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Adult health2 > Acute and Chronic Renal Failure > Flashcards

Acute and Chronic Renal Failure Flashcards

1
Q

What is acute renal failure?

A

a slight deterioration in kidney function; severe impairment

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2
Q

What is azotemia?

A

an accumulation of nitrogenous waste products in the blood

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3
Q

what is chronic kidney disease?

A

progressive irreversible loss of kidney function

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4
Q

What is dialysis?

A

The movement of fluid and molecules across a semi-permeable membrane from one compartment to another

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5
Q

What is oliguria?

A

<400 ml of urine output per day

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6
Q

What is hemodialysis?

A

The use of an artificial membrane as the semipermeable membrane and is in contact with the patients blood

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7
Q

What is peritoneal dialysis?

A

The use of the peritoneal membrane as a semi-permeable membrane

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8
Q

What is end stage renal disease?

A

occurs when the GFR is <15ml/minute and renal replacement therapy (RRT) is needed

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9
Q

What is acute renal failure or acute kidney injury?

A

rapid loss of renal function with progressive azotemia
uremia condition which renal function declines to the point that symptoms develop in multiple body systems
fluid and electrolyte status changes
oliguria <400ml/urine per day
develops over hours to days with progressive elevation of BUN, creatinine and potassium
follows prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent

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10
Q

What is uremia?

A

a condition which renal function declines to the point that symptoms develop in multiple body system

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11
Q

What are causes of acute renal failure or acute kidney injury?

A

pre-renal
intra-renal
post-renal

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12
Q

What could be a pre-renal cause of ARF or AKI?

A 
hypovolemia 
decreased cardiac output 
decreased peripheral vascular resistance 
decreased renal vascular blood flow 
could be an obstruction
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13
Q

What could be a intra-renal cause of ARF or AKI?

A 
prolonged pre-renal ischemia 
nephrotoxic injury 
interstitial nephritis 
acute glomerulonephritis 
could be trauma or polynephritis 
thrombotic disorders 
toxemia of pregnancy
malignant hypertension 
SLE
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14
Q

What could be a post-renal cause of ARF or AKI?

A 
BPH 
Bladder and prostate Ca
Calculi formation 
Neuromuscular disorders 
Spinal cord disease 
Strictures and trauma
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15
Q

What are the phases of ARF?

A

Initiating
Oliguric
Diuretic phase
Recovery phase

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16
Q

What is the Initiating phase of ARF?

A

When it is just starting

Asymptomatic at first and then progresses quickly

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17
Q

What is the Oliguric phase of ARF?

A 
Decreased urine output
fluid volume overload (edema)
metabolic acidosis 
   kidneys cannot synthesize ammonia or excrete   acid products of metabolism 
increased sodium secretion
   damaged tubules cannot conserve sodium 
   sodium goes back in to the blood 
      put them on the cardiac monitors 
hyperkalemia 
   kidneys excrete potassium
     put them on Kayexellate (Assess bowel sounds)
Waste product accumulation
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18
Q

What is the diuretic phase of ARF?

A 
gradual increase of daily urine output 
  1-3L/day 
  Up to 3-5L/day
regained ability to excrete wastes but not concentrate urine
hypovolemia and hypotension can occur
electrolyte loss
may last 1-3 weeks
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19
Q

What is the recovery phase of ARF?

A

begins when GFR increases
BUN and Creatinine stabilize and then decrease
May take up to 12 months to stabilize

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20
Q

What are the diagnostic studies done to diagnose ARF?

A 
History and physical exam
BUN
Creatinine 
Urine Analysis
Renal ultrasound
Renal scan 
CT 
Renal biopsy
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21
Q

What is the clinical management for someone with ARF?

A 
eliminate the cause 
manage signs and symptoms 
prevent complications while kidneys recover
volume assessment 
diuretics (to get rid of the excess potassium)
monitor/restrict fluid intake
monitor for hyperkalemia 
dialysis
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22
Q

What is the treatment for hyperkalemia?

A

regular insulin IV
Potassium moves into the cells when insulin is given
sodium bicarbonate
can correct acidosis and causes shift of K into the cell
Calcium gluconate
raises the threshold for excitation, that result in dysrhythmias
Dialysis
can bring K levels down to normal within 30min-2hours
Kayexalate
cation exchange resin is given PO or by retention enema
Dietary restriction
daily K intake is limited to 40mEq

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23
Q

What are the indications for dialysis in ARF?

