering e. Collaborate with nutritionist as indicated.
medications, meeting nutritional needs, preventing 9. Monitor for signs of skin breakdown, and implement
infection, and providing emotional support to the corrective measures:
child and parents. a. Turn frequently, avoid placing on hard
surfaces (tubing, monitor cables, wrinkled
Nursing Interventions sheets) and use pressure-relief surfaces with
1. Monitor and maintain fluid balance. severe edema and/or skin breakdown
a. Frequently assess hydration status. b. Perform frequent mouth and skin care.
b. Record accurate input and output. c. Administer medications for pruritus as
c. Monitor and record daily weights. needed.
d. Monitor type of fluids and administration rate. 10. Assess child's comfort level and implement pain
 Maintain fluid limit and avoid fluid control measures
overload. Avoid using excess fluids when 11. Provide developmentally appropriate activity while
administering medications and flushing ensuring adequate rest periods.
lines. 12. Assess coping responses and provide therapeutic
 Maintain circulatinq volume: replace fluids environment for the child and family.
(vascular loss from excessive edema, a. Encourage child and parents to ventilate
aggressive dialysis), promptly correct feelings and concerns.
hypotension, and carefully monitor fluid b. Assess knowledge base, provide
losses related to dialysis and other developmentally appropriate teaching, and
therapies. reinforce information provided to child and
2. Monitor serum electrolytes and acid-base balance. parents
Implement corrective measures as indicated 13. Assess family's ability to manage their child's long-
3. Frequently reassess respiratory and cardiovascular term care and provide supportive measures as
status, supportive measures, and airway stabilization as indicated.
indicated.
a. Position child to open the airway.
b. Administer oxygen and/or mechanical CHRONIC RENAL FAILURE
ventilation as needed.
 Pale, Shrunken, Firm Kidney with Pitted Surface  Glomerular disease (e.g., pyelonephritis,
Scarring Chronic renal failure (CRF) is most frequently a glomerulonephritis, glomerulouropathy)
result of chronic kidney disease (CKD). \  Obstructive uropathies(e.g., vesicoureteral reflux)
 The National Kidney Foundation's Kidney Disease  Renal hypoplasia or dysplasia
Outcomes Quality Initiative has defined CKD as  Inherited renal disorders (e.g., polycystic kidney
structural or functional abnormalities that persist for disease, congenital nephrotic syndrome, Alport
3 months or longer. syndrome)
 Pathologic abnormalities or other markers of kidney  Vascular neuropathies (e.g., hemolytic-uremic
damage (abnormal blood or urine tests or imaging syndrome [HUS], renal thrombosis) Kidney loss or
studies) are present, with either normal or decreased damage (e.g., severe renal trauma, Wilms' tumor)
glomerular filtration rate (GFR).
 CKD also includes conditions in which the GFR is less Clinical Manifestations
than 60 mL/min for 3 months or longer. 1. Fluid and electrolyte imbalance, leading to the
 Irreversible deterioration of renal function may occur following:
over months to years. a. Fluid overload
5 STAGES OF CKD b. Vascular volume depletion
During stage 1, kidney damage is present, with 2. Metabolic acidosis causing tachypnea and/or
normal or increased glomerular filtration rate decreased serum bicarbonate
(GFR). The focus of stage 1 is on diagnosis, 3. Blood cell functioning
treatment of associated conditions, and slowing 4. Anemia, resulting in the following:
the disease process. a. Shortness of breath
Stages 2, 3, and 4 represent a progressive decline b. Pallor
in GFR. The focus of these stages is on monitoring c. Tachycardia
and treating complications. Preparation for kidney d. Fatigue
replacement therapy (dialysis) occurs during stage e. Exercise intolerance
4. 5. Uremic neurologic effects (neuropathy and
Stage 5 represents renal failure, when the GFR encephalopathy), leading to the following:
falls below 15 mL/min. During this stage, the loss a. Itching (uremic frost skin deposits)
of nephrons and renal function affects the kidney's b. Muscle cramps and weakness
ability to maintain normal physiologic functioning. c. Slurred speech d. Paresthesia of the palms
and/or soles
d. Poor concentration and/or memory loss
e. Drowsiness
f. Seizures
g. Elevated intracranial pressure (IP) and/or
coma
6. Renal osteodystrophy leading to the following:
 CRF is associated with a variety of biochemical a. Abnormal bone growth patterns
dysfunctions. b. Small stature for age
o Sodium and fluid imbalances result from the c. Bone deformities and fractures
kidney's inability to concentrate urine. 7. Growth and development dysfunction leading to the
Hyperkalemia results from decreased potassium following:
secretion. a. Delayed sexual development
o Impaired resorption of bicarbonate and b. Menstrual irregularities
hydrogen ion retention lead to metabolic c. Malnutrition
acidosis. d. Muscle wasting
