which clinical finding should a nurse look for in a client with chronic renal failure?

Fundamental Terms:

• Homeostasis:The body's natural tendency to maintain a relatively abiding internal surround through negative and positive feedback loops.
• Hyperkalemia: An excessive amount of potassium in the bloodstream.
• Myoglobinuria: The presence of myoglobin in the urine that is commonly evidenced as a brown discoloration.
• Rhabdomyolysis: Breakdown of skeletal musculus tissue, leading to release of myoglobin and other cellular components into the bloodstream.
• Uremia: An aberrant accumulation of urea and other waste material products in the blood resulting from the kidneys' disability to eliminate urea from the body.

It's another hot and humid summer day when the crew of Rescue 102 is summoned to a individual residence for a report of meaning muscular pain and discolored urine. On arrival, a woman greets the coiffure and takes them to the restroom where her husband is hunched over the sink in obvious distress. The patient reports feeling significant pain and swelling in his legs and has been nauseous and vomited twice. His wife states that he ran an ultramarathon yesterday and has been feeling sick since. She also reports that he has tea-colored urine.

The patient's vital signs reveal an elevated temperature and mild hypotension. Oxygen is provided by an EMT while the test continues. A paramedic questions the patient about his by medical history, which reveals nothing noteworthy. The patient reports having taken ibuprofen for an arm injury prior to the marathon but takes no prescribed medications. The coiffure completes their assessment and loads the patient into the ambulance. Iv access is established, and a 500 mL fluid bolus is administered.

No changes occur during send. The patient is transferred to the infirmary staff with a full report. Later in the 24-hour interval, the coiffure learns that the patient underwent hemodialysis for acute renal failure due to rhabdomyolysis likely acquired by extreme muscle strain.

Introduction

The kidneys play an incredibly important role in maintaining homeostasis in the body. Well-nigh of us will live our entire lives without compromise to these vital organs, just they tin can be injured through a number of mechanisms. If the injury to the kidneys is significant and abrupt, the patient may experience acute renal failure, which can be life-threatening. In other cases, the kidneys are injured over time and shut down due to chronic renal failure. It's fairly common; 1 in 10 American adults will suffer from some form of chronic kidney affliction during their lifetime.^ane

Prehospital caregivers play a vital role in ensuring that renal failure patients are rapidly identified, properly treated and transported to an appropriate ED for continued care.

Beefcake & Physiology

The kidneys are bean-shaped organs located in the retroperitoneal infinite at approximately the level of the 12th ribs. The left kidney is positioned slightly higher than the right. In adults, the kidneys are approximately four inches long, 2.5 inches wide and 1.five inches thick. A fat pouch comprised of the renal sheathing, adipose capsule and renal fascia surrounds each kidney. Big renal arteries bring approximately one.2 liters of blood to the kidneys every minute for filtration and production of urine. The blood passes through a complex organization of vessels, somewhen leaving the kidneys through the renal veins.

The kidneys take two layers: the outer cortex and inner medulla. Although the two layers are visible during dissection, they function every bit 1 complete unit in the healthy individual. The outer cortex contains near of the glomeruli (described in more detail later) and the vast corporeality of nephrons that function to create urine. The medulla is the inner layer that is largely comprised of the renal pyramids. These cone-shaped structures serve to channel urine into the renal calyces.

On a microscopic level, a kidney's main functional unit is the nephron, which consists of the renal corpuscle (glomerulus and Bowman's capsule) and tubules. Filtration occurs in the renal corpuscle where the glomerulus filters blood beyond Bowman'southward sheathing. Filtration is the first step in forming urine.

Reabsorption occurs through specialized capillaries known as peritubular capillaries. Water, glucose, sodium and other nutrients and ions are brought back into the blood. The side by side step in the formation of urine is known equally secretion whereby the remaining fluid and constituents pass through the loop of Henle and into the collecting tubule. The urine and so passes into larger ducts that somewhen empty into a renal calyx. From the renal calyx (plural is calyces), the urine so passes into the renal pelvis, down the ureter and into the urinary float until it is passed through the process of urination. Through filtration, reabsorption and secretion, the kidneys help to regulate the body'south fluid, electrolyte and acid-base balance.

The kidneys as well produce important hormones known equally erythropoietin (EPO) and calcitriol. EPO serves to stimulate production of red blood cells in the red marrow of bone while calcitriol is the active class of vitamin D, which helps the body absorb calcium from food and obtain calcium from the bone for distribution in the blood stream. Lastly, the kidney secretes an enzyme known as renin. This important enzyme helps to maintain claret pressure through the renin-angiotensin-aldosterone pathway.