A 
volume overload resulting in compromised cardiac output and/or pulmonary status 
elevated K levels with ECG changes 
Metabolic acidosis 
BUN>120
Significant change in mental status 
Pericarditis, pericardial effusion or cardiac tamponade 
temporary
would want a central catheter device
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24
Q

What type of diet should a patient with ARF be on?

A

low potassium
protein
fluid restriction

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25
Q

What is the nursing management for ARF?

A 
Health promotion 
  cessation of alcohol use 
  diet
  lifestyle changes
  lose weight 
  take medication
Acute intervention
  give a bolus of fluid 
  give a diuretic if not on dialysis 
  put on heart monitor 
  fix the problem
Ambulatory and home care
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26
Q

What are the outcomes you are looking for with a patient with ARF?

A

regain and maintain normal fluid and electrolyte balance
comply with treatment regimen
experience no infectious complications
have complete recovery

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27
Q

What is chronic kidney disease?

A

progressive, irreversible loss of kidney function
presence of kidney damage
GRF<15ml/min

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28
Q

What are the clinical manifestations of chronic kidney disease that relate to the urinary system?

A

decreased urine output

edema

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29
Q

What are the clinical manifestations of chronic kidney disease that relate to metabolics?

A 
acidosis 
carbohydrate intolerance 
hyperlipidemia 
nutritional deficiencies 
gout
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30
Q

What are the clinical manifestations of chronic kidney disease that relate to electrolyte imbalances?

A

high potassium
high BUN
high creatinine
anemia

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31
Q

what are the clinical manifestations of chronic kidney disease that relate to hematologic studies?

A

decrease hemoglobin and hematocrit
anemia
bleeding
infection

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32
Q

What are the clinical manifestations of chronic kidney disease that relate to the reproductive system?

A 
difficulty conceiving 
amenorrhea 
infertility 
sexual dysfunction 
azoospermia
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33
Q

What are the clinical manifestations of chronic kidney disease that relate to the endocrine system?

A

diabetes
hyperparathyroidism
thyroid abnormalities

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34
Q

What are the clinical manifestations of chronic kidney disease that relate to the cardiovascular system?

A 
dysrhythmias - hypertension 
heart failure 
atherosclerotic heart disease 
pericarditis 
myocardiopathy
pericardial effusion
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35
Q

What are the clinical manifestations of chronic kidney disease that relate to the respiratory system?

A 
congestive heart failure 
shortness of breath 
uremic lung 
pulmonary edema 
uremic pleuritis 
pneumonia 
depressed cough reflex
36
Q

What are the clinical manifestations of chronic kidney disease that relate to the GI system?

A 
low motility 
anorexia 
nausea/vomiting 
uremic fetor
gastrointestinal bleeding 
peptic ulcer 
stomatitis 
gastritis
37
Q

What are the clinical manifestations of chronic kidney disease that relate to the neurological system?

A 
pain
confusion 
lethargy
somulance 
fatigue 
headache 
sleep disturbances 
muscular irritability 
seizures 
coma
38
Q

What are the clinical manifestations of chronic kidney disease that relate to the musculoskeletal system?

A

weakness

39
Q

What are the clinical manifestations of chronic kidney disease that relate to the integumentary system?

A 
pallor 
pigmentations changes 
pruritus 
ecchymosis 
excoriations 
CaPO4 deposition 
uremic frost 
dry, scaly skin
40
Q

What are the clinical manifestations of chronic kidney disease that relate to the psyche?

A

denial
anxiety
depression
psychosis

41
Q

What are the clinical manifestations of chronic kidney disease that relate to the ocular

A

hypertensive retinopathy

42
Q

What are the clinical manifestations of chronic kidney disease that relate to peripheral neuropathy?

A

paresthesias
motor weakness
restless legs syndrome

43
Q

What are the electrolyte imbalances when related to chronic kidney disease?

A 
Potassium
Sodium 
Calcium and phosphate 
Magnesium
Metabolic acidosis
44
Q

What are the diagnostic studies done for chronic kidney disease?

A

urine analysis for protein and microalbuminuria
GFR
Serum Creatinine

45
Q

What is chronic kidney disease?

A

involves progressive, irreversible loss of kidney function
defined as the presence of kidney damage (pathologic abnormalities, markers of damage - blood, urine, imaging tests)
Glomerular filtration rate (GFR)
<60mL/min for 3 months or longer

46
Q

What does the GFR have to do in relation to chronic kidney disease?