o Uremia occurs, with a build-up of blood urea, e. Bone pain and/or activity intolerance
creatinine, and waste products. 8. Psychosocial factors
o Encephalopathy and neuropathy have been a. Anxiety
associated with the accumulation of uremic b. Altered self image
toxins. Poor appetite, nausea, and vomiting lead c. Depression
to malnutrition. d. Social isolation from peers
o Anemia results from impaired red blood cell e. Family stress
(RBC) production, decreased RBC life span, an Complications
increased tendency to bleed (due to impaired  Cardiovascular: alteration in fluid and electrolytes,
platelet function), and poor nutrition. acid-base imbalance (metabolic acidosis), and
anemia can lead to cardiac dysfunction, congestive
Causes of CRF can be congenital or acquired: heart failure, hypertension, left-ventricular
 hypertrophy, tachycardia, arrhythmias, cardiac A. Blood urea nitrogen (BUN) and serum
arrest, and/or vascular volume depletion (with creatinine- increased due to impaired clearance;
excessive fluid loss or removal). Fluid overload can leads to the buildup of toxic wastes in the blood
lead to edema, oliguria, hypertension, and/or B. Serum potassium, magnesium, and phosphorus-
congestive heart failure. Conversely, polyuria, increased; related to altered renal filtration
decreased fluid intake, and other factors causing and/or decreased excretion. Potassium can
vascular volume depletion can lead to reach critical levels with CRF
dehydration, hypotension, and shock. C. Serum sodium-increased due to hemodilution
 Electrolyte imbalances: hyperkalemia can lead to from fluid retention
cardiac rhythm disturbances and myocardial D. Serum calcium-decreased; related to
dysfunction Hypernatremia can lead to thirst, hemodilution, calcium inversely related to
stupor, tachycardia, increased deep tendon increased phosphorus
reflexes, and/or decreased level of consciousness. E. Bicarbonate (CO2)-decreased; due to impaired
Hypercalcemia and/or hyperphosphatemia can renal excretion of acid causing metabolic
lead to muscle cramps, tetany, paresthesias, acidosis
irritability, depression, and/or psychosis. F. Serum albumin and total protein--decreased;
 Respiratory: fluid overload can lead to pulmonary related to decreased intake, nausea and
edema, increased work of breathing, and vomiting related to uremia, fluid shifts and/or
respiratory failure. Shortness of breath and urinary protein loss
exercise intolerance related to anemia can G. Serum glucose-is decreased particularly in
exacerbate respiratory compromise. infants; related to decreased intake and/or
 Neurologic: altered level of consciousness, stress, which initially increases serum glucose
increased ICP, seizures, and coma can result from 2. Complete blood count (CBC) -provides information
the build-up of toxins, fluid and electrolyte related to alterations of the hematocrit, hemoglobin,
imbalance, and other metabolic factors. and white blood cell (WBC) count associated with renal
 Hematologic: bleeding and/or anemia--bruising, disease
mouth sores, gastrointestinal bleeding, oozing a. Hemoglobin, hematocrit, platelet count-
from puncture sites, and other bleeding can occur decreased; related to bleeding, hemolysis,
related to hematologic dysfunction and/or hemodilution, decreased production and/or
prolonged bleeding time decreased life span of blood cells,n platelet
 Infection: increased susceptibility, decreased dysfunction and white blood cell and platelet
ability to fight infection, and invasion of function
opportunistic organisms is related to invasive lines b. WBC-normal, increased or decreased; related
and procedures, skin breakdown, poor nutrition, to presence of infection, impaired blood cell
and the need to administer antibiotics with caution production, and white cell function
(related to the kidneys' limited ability to 3. Serum uric acid- increased; related to decrease renal
metabolize and excrete). excretion
 Alteration in growth and bone: altered growth 4. Serum blood gas results (arterial, capillary or venous)
patterns, short stature, osseous deformities, provide data related to oxygenation and acid-base
dental defects, and mouth sores are related to status
poor nutrition, osteodystrophy, and/or other a. Serum pH and bicarbonate-decreased; related
factors affecting bone growth and formation. to metabolic acidosis
 Psychosocial: living with a chronic disease, b. Serum oxygen-normal, increased or
repeated hospitalizations, dealing with frequent decreased; related to effectiveness of
and painful medical interventions, altered growth breathing, and use of supplemental oxygen
patterns, chronic stress, and other factors can lead use
to developmental delays, altered body image, 5. Cultures- should be obtained with signs of infection
behavioral issues, altered family functioning, (i.e., fever; high or low WBC count; localized redness,
anxiety, depression, and/or other psychosocial odor, swelling and/or white or yellow drainage; cloudy
issues. urine, etc.)