Figure one: Kidney

Acute & Chronic Renal Failure

Acute renal failure tin occur over hours to days based on the underlying mechanism of injury and relative health of the individual. Complications that arise when acute renal failure is present include disturbances in fluid and electrolyte balances and accumulation of metabolic wastes in the blood. Acute renal failure is often reversible if it's recognized early and treated promptly. Despite the chances that it may exist reversible, it has a bloodshed rate ranging from l—80%.²

The causes of astute renal failure are ordinarily grouped into three major categories: pre-renal, intrarenal and mail service-renal failure.³ Pre-renal is the well-nigh common for renal failure and arises from such conditions as rhabdomyolysis, hemorrhage, sepsis, burns, trauma and a host of other factors. Intrarenal causes are classified past area affected: tubular, glomerular, interstitial and vascular.ⁱⁱⁱ Diseases that can injure the kidneys include diabetes mellitus, systemic lupus erythematosis, persistent hypertension, renal blood vessel occlusion and other disease processes. Post-renal failure tin occur when there's an obstruction in the urinary tract. Kidney stones, trauma, bladder cancer and enlargement of the prostate can atomic number 82 to post-renal failure.

In dissimilarity to astute renal failure, chronic renal failure is a gradual process occurring over time with a resulting decline in renal function. Depending on the level of severity, chronic renal failure may exist treated with dialysis and possibly by kidney transplantation. Over time, chronic renal failure can atomic number 82 to a permanent and irreversible loss of renal functioning, known as terminate phase renal affliction (ESRD).

Complications that tin can exist expected to arise in the acute or chronic renal failure patient include fluid and electrolyte abnormalities, particularly hyperkalemia. Ems providers should exist alert to the possibility of fluid retention, which may be evidenced past pulmonary and systemic edema. The patient may develop hypo- or hypertension depending on the cause and type of renal failure.

Figure 2: The Retroperitoneal Space

Cess Considerations

Assessment of the renal failure patient begins with performing an initial assessment to detect and care for threats to life. Once life-threatening conditions are addressed, the Ems provider should turn to gathering a complete patient history and performing a detailed exam. Use the SAMPLE (signs/symptoms, allergies, medications, past medical history, terminal oral intake and events preceding the phone call for assistance) mnemonic as a guide to asking bones questions. Question the patient near vomiting, diarrhea or inadequate fluid intake, and exist alert for signs of dehydration. While patient questioning is occurring, ensure that other providers are assessing vital signs. Pulse oximetry, claret pressure, pulse, respirations and temperature should all be assessed and recorded.

Ask if the patient has been diagnosed with renal failure. Question the patient about difficulties or changes in urination, including a reduction or cessation in urinary period, any discoloration to the urine, and passage of whatever kidney stones. Make up one's mind if the patient has pain. When pain is present, appraise it using the OPQRST mnemonic (onset, provocation, quality, region/radiation, severity and time).

Since astute and chronic renal failure can manifest in many dissimilar ways, the EMS provider should assess the entire body following the caput-to-toe format. Make up one's mind if at that place's whatever trauma. If present, assess the mechanism of injury and determine the likelihood of kidney injury past because the forces involved and location of injury.

Unlike many organs in the abdomen, the kidneys are located outside of the protective peritoneum, a membrane that contains adipose and connective tissue that oftentimes serves as a cushion to blot kinetic forces. While there is a good level of protection from the posterior muscular wall of the intestinal cavity, the kidneys tin can exist injured from blunt or penetrating trauma, particularly when forces are transmitted posteriorly. In fact, the kidneys are the well-nigh commonly injured genitourinary organ with blunt trauma being the most mutual offending insult.⁴ Adding to the risk is the fact that bleeding into the retroperitoneal space can accumulate as much as 3,000 milliliters of blood. Given the corporeality of blood that tin be lost in this space, acute renal failure can develop with or without direct insult to the kidneys.

Check for jugular venous distention, and assess the breath sounds for any abnormalities. Audit and palpate the abdomen to determine if there'due south tenderness, guarding or injury. A patient with an obstacle that prevents emptying the bladder may be in significant distress with the bladder palpable to a higher place the pubic symphysis.

Assess the extremities for signs of edema. If the patient is bedridden, the edema may accumulate posteriorly in the pre-sacral expanse. Assess the skin color, condition and temperature. A patient with chronic renal failure may have uremic frost on the peel, which is a powdery deposit of urea and uric acrid salts resulting from astringent uremia. Examine both upper extremities to decide if the patient has a vascular access indicate for hemodialysis through an arteriovenous fistula or graft.^five If neither is present, information technology's as well possible that the patient may take a catheter inserted at the neck, chest or groin area.

Question the patient nearly the ability to void ordinarily. Patients with chronic renal failure may accept the power to pass some urine. Ask the patient about contempo changes in urinary habits. The patient may study a change in color or report the presence of blood in the urine. Tea-colored urine is indicative of protein in the urine, more than formally known as myoglobinuria.

