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Raynaud's Disease

Raynaud's disease is a form of intermittent arteriolar vasoconstriction that aff


ects the fingers and toes. The cause is unknown, but episodes may be associated
with immunologic disorders (scleroderma, systemic lupus erythematosus, rheumatoi
d arthritis, obstructive arterial disease). Episodes may be triggered by emotion
al factors or by unusual sensitivity to cold. Raynaud's disease is most common i
n women between the ages of 16 and 40 years and is seen much more frequently in
cold climates and during the winter months. The term "Raynaud's phenomenon," as
opposed to Raynaud's disease, is currently used to refer to localized, intermitt
ent episodes of vasoconstriction of small arteries of the feet and hands, causin
g color and temperature changes. It is generally unilateral and affects only one
or two digits. It is always associated with an underlying systemic disease. The
prognosis for Raynaud's disease varies: some patients slowly improve, some grow
slowly worse, and others show no change.
Clinical Manifestations
Coldness, pain, and pallor brought on by sudden vasoconstriction followed by cya
nosis followed by vasodilation and hyperemia (exaggerated reflow) with a resulta
nt red color (rubor); the progression follows the characteristic color change wh
ite, blue, red.
Numbness, tingling, and burning pain occur as color changes.
Involvement tends to be bilateral and symmetric.
Medical Management
The prime objective in controlling Raynaud's disease is avoiding the stimuli (co
ld, tobacco) that provoke vasoconstriction. Calcium-channel blockers may be effe
ctive in relieving symptoms. Sympathectomy (interruption of sympathetic nerves b
y removal of sympathetic ganglia or division of their branches) may be helpful.
Nursing Management
Instruct patient to avoid situations that may be upsetting, stressful, or unsafe
.
Reassure patient that serious complications (gangrene and amputation) are not us
ual.
Emphasize the importance of avoiding nicotine (smoking cessation without use of
nicotine patches); assist in finding support group.
Advise patient to minimize exposure to cold, remain indoors as much as possible,
and wear protective clothing when outdoors during cold weather.
Advise patient to handle sharp objects carefully to avoid injuring the fingers.
Caution about postural hypotension (results from drugs and is increased by alcoh
ol, exercise, and hot weather).

For more information, see Chapter 31 in Smeltzer and Bare: Brunner and Suddarth'
s Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia: Lippincott W
illiams & Wilkins, 2008.
Regional Enteritis (Crohn's Disease)
Regional enteritis is a subacute and chronic inflammation that extends through a
ll layers of the bowel wall. It commonly occurs in adolescents or young adults a

nd is seen frequently in the older population (50 to 80 years), but it can occur
at any time of life. Although the most common areas in which it is found are th
e distal ileum and colon, it can occur anywhere along the gastrointestinal tract
. Fistulas, fissures, and abscesses form as the inflammation extends into the pe
ritoneum. In advanced cases, the intestinal mucosa has a cobblestone-like appear
ance. As the disease advances, the bowel wall thickens and becomes fibrotic and
the intestinal lumen narrows. The clinical course and symptoms vary. In some pat
ients, periods of remission and exacerbation occur; in others, the disease follo
ws a fulminating course.
Clinical Manifestations
Onset of symptoms is usually insidious, with prominent abdominal pain and diarrh
ea unrelieved by defecation.
Diarrhea is present in 90% of patients.
Crampy pains occur after meals; the patient tends to limit intake, causing weigh
t loss, malnutrition, and secondary anemia.
Chronic diarrhea may occur, resulting in an uncomfortable person who is thin and
emaciated from inadequate food intake and constant fluid loss. The inflamed int
estine may perforate and form intra-abdominal and anal abscesses.
Fever and leukocytosis occur.
Abscesses, fistulas, and fissures are common.
Symptoms extend beyond the gastrointestinal tract to include joint problems (art
hritis), skin lesions (erythema nodosum), ocular disorders (conjunctivitis), and
oral ulcers.
Assessment and Diagnostic Methods
Barium study of the upper gastrointestinal tract is the most conclusive diagnost
ic aid; shows the classic "string sign" of the terminal ileum (constriction of a
segment of intestine) as well as cobblestone appearance, fistulas, and fissures
.
Proctosigmoidoscopic examination, computed tomography (CT) scan
Stool examination for occult blood and steatorrhea
Complete blood count (decreased Hgb and Hct), sedimentation rate (elevated), alb
umin, and protein levels (usually decreased due to malnutrition)
Medical Management
See Medical Management under Ulcerative Colitis for additional information.
Nursing Management
See Nursing Process: The Patient With Inflammatory Bowel Disease under Ulcerativ
e Colitis for additional information.