Laboratory and Diagnostic Tests a. Blood cultures-positive with systemic
1. Blood chemistry panel -provides information about bacterial infections such as sepsis
common CRF-related alterations including blood urea b. Urine cultures-positive with the presence of
nitrogen (BUN), creatinine, electrolytes (potassium, urinary tract infection
sodium, calcium, magnesium, and phosphorus), acid- c. Wound cultures-positive with infected
base status (bicarbonate), glucose and protein wounds or invasive lines
(albumen, total protein) 6. Urine tests provide information related to alterations
in excretion of electrolytes, urine osmolality, and urine
 specific gravity and presence of hematuria and/or nutritional support, management of anemia, and
proteinuria associated with renal disease bleeding control.
A. Urinalysis-RBCs, protein and/or casts; o When CKD progresses to CRF, dialysis is often
indicates renal damage from various causes needed to prevent uremia.
B. Urine electrolytes, osmolality, and specific o For children with severe CRF, renal transplantation
gravity-~-varies with disease process may be an option
C. Urine sodium (24-hour collection)-quantifies
sodium secretion Nursing Assessment
D. Uric acid (24-hour)- decreased excretion 1. Assess for signs of fluid and electrolyte status.
with some types of renal disease a. Urine amount, quality, intake-output balance,
7. Electrocardiogram (ECG) to assess for ECG changes weight gain-loss patterns
and/or arrhythmias b. Signs of fluid overload
8. Chest and abdominal x-ray studies- to assess for fluid  Localized edema (periorbital, facial, external
retention and kidney presence and size genitalia, extremities) progressing to
9. Ultrasonography-to determine kidney size, urinary generalized edema
tract obstruction, tumors, cysts  Pulmonary congestion progressing to
10. Renal Doppler blood flow -to assess for renal vascular pulmonary edema and respiratory distress
disease  Ascites with taut and shiny skin over the
11. Radiographic imaging: computed tomography (CT) abdomen
scan, magnetic resonance imaging (MRI), intravenous  Weight gain and decreased output c. Signs of
pyelography, radionuclide studies, renal arteriogram-to hyperkalemia, hypocalcemia, hyponatremia,
examine for renal obstruction, blood flow, kidney hypermagnesemia and hypoglycemia
structures, renal function 2. Assess for signs of cardiovascular dysfunction
(tachycardia, severe hypertension, delayed capillary
Medical Management refill, cool extremities, weak pulses, hypotension,
o A primary goal is to stabilize the fluid volume and cardiac arrhythmias).
balance by limiting fluids, which is an important 3. Asses for sighs of respiratory compromise
and ongoing aspect of CRF management. ( pulmonary edema, increased work of breathing and
o This is achieved through closely monitoring intake use of accessory muscles [retractions, nasal flaring,
and output, monitoring weight gain patterns, grunting], oxygen desaturation, respiratory acidosis)
administering fluid therapy to maintain adequate 4. Assess for signs of infection (fever, increased WBC
circulation and avoid volume overload, and count, positive cultures, shock).
removing excess fluids when needed. 5. Assess for signs of uremia.