A

disease staging is based on the decrease in GFR
Normal GFR 125mL/min, which is reflected by urine creatinine clearance
The last stage of kidney failure
end-stage renal disease occurs when GFR <15mL/min

47
Q

What are the leading causes of end-stage renal disease?

A

diabetes

hypertension

48
Q

What is the appropriate diet for patients receiving hemodialysis?

A 
low potassium (apple juice)
high protein (scrambled eggs)
avoid milk of magnesia and fleet enema if calcium and phosphate levels are high
49
Q

In the nursing process for a patient with chronic kidney disease what does the nursing assessment entail?

A

Complete history of any existing renal disease, family history, Long-term health problems, Dietary habits. Because many drugs are potentially nephrotoxic, the nurse should ask the patient about both current and past use of prescription and over-the-counter drugs and herbal preparations. Medications of concern include antacids, NSAIDs, decongestants, and antihistamines.
If you don’t know what drugs filter out then call the dialysis nurse
If patient becomes hypertensive then slow down the dialysis (the first thing you do is look at the monitor)

50
Q

In the nursing process for a patient with chronic kidney disease what are the nursing priorities/diagnoses?

A 
Excess fluid volume
Risk for injury 
Imbalanced nutrition: less than body requirements
Grieving 
Risk for infection
51
Q

In the nursing process for a patient with chronic kidney disease what dose planning entail?

A

Overall goals: Demonstrate knowledge and ability to comply with therapeutic regimen. Participate in decision making. Demonstrate effective coping strategies. Continue with activities of daily living within psychologic limitations.

52
Q

In the nursing process for a patient with chronic kidney disease what are the type of interventions that are implemented?

A

Health promotion: Identify individuals at risk for CKD- History of renal disease-Hypertension-Diabetes mellitus-Repeated urinary tract infection-Regular checkups and changes in urinary appearance, frequency, and volume should be reported. Individuals with diabetes need to have their urine checked for microalbuminuria if routine urinalysis is negative for protein. Individuals identified as at risk need to take measures to prevent or delay the progression of CKD, but even more important to reduce the risk for cardiovascular disease. These include glycemic control for patients with diabetes, optimizing BP control, and lifestyle modifications such as smoking cessation.
Acute Intervention: Daily weight, Daily BPs, Identify signs and symptoms of fluid overload, Identify signs and symptoms of hyperkalemia, Strict dietary adherence, Medication education and Motivate patients in management of their disease.
Continued Interventions: When conservative therapy is no longer effective, HD, PD, and transplantation are treatment options. Patient/family need clear explanation of dialysis and transplantation.

53
Q

n the nursing process for a patient with chronic kidney disease what type of evaluations can we expect?

A 
Maintenance of ideal body weight, 
Acceptance of chronic disease, 
No infection,
 No edema, 
Hematocrit, hemoglobin, and serum albumin levels in acceptable range.
54
Q

What are the goals of conservative treatment for patients with chronic renal disease?

A

preserve existing renal function
treat clinical manifestations
prevent complications
provide patient comfort

55
Q

With a patient with chronic kidney disease how do you pharmacologically treat hyperkalemia

A

IV insulin: IV glucose to manage hypoglycemia. IV 10% calcium gluconate. Sodium polystyrene sulfonate (Kayexalate),Cation-exchange resin, Resin in bowel exchanges potassium for sodium. Sodium polystyrene sulfonate (Kayexalate) is commonly used to lower potassium levels in stage 4 and can be administered on an outpatient basis. Tell the patient to expect some diarrhea because this preparation contains sorbitol, a sugar alcohol that has an osmotic laxative action and ensures evacuation of potassium from the bowel.

56
Q

With a patient with chronic kidney disease how do you pharmacologically treat hypertension?

A

Weight loss, Lifestyle changes, Diet recommendations, Sodium and fluid restriction. It is recommended that the target BP should be <130/80 mm Hg for patients with CKD and 125/75 for patients with significant proteinuria. The BP should be measured periodically in supine, sitting, and standing positions to effectively monitor the effects of antihypertensive drugs. Also drugs to be used are: diuretics, calcium channel blockers, ACE inhibitors and ARB agents.

57
Q

With a patient with chronic kidney disease how do you pharmacologically treat renal osteodystrophy?