For more information, see Chapter 38 in Smeltzer and Bare: Brunner and Suddarth'
s Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia: Lippincott W
illiams & Wilkins, 2008.
Renal Failure, Acute
Renal failure results when the kidneys are unable to remove metabolic waste and
perform their regulatory functions. Acute renal failure (ARF) is a sudden and al

most complete loss of kidney function (decreased glomerular filtration rate [GFR
]). Three major categories of ARF are prerenal (hypoperfusion, as from volume de
pletion disorders, extreme vasodilation, or impaired cardiac performance); intra
renal (parenchymal damage to the glomeruli or kidney tubules, as from burns, cru
sh injuries, infections, transfusion reaction, or nephrotoxicity, which may lead
to acute tubular necrosis [ATN]); and postrenal (urinary tract obstruction, as
from calculi, tumor, strictures, prostatic hyper-plasia, or blood clots).
Clinical Stages
Initiation period: initial insult and oliguria
Oliguric period (urine volume less than 400 mL/d): uremic symptoms first appear
and hyperkalemia may develop
Diuresis period: gradual increase in urine output signaling beginning of glomeru
lar filtration's recovery. Laboratory values stabilize and start to decrease.
Recovery period: improving renal function (may take 3 to 12 months)
Clinical Manifestations
Critical illness and lethargy with persistent nausea, vomiting, and diarrhea
Skin and mucous membranes are dry; breath has odor of urine (uremic fetor).
Central nervous system manifestations: drowsiness, headache, muscle twitching, s
eizures
Urine output scanty to normal; urine may be bloody with low specific gravity
Steady rise in BUN may occur depending on degree of catabolism; serum creatinine
values increase with disease progression.
Hyperkalemia may lead to dysrhythmias and cardiac arrest.
Progressive acidosis, increase in serum phosphate concentrations, and low serum
calcium levels may be noted.
Anemia from blood loss due to uremic gastrointestinal lesions, reduced red blood
cell life-span, and reduced erythropoietin production
Assessment and Diagnostic Methods
BUN, creatinine, electrolyte analyses
Urine output measurements
Renal ultrasonography, CT and MRI scans
Gerontologic Considerations
With normal aging, changes in kidney function increase susceptibility to kidney
dysfunction and renal failure.
Alterations in renal blood flow, GFR, and renal clearance increase the risk for
drug-associated changes in renal function; administer all medications with cauti
on.
Because the older kidney is less able to respond to fluid and electrolyte change
s, renal problems need to be recognized and treated quickly to avoid kidney dama
ge.
When elderly patients must undergo extensive diagnostic tests or when new medica
tions (eg, diuretics) are added, take precautions to prevent dehydration leading
to ARF.
The mortality rate for ARF is slightly higher in elderly patients. Its etiology
includes prerenal causes (eg, dehydration) and intrarenal causes (eg, nephrotoxi
c agents, such as nonsteroidal anti-inflammatory drugs and contrast agents).
Diabetes mellitus increases the risk for contrast agent-induced renal failure be
cause of preexisting renal insufficiency and imposed fluid restriction.
Medical Management