o Maintaining electrolyte and glucose balances is a. Neurologic: lethargy, confusion, tremors, muscle
critical. This is achieved by closely monitoring twitching, seizures
electrolytes, limiting potassium and sodium intake, b. Cardiovascular: hypertension, congestive heart
and promptly correcting imbalances. failure
o If hyperkalemia is present, resin binding agents c. Respiratory: pulmonary edema
(Kayexalate), glucose and insulin, calcium d. Gastrointestinal: nausea, vomiting, anorexia,
gluconate, sodium bicarbonate, and/or dialysis bloody iarrhea, unpleasant breath odor
may be needed. e. Hematologic: anemia, thrombocytopenia,
o Calcium supplements, vitamin D, and phosphate bruising, platelet dysfunction, increased bleeding
binders may be helpful in maintaining calcium and time
phosphate balance. Glucose is administered when f. Skin: uremic frost, severe itching, mouth sores
needed for hypoglycemia. 6. Assess for signs of life-threatening complications:
o Supporting cardiovascular and respiratory function sepsis, shock, fluid overload, severe hypertension,
is important, particularly when complications are heart failure, respiratory failure, severe electrolyte
present. imbalance, severe acidosis, uncontrolled bleeding,
o This is achieved by avoiding fluid overload while coma, and seizures.
maintaining circulating volume, controlling 7. Assess for signs of malnutrition, growth retardation,
hypertension (with antihypertensive medications and bone deformity.
and sodium restriction), and providing 8. Assess child's comfort level, activity level, and
cardiovascular and respiratory support developmental level.
medications as needed (diuretics, inotropes, 9. Assess child's coping response to long-term illness,
antiarrhythmic medications, oxygen). alteration in development, treatment regimen, and
o Other important aspects of CRF management possibility of renal transplant and/or death.
include preventing and treating infections, 10. Assess family's ability to cope with their child's long-
term needs and provide effective care
Nursing Interventions 4. Promote growth and nutrition (work with dietitian).
1. Monitor fluid-electrolyte and acid-base balance. a. Assist patient in finding appetizing choices in a low
a. Record accurate input and output; frequently potassium, low-sodium, low-phosphorus, high-
reassess hydration status. calcium, high-protein diet.
b. Record frequent weights as ordered. b. Monitor caloric intake.
c. Maintain fluid limit. c. Monitor patient's growth status by assessing
d. Administer diuretics as needed; monitor response. growth trends.
e. Monitor serum electrolytes and glucose; d. Administer enteral or intravenous IV nutrition as
implement corrective measures as indicated. needed (assess tolerance of feeds).
f. Administer dialysis as ordered. e. Administer vitamins (including vitamin D), iron
g. Monitor acid-base balance; implement corrective supplements, calcium supplements, and
measures as indicated. phosphate binders as indicated.
h. Teach patient and family about fluid limits and f. Administer growth hormone as ordered.
dietary electrolyte restrictions 5. Assess child's comfort level, and implement pain
2. Support cardiovascular, pulmonary, and hematologic control measures
functioning. 6. Assess coping responses and provide psychosocial
a. Monitor for fluid volume overload; administer support for the child and family
diuretics and dialysis as ordered.
b. Monitor for signs of dehydration (dry membranes, DIALYSIS
tachycardia, altered skin turgor and restlessness,  Dialysis is the process of separating colloids and
leading to delayed capillary refill, weak pulses, cool crystalline substances in solution by the difference in
extremities, lethargy, and hypotension); replace their rate of diffusion through a semipermeable
fluids as needed. membrane.
c. Monitor for ECG changes related to electrolyte  Methods of dialysis currently available for clinical
imbalance. management of renal failure are
d. Monitor vital signs, including blood pressure; peritoneal dialysis - wherein the abdominal cavity
administer antihypertensives as indicated. acts as a semipermeable membrane through which
e. Administer erythropoietin (to promote red blood water and solutes of small molecular size move by
cell production) and iron supplements (to treat osmosis and diffusion according to their respective
anemia) as indicated. concentrations on either side of the membrane,
f. Administer blood products as ordered; assess for and
transfusion reaction; use minimum volumes for Hemodialysis – which body is circulated outside
blood draws. the body through artificial membranes that permit
g. Assess adequacy of ventilation and promptly a similar passage of water and solutes
implement airway stabilization methods as Hemofiltration - in which blood filtrate is
indicated; encourage patient to cough and deep circulated outside the body by hydrostatic
breathe. pressure exerted across a semipermeable
h. Promote periods of rest and sleep membrane with simultaneous infusion of a
replacement solution
3. Maintain skin integrity and prevent infection.
a. Provide daily bath, frequent mouth care, and skin
care.
