Paediatric Renal Nursing Care

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Paediatric Renal Nursing Care Principles of
Treatment

• Cathy Poole
• Lecturer Practitioner

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AIMS

• To outline the definition of acute renal failure
  linked to basic physiology
• To define the causes of acute renal failure
• To discuss the principles of management of
  children with acute renal failure

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OBJECTIVES

• At the end of this session you should be able to
• Discuss the definition and causes of acute renal
  failure
• Describe the management of children in acute
  renal failure

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DEFINITIONS OF ARF

• The syndrome is characterised by a sudden in
  parenchymal function which is usually but not
  always reversible
• This produces disturbance of water, electrolyte,
  acid base balance and nitrogenous waste products
  blood pressure.

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PATHOPYSIOLOGY(1)

• Severe reduction in renal blood flow (RBF)
• Often occurs despite normal systemic arterial
  pressure
• This leads to reduced GFR and renal cortical
  blood flow
• This stimulates renin and aldosterone secretion

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PATHOPHYSIOLOGY(2)

• Na and H20 are retained
• Thus decreasing urinary output

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Mortality and Morbidity

• Outcomes of ARF in paeds viewed as potentially
  reversible.
• Mortality rates lt than those in adults.
• Mortality is related to the nature of the primary
  disease process as opposed to the renal failure
  itself.

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ORIGINS Of ARF

• Prerenal origins compromise renal perfusion
  leading to a GFR.
• Intrarenal failure is the result of damage to the
  renal parenchymal cells. (acute tubular necrosis
  ATN)
• Post renal ARF arises from urine out flow
  obstruction

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PRERENAL(1)

• Hypovolaemia
• Hypotension
• Hypoxia

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INTRARENAL(1)

• GlomerulonephritisSLE
• Vascular Disorders
• Tumours
• Acute Tubular Necrosis (ATN)
• Acute Interstitial Nephritis
• Developmental Abnormalities

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? Pathophysiology of ATN

• NB. This is not completely understood
• related events include-
• induction by hypoxia of nitric oxide synthases
  with increased production of nitric oxide
• vasoconstriction
• liberation of toxic endothelial factors
• tubular obstruction by desquamated cells and
  casts..

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POST RENAL

• Obstructive Uropathy
• Vesico-ureteric Reflux (bilateral)
• Acquired

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Investigations in ARF (1)

• Dipstick Blood protein
• Microscopy RBC, WBC, casts crystals
• Culture sensitivity
• Na, SG/osmolality

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Investigations in ARF (2)

• Plasma urea, creatinine, Na, K, Cl, Ca
• Blood gases
• FBC Film
• Ultrasound of abdomen
• X-ray chest

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Management of ARF

• Fluid balance
• Electrolyte disturbances
• Acid-base disturbances
• Drugs
• Nutrition
• Family Centred Care..

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Water Balance emergent care.

• ? Fluid depletion IV saline 5 ml/kg/bolus
  rapidly, repeated until adequate circulating
  volume
• ? Fluid overload loop diuretic in escalating
  doses up to max. 10 mg/kg. If unsuccessful,
  dialysis or haemofiltration.

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Fluid Requirements

• Insensible losses
• Preterm30 ml/kg/day
• Infants 20 ml/kg/day
• Children15 ml/kg/day
• Urine output
• GIT losses
• Other losses, e.g. 10-14 increase for each 1?C
  fever

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Prevention is better than cure..

• Be alert for potential acute renal failure
  related to-
• Poor systemic perfusion
• Inadequate renal perfusion

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Nursing Care

• Hourly intake / output record
• output lt1-2 ml/kg/hr
• ? Catheterise for accuracy
• ? Repeat samples for osmolality / SG
• Monitor colour of urine
• Assess systemic perfusion...

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• i.e. Warm skin
• Strong peripheral pulses
• Brisk capillary refill
• Mucous membranes should be pink moist
• Support cardiovascular function as needed
• ? Fluid challenge
• ? Colloid
• ? Inotropic agents or vasodilators if systemic
  perfusion does not improve

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• Digoxin, dobutamine or dopamine
• Which increase myocardial contraction
• Tension development relaxation occur fast with
  relatively little increase in O2 demand
• ? administer diuretic agents

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Nursing Considerations (1)

• Potential fluid volume excess related to-
• Oliguria
• Excessive fluid administration
• Sodium water retention

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Nursing Care

• Input/output
• ? Fluid restriction 300ml/m2 BSA/day plus urine
  output
• Minimise fluid utilisation i.e flushing lines,
  diluting medication
• Administer diuretics
• Monitor for signs of hypervolaemia

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Nursing Considerations (2)

• Potential electrolyte imbalance related to-
• Decreased renal potassium excretion
• Increased renal sodium excretion
• Decreased renal excretion of phosphate,
  calcium-phosphate precipitation decreased renal
  activation of Vitamin D

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Nursing Care (a)

• Monitor UEs
• Watch K intake
• Monitor for signs of hyperkalaemia
• ? Peaked T wave
• Arrythmias
• Muscle weakness
• Action needed to reduce serum K
• ? dialyse

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Nursing Care (b)

• Watch for hyponatraemia
• change in consciousness
• muscle cramps
• anorexia
• abnormal reflexes
• Cheyne-stokes respiration
• or seizures

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Nursing Care (c)

• Watch for hypocalcaemia
• muscle tingling or changes in muscle tone
• Seizures
• Tetany
• ve Chvostek sign ( twitching of side of face
  when the facial nerve is tapped in front of the
  ear)
• Drugs antacid phosphate binders Vit D

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Nursing Considerations (3)

• Potential metabolic acidosis related to-
• Poor systemic perfusion associated with pre-renal
  failure
• Decreased renal ability to excrete hydrogen ions

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Nursing Care (a)

• Assist with arterial blood gases
• Administer medication i.e. Na Bicarbonate
• Reassess serum K

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Nursing Considerations (4)

• Potential drug toxicity related to-
• Reduced renal excretion of drugs or drug
  metabolites

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Nursing Care (a)

• Review patients drug doses and administration
  schedule
• Note clinical signs of toxicity
• Document report

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Nursing Considerations (5)

• Potential for infection related to-
• Multiple invasive catheters
• Compromised nutritional intake
• Poor nutritional status ?

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Nursing Care (a)

• Meticulous hand washing by all !!!!!!
• Adhere to unit policy for all dressing changes
• Monitor temp WBC
• Assess all skin puncture sites
• Swabs, blood cultures urine etc if infection
  suspected
• Administer antibiotic therapy if prescribed

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Nursing Considerations (6)

• Potential pain related to-
• Multiple invasive catheters treatments
• Neuropathies associated with electrolyte
  imbalances

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Nursing Care (a)

• Assess for evidence of pain using local pain
  assessment tool
• Assess severity
• Administer analgesia as prescribed
• Careful positioning
• Family support

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Nursing Consideration (7)

• Skin integrity, impaired related to-
• Uraemia
• Nursing Care-
• Keep skin warm dry
• Change patients position frequently
• Nursing aids ?..

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Nursing Considerations (8)

• Nutrition, altered, less than body requirements
• Nursing Care-
• Dietetic involvement
• Record intake
• Observe restrictions
• J. Kennedy Renal Disorders

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Drug Therapies

• In pairs
• List the medications commonly used in ARF Rx
• Feed back

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Treatment goals

• Elimination of K
• Correction of Na imbalance
• Maintenance of normal calcium Phosphate
• Correction of metabolic acidosis
• Maintain Bp
• Treat convulsions