Treatment objectives are to restore normal chemical balance and prevent complica
tions until renal tissues are repaired and renal function is restored. Possible
causes of damage are identified and treated.
Fluid balance is managed based on daily weight, serial measurements of central v
enous pressure, serum and urine concentrations, fluid losses, blood pressure, an
d clinical status. Fluid excesses are treated with mannitol, furosemide, or etha
crynic acid to initiate diuresis and prevent or minimize subsequent renal failur
e.
Blood flow is restored to the kidneys with the use of intravenous fluids, albumi
n, or blood product transfusions.
Dialysis (hemodialysis, hemofiltration, or peritoneal dialysis) is started to pr
event complications of uremia, including hyperkalemia, pericarditis, and seizure
s.
Ion exchange resins (orally or by retention enema)
Intravenous glucose and insulin or calcium glutamate as an emergency and tempora
ry measure to treat hyperkalemia
Sodium bicarbonate to elevate plasma pH
Parenteral erythropoietin (Epogen) to treat reduced erythropoietin production an
d prevent anemia
Shock and infection are treated if present.
Arterial blood gases are monitored when severe acidosis is present.
If respiratory problems develop, ventilatory measures are started.
Phosphate-binding agents such as aluminum hydroxide to control elevated serum ph
osphate concentrations
Dietary protein is limited to about 1 g/kg during oliguric phase to minimize pro
tein breakdown and to prevent accumulation of toxic end products.
Caloric requirements are met with high-carbohydrate feedings; parenteral nutriti
on (PN)
Foods and fluids containing potassium and phosphorus are restricted; potassium i
ntake is limited to 40 to 60 mEq/d. Sodium intake is restricted to 2 g/d.
Blood chemistries are evaluated to determine amount of replacement sodium, potas
sium, and water during oliguric phase.
After the diuretic phase, high-protein, high-calorie diet is given with gradual
resumption of activities.
NURSING PROCESS: The Patient with Acute Renal Failure
Assessment
Take nursing history and perform physical assessment, particularly for patients
at risk for ARF.
Monitor intake and output for indications of failing renal function.
Assess diagnostic test values and monitor patient's response to therapy regularl
y for signs of progress or deterioration.
Direct attention to patient's primary disorder; monitor for complications.
Diagnosis
NURSING DIAGNOSES
Fluid volume excess related to decreased urine output
Activity intolerance related to fatigue, toxins, and fluid buildup
Risk for impaired skin integrity related to edema, toxins, or impaired tissue pe
rfusion
Risk for infection related to intravenous lines or catheters or uremic toxins
Deficient knowledge regarding condition and its treatment
COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Pericarditis
Anemia
Bone disease
Hyperkalemia, or risk for hyperkalemia
Planning and Goals
Major goals include ideal fluid balance, body weight, and electrolyte levels, in
creased knowledge about condition and treatment, participation in activities as
tolerated, and absence of complications.
Nursing Interventions
Stay focused on the primary disorder, and monitor for complications.
Assist in emergency treatment of fluid and electrolyte imbalances.
Assess progress and response to treatment; provide physical and emotional suppor
t.
Keep family informed about condition and provide support.
MONITORING FLUID AND ELECTROLYTE LEVELS
Screen parenteral fluids, all oral intake, and all medications for hidden source
s of potassium.
Monitor cardiac function and musculoskeletal status for signs of hyperkalemia. M
onitor serum electrolyte levels and ECG for peaked T waves.
Pay careful attention to parenteral and oral intake, urine output, gastric and s
tool output, wound drainage and perspiration, changes in body weight, edema, dis
tention of jugular veins, changes in heart and breath sounds, and increasing dif
ficulty breathing.
Auscultate lungs for moist crackles.
Assess for generalized edema by examining presacral and pretibial areas regularl
y.
Report indicators of deteriorating fluid and electrolyte status immediately. Pre
pare for emergency treatment of hyperkalemia. Prepare patient for dialysis as in
dicated to correct fluid and electrolyte imbalances.
REDUCING METABOLIC RATE
Reduce exertion and metabolic rate during most acute stage with bed rest.
Prevent or treat fever and infection promptly.
PROMOTING PULMONARY FUNCTION
Assist patient to turn, cough, and take deep breaths frequently. Encourage and a
ssist patient to move and turn.
AVOIDING INFECTION
Practice asepsis when working with invasive lines and catheters.
Avoid using an indwelling catheter if possible.
PROVIDING SKIN CARE
Perform meticulous skin care.
Massage bony prominences, turn patient frequently, encourage bathing with tepid
water for comfort, and prevent skin breakdown.