b. Assist with turning and prevent pressure ulceration
(pressure-relief and pressure-reduction surfaces;
avoid lying on hard objects; avoid pressure on
bony prominences).
c. Use bleeding precautions (soft toothbrush;
minimize needle sticks when possible).
d. Avoid patient's contact with infectious visitors.
e. Maintain sterility of all invasive lines; perform Peritoneal dialysis
meticulous vascular access device dressing  Peritoneal dialysis is the preferred form of dialysis for
changes and site care. infants, children and parents who wish to remain
f. Monitor for signs of infection (fever, lethargy, independent, families who live a long distance from the
nausea, vomiting, diarrhea, increased WBC count, medical center, and children who prefer fewer dietary
wound infection), and begin antibiotic therapy restrictions and a gentler form of dialysis
promptly.  Chronic peritoneal dialysis is most often performed at
g. Administer medications for pruritus home.
 The two types of peritoneal dialysis are continuous  The most commonly used material is expanded
ambulatory peritoneal dialysis and continuous cycling polytetrafluoroethylene (ePTFE).
peritoneal dialysis. In both methods, commercially  Both the graft and the fistula require needle
available sterile dialysis solution is instilled into the insertions with each dialysis treatment.
peritoneal cavity through a surgically implanted  For external vascular access devices, percutaneous
indwelling catheter tunneled subcutaneously and catheters are inserted in the femoral, subclavian,
sutured into place or internal jugular veins, even in very small
children.
 A more permanent form of external access is
available via a central catheter inserted surgically
into the internal jugular vein. This catheter has a
dual lumen, which allows a larger volume of blood
flow with minimum recirculation.
 The dialyzer, or filter, has two parts, one for
your blood and one for a washing fluid called
dialysate. A thin membrane separates these
 The warmed solution is allowed to enter the two parts. Blood cells, protein and other
peritoneal cavity by gravity and remains a variable important things remain in your blood
length of time according to the rate of solute removal because they are too big to pass through the
and glucose absorption in individual patients. membrane. Arteriovenous fistula Artery
 The care and management of the procedure are the Waste products' Artificial membrane Dialysate
responsibility of the parents of young children. Vein Purified blood is pumped from the
 Some centers have initiated use of home health dialyzer into the arteriovenous fistula
nurses to give parents respite from care. Hemodialysis
 Older children and adolescents can carry out the  Dialysate, also called dialysis fluid, dialysis
procedure themselves, which provides them with solution or bath, is a solution of pure water,
some control and less dependency. This is especially electrolytes and salts, such as bicarbonate and
important for adolescents. sodium. The purpose of dialysate is to pull
toxins from the blood into the dialysate. The
Hemodialysis way this works is through a process called
 Hemodialysis requires the creation of a vascular diffusion.
access and the use of special dialysis equipment-
the hemodialyzer, or so-called artificial kidney.
 Vascular access may be one of three types:
fistulas, grafts, or external vascular access
devices.
 An arteriovenous fistula is an access in which a
vein and artery are connected surgically.
 The preferred site is the radial artery and a
forearm vein that produces dilation and
thickening of the superficial vessels of the  Catheters eliminate the need for skin punctures but
forearm to provide easy access for repeated may require some home care.
venipuncture.  Hemodialysis is best suited to children who do not
 An alternative is the creation of a subcutaneous have someone in the family who is able to perform
(internal) arteriovenous graft by anastomosing home peritoneal dialysis and to those who live
artery and vein, with a synthetic prosthetic graft close to a dialysis center.
for circulatory access  The procedure is usually performed three times per
week for 4 to 6 hours, depending on the child's size.
 Hemodialysis achieves rapid correction of fluid and
electrolyte abnormalities but can cause problems in
association with this rapid change, such as muscle
cramping and hypotension.
 Disadvantages include school absence during
dialysis and strict fluid and dietary restrictions
between dialysis sessions.
 Boredom for the child and family is often a problem
during dialysis, and planned activities should be
introduced.
 Most children show rapid clinical improvement with
the implementation of dialysis, although it is
directly related to the duration of uremia before
dialysis and good nutrition.
 Growth rate and skeletal maturation improve, but
recovery of normal growth is infrequent.
 In many cases, sexual development, although
delayed, progresses to completion