A

CKD-MBD: Phosphate intake restricted to <1000 mg/day. Interventions for CKD mineral and bone disorder include limiting dietary phosphorus, administering phosphate binders, supplementing vitamin D, and controlling hyperparathyroidism.CKD-MBD: Phosphate binders-Calcium carbonate (Caltrate)-Binds phosphate in bowel and excretes. Sevelamer hydrochloride (Renagel)-Lowers cholesterol and LDLs. Another example of calcium-based binders is calcium acetate (PhosLo). Should be administered with each meal.Side effect: Constipation. Supplementing vitamin D Calcitriol (Rocaltrol). Serum phosphate level must be lowered before calcium or vitamin D is administered. Active vitamin D is available as oral or intravenous calcitriol (Rocaltrol, Calcijex), intravenous paricalcitol (Zemplar), and oral or intravenous doxercalciferol (Hectoral), and can reduce elevated levels of PTH. Controlling secondary hyperparathyroidism: Calcimimetic agents, Cinacalcet (Sensipar), ↑ sensitivity of calcium receptors in parathyroid glands, Subtotal parathyroidectomy.

58
Q

With a patient with chronic kidney disease how do you pharmacologically treat anemia?

A

Erythropoietin: Epoetin alfa (Epogen, Procrit), Administered IV or subcutaneously, Increased hemoglobin and hematocrit in 2 to 3 weeks. Side effect: Hypertension. Darbepoetin alfa (Aranesp) is longer acting and can be administered weekly or biweekly. High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when EPO is administered to a target hemoglobin of >12 g/dL. Iron supplements: If plasma ferritin <100 ng/mL, Side effects: Gastric irritation, constipation, May make stool dark in color. Another side effect of EPO therapy is the development of iron deficiency resulting from increased demand for iron to support erythropoiesis. Orally administered iron should not be taken at the same time as phosphate binders because calcium binds the iron, preventing its absorption. Folic acid supplements: Needed for RBC formation, Removed by dialysis and Avoid blood transfusions. Undesirable effects of transfusions include suppression of erythropoiesis as a result of a decrease in the hypoxic stimulus and the possibility of iron overload, because each unit of blood contains about 250 mg of iron.

59
Q

With a patient with chronic kidney disease how do you pharmacologically treat dyslipidemia?

A

Goal: Lowering LDL below 100 mg/dL, Triglyceride level below 200 mg/dL. Statins: HMG-CoA reductase inhibitors and Most effective for lowering LDL. Evidence supports the use of statins in patients with CKD (especially diabetics) not yet on dialysis. The effectiveness of statins in patients on dialysis is still being studied. Fibrates (fibric acid derivatives), such as gemfibrozil (Lopid), are used to lower triglyceride levels and can also increase HDLs.

60
Q

With a patient with chronic kidney disease how do you pharmacologically treat complications?

A

Drug toxicity: Digitalis, Antibiotics, Pain medication (Demerol, NSAIDs). Delayed and decreased elimination lead to accumulation of drugs and the potential for drug toxicity. Drug doses and frequency of administration must be adjusted on the basis of severity of the kidney disease.

61
Q

What is dialysis?

A

movement of fluid and molecules across a semi-permeable membrane from one compartment to another
used to correct f/e imbalances and remove waste products
Two types
peritoneal dialysis (PD)
hemodialysis (HD)

62
Q

What is peritoneal dialysis?

A

peritoneal access is obtained through a catheter in the anterior abdominal wall
dialysis solution is put into the peritoneal space
inflow (in)
dwell (staying in there and mixing)
drain (out)

63
Q

What types of peritoneal dialysis are there?

A 
automated peritoneal dialysis (APD)
  done at night 
  most popular form of PD
continuous ambulatory peritoneal dialysis (CAPD)
  done during the day 
  4 or more exchanges a day
64
Q

What are complications of peritoneal dialysis?

A 
exit site infection
peritonitis 
hernias 
low back problems 
bleeding 
pulmonary complications 
protein loss
65
Q

What are the nursing interventions/ patient responsibilities for a patient with chronic renal failure receiving peritoneal dialysis?

A 
daily weight 
strict aseptic technique 
hand washing 
monitoring I/O (make sure you get enough fluid back)
Instill in 10-15 minutes 
give them a private room
66
Q

What does the dialysate (dialysis solution) for PD contain?

A

Electrolytes in an equal concentration to that of the blood
Sodium in a higher concentration than in blood
Dextrose in a higher concentration than in the blood
need to do extra blood glucose testing

67
Q

What do you have to look at with hemodialysis?

A

obtaining vascular access can present challenges
3 times a week for 3-4 hours
you have to assess vitals, weight, heart and lung sounds and the presence of edema prior to treatment

68
Q

What are the types of vascular access for hemodialysis?