PROVIDING SUPPORT DURING DIALYSIS


Assist, explain, and support patient and family; do not overlook psychological n
eeds and concerns.
Explain rationale of treatment to patient and family. Repeat explanations and cl
arify answers as needed.
Encourage family to touch and talk to patient during dialysis.
Continually assess patient for complications (eg, pericarditis, bone disease, an
emia) and their precipitating causes.

For more information, see Chapter 44 in Smeltzer and Bare: Brunner and Suddarth'
s Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia: Lippincott W
illiams & Wilkins, 2008.
Renal Failure, Chronic (End-Stage Renal Disease)
Chronic renal failure, or end-stage renal disease (ESRD), is a progressive, irre
versible deterioration in renal function in which the body's ability to maintain
metabolic and fluid and electrolyte balance fails, resulting in uremia or azote
mia. It may be caused by diabetes, hypertension, chronic glomerulonephritis, pye
lonephritis, hereditary lesions (eg, polycystic disease), vascular disorders, ob
struction of the urinary tract, infections, or toxic agents. Environmental and o
ccupational agents that have been implicated in chronic renal failure include le
ad, cadmium, mercury, and chromium. Dialysis or kidney transplantation eventuall
y becomes necessary for survival. The rate of decline and progression of ESRD is
related to the underlying disorder, urinary excretion of protein, and the prese
nce of hypertension.
Clinical Manifestations
Cardiovascular: hypertension, pitting edema (feet, hands, sacrum), periorbital e
dema, pericardial friction rub, engorged neck veins, pericarditis, pericardial e
ffusion, pericardial tamponade, hyperkalemia, hyperlipidemia
Integumentary: gray-bronze skin color, dry flaky skin, severe pruritus, ecchymos
is, purpura, thin brittle nails, coarse thinning hair
Pulmonary: crackles; thick, tenacious sputum; depressed cough reflex; pleuritic
pain; shortness of breath; tachypnea; Kussmaul-type respirations; uremic pneumon
itis ("uremic lung")
Gastrointestinal: ammonia odor to breath (fetor uremicus), metallic taste, mouth
ulcerations and bleeding, anorexia, nausea and vomiting, hiccups, constipation
or diarrhea, bleeding from gastrointestinal tract
Neurologic: weakness and fatigue, confusion, inability to concentrate, disorient
ation, tremors, seizures, asterixis, restlessness of legs, burning of soles of f
eet, behavior changes
Musculoskeletal: muscle cramps, loss of muscle strength, renal osteodystrophy, b
one pain, fractures, foot drop
Reproductive: amenorrhea, testicular atrophy, infertility, decreased libido
Hematologic: anemia, thrombocytopenia
Gerontologic Considerations
Diabetes mellitus and hypertension are the leading causes of chronic renal failu
re in elderly patients. The symptoms of other disorders (heart failure, dementia
) can mask the symptoms of renal disease and delay or prevent diagnosis and trea
tment. The patient often complains of signs and symptoms of nephrotic syndrome,