Advanced-level providers should perform an ECG to make up one's mind if in that location are whatever dysrhythmias or abnormalities and when in that location'south known or suspected hyperkalemia.^six Patients with hyperkalemia may present initially with peaked T waves.⁷ If the patient has significant hyperkalemia, there may exist widening of the QRS complexes to the point where they may become indistinguishable from the T waves. It's of import to discover hyperkalemia apace because the mortality can reach as high as 67%.^eight

Treatment

Basic treatment of the patient in renal failure should include providing oxygen and establishing IV access. A patient with renal failure combined with signs of dehydration and hypotension should be treated cautiously with IV fluids. Provide the fluid in small, incremental boluses (200—250 mL) while frequently assessing for changes in blood pressure and auscultating breath sounds for the evolution of pulmonary edema.

If pulmonary edema is present, the patient may exist a candidate for bi-level positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP). The patient in severe respiratory distress may require endotracheal intubation and positive-pressure level ventilation. Pharmacological interventions vary by local protocol simply may include administration of furosemide for its diuretic and vasodilatory backdrop. Sublingual nitroglycerin is too a mutual handling in many Ems protocols; however, the provider should ensure that the blood force per unit area is 90 mm/Hg or greater prior to administering nitroglycerin. Fluid overload in a patient in chronic renal failure is typically best managed by transporting the patient to a facility that can provide dialysis.

Treatment of hyperkalemia may include the administration of calcium, bicarbonate, insulin and dextrose 50%. Protocols vary widely in which whatever of these medications tin can exist administered in the out-of-hospital setting. Mutual developed dosing for calcium chloride

is 8—16 mg/kg via Four, dextrose 50% at 25 grams via 4, and sodium bicarbonate administered at ane mEq/kg of an 8.4% solution via 4. If regular insulin is administered in the out-of-hospital surround, the dosage is typically 10 units administered subcutaneously. Some protocols also phone call for the administration of nebulized albuterol at 2.five mg.

Definitive therapy for patients in renal failure is provided in the hospital environment or dialysis centers. Dialysis is 1 of the best therapies for patients in chronic renal failure, specially when the patient hasn't undergone the standard scheduled therapy. Long-term treatment for a patient with ESRD may include kidney transplantation; nevertheless, prospects of obtaining a donor from a not-family member are oftentimes dim. In 2010, nigh 76,000 patients were pending a kidney transplant, but simply 16,843 transplants were performed on patients over the age of 20.⁹

Conclusion

Prehospital providers can be faced with a patient experiencing either acute or chronic renal failure. While the opening case presented an interesting acute renal failure patient presentation, the purpose was to focus the reader on the assessment findings and not to exist distracted by singular presentations. The general assessment approaches piece of work well in caring for these patients, and they can be combined with some specific fact-gathering and physical assessment considerations. Standard therapy includes early on administration of oxygen and establishing Iv access. If fluids demand to be administered, they should be provided charily with frequent assessments before, during and subsequently assistants. All renal failure patients should exist transported to the emergency department for additional cess and treatment. jems

References

ane. National Kidney and Urologic Diseases Data Clearing House. (November. 15, 2012.) Kidney disease statistics for the U.s.a.. National Constitute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Wellness (NIH). Retrieved on June 30, 2013, from world wide web.kidney.niddk.nih.gov/kudiseases/pubs/kustats.

2. Schrier RW, Wang Due west, Poole B, et al. Acute renal failure: Definitions, diagnosis, pathogenesis, and therapy. J Clin Invest. 2004;114(one):5—14.

3. Needham E. Management of acute renal failure. Am Fam Physician. 2005;72(9):1739—1746.

4. Voelzke BB, McAninch JW. The current management of renal injuries. Am Surg. 2008;74(8):667—678.

5. National Kidney and Urologic Diseases Data Immigration Firm. (Sept. 2, 2010.) Vascular admission for hemodialysis. NIDDK, NIH. Retrieved on June 28, 2013, from www.kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess.

six. Khanna A, White WB. The management of hyperkalemia in patients with cardiovascular disease. Am J Med. 2009;122(iii):215—221.

7. Mitchell SH, Brady WJ. The electrocardiogram in hyperkalemia. In Brady WJ, Hudson K, Braithwaite S, et al. (Eds.), The ECG in Prehospital Emergency Care. Blackwell Publishing Ltd., Oxford, U.K., pp. 112—116, 2012.

viii. Weisberg LS. Direction of severe hyperkalemia. Crit Intendance Med. 2008;36(12):3246—3251.

9. U.S. Renal Data System (USRDS). USRDS 2012 Annual Information Report: Atlas of Chronic Kidney Disease and End-Stage Renal Affliction in the United States [written report]. National Institutes of Wellness, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda, Doctor., 2012.

Source: https://www.jems.com/patient-care/how-identify-assess-treat-renal-failure/

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