A

shunts
arteriouvenous grafts
AV fistula
Temporary vascular access

69
Q

What are complications of hemodialysis?

A

hypotension
muscle cramps
blood loss
hepatitis

70
Q

What is an arteriovenous fistula?

A

it is created by anastomosing an artery and vein

71
Q

What are the tyoe of vascular access used in patients with chronic renal failure?

A

arteriovenous graft (AVG)
synthetic tube surgically placed to connect a vein and an artery
Arteriovenous Fistula (AVF)
surgical anastomosis of a vein and artery (less likely to clot than AVG, longer to mature)
Central venous line (CVL)
Never Use for fluids, meds, blood draws

Don’t do blood pressures or blood draws in that arm

72
Q

What drugs shoul a patient avoid if they are doing dialysis?

A 
antacids containing magnesium
laxatives containing magnesium or phosphorus 
phenytoin 
protein bound drugs (give lower doses)
glucophage - risk of lactic acidosis
73
Q

What should a patient be cautious about taking if they are undergoing dialysis?

A

heparin is used during dialysis - no invasive procedures for 4-6 hours after dialysis
Nitrates - can cause fatal hypotension

74
Q

What are the advantages of kidney transplant compared to dialysis?

A

reverses many of the pathophysiologic changes associated with renal failure
eliminates dependence on dialysis
less expensive than dialysis after the first year

75
Q

How is a recipient selected for kidney transplantation?

A

candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers

76
Q

What are contraindications to transplantation when it comes to the recipient of a kidney transplant?

A 
disseminated malignancies 
untreated cardiac disease 
chronic respiratory failure 
extensive vascular disease 
chronic infection 
unresolved psychosocial disorders
77
Q

How do you find donors when it comes to kidney transplantation?

A 
compatible blood type deceased donors 
blood relatives 
emotionally related living donors 
altruistic living donors 
paired organ donation
78
Q

What is the surgical procedure for a living donor in kidney transplantation

A

nephrectomy performed by a urologist or transplant surgeon
begins an hour or two before the recipient’s surgery is started
rib may need to be removed for adequate view
takes about 3 hours
most commonly done laproscopically

79
Q

What is the surgical procedure for a kidney transplant recipient?

A

usually place extraperitoneally in the iliac fossa (the right iliac fossa is preferred)
before incision - a cath is place in bladder and an antibiotic solution is instilled (decreases risk for infection)
crescent shape incision
donor artery anastomosed to recipient internal/external iliac artery
donor vein anastomosed to recipient external iliac vein
when anastomoses complete clamps released and blood flow reestablished
urine may begin to flow, or diuretic may be given
surgery takes 3 to 4 hours

80
Q

What are the goals of immunosuppressive therapy in kidney transplantation?

A

adequately suppress the immune response

maintain sufficient immunity to prevent overwhelming infection

81
Q

In kidney transplantation what are the different types of rejection?

A

hyperacute (antibody-mediated, humoral) rejection
occurs minutes to hours after transplantation
Acute rejection
occurs days to months
Chronic rejection
process that occurs over months or years and is irreversible

82
Q

WIth kidney transplantation complications what are the most common types of infections

A 
Most common infections observed in the first month
  Pneumonia 
  Wound infections
  IV line and drain infections
Fungal infections
  Candida
  Cryptococcus 
  Aspergillus
  Pneumocystis jiroveci
83
Q

In kidney transplantation what are the complications having to do with cardiovascular disease and malignancies

A

Cardiovascular disease
Transplant recipients have increased incidence of atherosclerotic vascular disease.
Immunosuppressant can worsen hypertension and hyperlipidemia.
Adhere to antihypertensive regimen.
Malignancies
Primary cause is immunosuppressive therapy.
Regular screening is important preventive care.

84
Q

In kidney transplantation what type of complications signal a reoccurrence of the original renal disease

A

Glomerulonephritis, IgA nephropathy

Diabetes mellitus, Focal segmental sclerosis

85
Q

What are the corticosteroid- related complications related to kidney transplantation?

A

Aseptic necrosis of the hips, knees, and other joints, Peptic ulcer disease, Glucose intolerance and diabetes, Dyslipidemia
Cataracts, Increased incidence of infection and malignancy,
Close monitoring of side effects

86
Q

What are the evaluations in nursing management for kidney transplants?

A 
Maintenance of ideal body weight
Acceptance of chronic disease
No infection
No edema
Hematocrit, hemoglobin, and serum albumin levels  in acceptable range

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