such as edema and proteinuria. The elderly patient may develop nonspecific signs
of disturbed renal function and fluid and electrolyte imbalances. Hemodialysis
and peritoneal dialysis have been used effectively in elderly patients. Concomit
ant disorders have made transplantation a less common treatment for the elderly.
Conservative management, including nutritional therapy, fluid control, and medi
cations (such as phosphate binders), may be used if dialysis or transplantation
is not suitable.
Medical Management
Goals of management are to retain kidney function and maintain homeostasis for a
s long as possible. All factors that contribute to ESRD and those that are rever
sible (eg, obstruction) are identified and treated.
Complications can be prevented or delayed by administering prescribed antihypert
ensives, cardiovascular agents, anticonvulsants, erythropoietin (Epogen), iron s
upplements, phosphate-binding agents (antacids), and calcium supplements.
Dietary intervention is needed, with careful regulation of protein intake, fluid
intake to balance fluid losses, and sodium intake, and with some restriction of
potassium.
Adequate intake of calories and vitamins is ensured. Calories are supplied with
carbohydrates and fats to prevent wasting.
Protein is restricted; protein must be of high biologic value (dairy products, e
ggs, meats).
Vitamin supplementation
Fluid allowance is 500 to 600 mL of fluid or more than the 24-hour urine output.
Pharmacologic Management
Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids or c
alcium carbonate; both must be given with food.
Hypertension is managed by intravascular volume control and antihypertensive med
ication.
Heart failure and pulmonary edema are treated with fluid restriction, low-sodium
diet, diuretics, inotropic agents (eg, digitalis or dobutamine), and dialysis.
Metabolic acidosis is treated, if necessary, with sodium bicarbonate supplements
or dialysis.
Hyperkalemia is treated with dialysis; medications are monitored for potassium c
ontent; patient is placed on potassium-restricted diet; Kayexalate is administer
ed as needed.
Patient is observed for early evidence of neurologic abnormalities (eg, slight t
witching, headache, delirium, or seizure activity).
The onset of seizures, type, duration, and general effect on patient are recorde
d; physician is notified immediately and patient is protected from injury with p
added side rails. Intravenous diazepam (Valium) or phenytoin (Dilantin) is admin
istered to control seizures.
Anemia is treated with recombinant human erythropoietin (Epogen); hematocrit is
monitored frequently.
Heparin is adjusted as necessary to prevent clotting of dialysis lines during tr
eatments.
Serum iron and transferrin levels are monitored to assess iron states (iron is n
ecessary for adequate response to erythropoietin).
Blood pressure and serum potassium levels are monitored.
Patient is referred to a dialysis and transplantation center early in the course
of progressive renal disease. Dialysis is initiated when patient cannot maintai
n a reasonable lifestyle with conservative treatment.
NURSING PROCESS: The Patient with Chronic Renal Failure

Assessment
Assess fluid status and help patient limit fluid intake to prescribed limit.
Assess nutritional status and address factors contributing to nutritional imbala
nce.
Assess patient's understanding about the condition and it treatment, explain ren
al function, and assist patient to identify ways to incorporate lifestyle change
s related to illness and treatment.
Assess factors contributing to fatigue.
Assess patient's and family's responses and reaction to illness and treatment. E
ncourage open discussion of concerns about changes produced by disease and treat
ment.
Assess for and monitor collaborative problems (eg, hyperkalemia, pericarditis, p
ericardial effusion and pericardial tamponade, hypertension, anemia, bone diseas
e, and metastatic calcifications).
Diagnosis
NURSING DIAGNOSES
Excess fluid volume related to decreased urine output, dietary excesses, and ret
ention of sodium and water
Imbalanced nutrition: Less than body requirements related to anorexia, nausea an
d vomiting, dietary restrictions, and altered oral mucous membranes
Deficient knowledge regarding condition and treatment regimen
Planning and Goals
Goals for the patient are fluid balance, optimal nutritional status, and knowled
ge about the disease and treatment regimen.
Nursing Interventions
MANAGING EXCESS FLUID VOLUME
Assess fluid status and identify potential sources of imbalance.
Monitor patient's progress and compliance with treatment regimen.
PROMOTING BALANCED NUTRITION
Implement a dietary program to ensure proper nutritional intake within the limit
s of the treatment regimen.
Provide a referral for a nutritional consultation.
Educating the Patient and Family
TEACHING PATIENTS SELF-CARE
Provide ongoing explanations and information to patient and family concerning ES
RD, treatment options, and potential complications.
Refer patient for dietary counseling and assist with nutritional planning.
Assist patient with an activity plan to conserve energy and maximize activity to
lerance.
Teach patient and family what problems to report: signs of worsening renal failu
re, hyperkalemia, access problems.
Provide medication teaching and show patient undergoing hemodialysis how to asse

ss vascular access for patency and precautions to take (no venipunctures or bloo
d pressure on access arm).
CONTINUING CARE
Provide assistance and emotional support to patient and family in dealing with d
ialysis and its long-term implications.
Stress the importance of follow-up examinations and treatment.
Refer patient to home care nurse for continued monitoring and support.
Evaluation
EXPECTED PATIENT OUTCOMES
Demonstrates fluid balance
Maintains adequate nutritional intake
Tolerates activities of daily living
Experiences absence of complications