Acute and Chronic Renal Failure Flashcards
What is acute renal failure?
a slight deterioration in kidney function; severe impairment
What is azotemia?
an accumulation of nitrogenous waste products in the blood
what is chronic kidney disease?
progressive irreversible loss of kidney function
What is dialysis?
The movement of fluid and molecules across a semi-permeable membrane from one compartment to another
What is oliguria?
<400 ml of urine output per day
What is hemodialysis?
The use of an artificial membrane as the semipermeable membrane and is in contact with the patients blood
What is peritoneal dialysis?
The use of the peritoneal membrane as a semi-permeable membrane
What is end stage renal disease?
occurs when the GFR is <15ml/minute and renal replacement therapy (RRT) is needed
What is acute renal failure or acute kidney injury?
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
What is uremia?
a condition which renal function declines to the point that symptoms develop in multiple body system
What are causes of acute renal failure or acute kidney injury?
pre-renal
intra-renal
post-renal
What could be a pre-renal cause of ARF or AKI?
hypovolemia decreased cardiac output decreased peripheral vascular resistance decreased renal vascular blood flow could be an obstruction
What could be a intra-renal cause of ARF or AKI?
prolonged pre-renal ischemia nephrotoxic injury interstitial nephritis acute glomerulonephritis could be trauma or polynephritis thrombotic disorders toxemia of pregnancy malignant hypertension SLE
What could be a post-renal cause of ARF or AKI?
BPH Bladder and prostate Ca Calculi formation Neuromuscular disorders Spinal cord disease Strictures and trauma
What are the phases of ARF?
Initiating
Oliguric
Diuretic phase
Recovery phase
What is the Initiating phase of ARF?
When it is just starting
Asymptomatic at first and then progresses quickly
What is the Oliguric phase of ARF?
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 accumulationWhat is the diuretic phase of ARF?
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
What is the recovery phase of ARF?
begins when GFR increases
BUN and Creatinine stabilize and then decrease
May take up to 12 months to stabilize
What are the diagnostic studies done to diagnose ARF?
History and physical exam BUN Creatinine Urine Analysis Renal ultrasound Renal scan CT Renal biopsy
What is the clinical management for someone with ARF?
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
What is the treatment for hyperkalemia?
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
What are the indications for dialysis in ARF?
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
What type of diet should a patient with ARF be on?
low potassium
protein
fluid restriction
What is the nursing management for ARF?
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
What are the outcomes you are looking for with a patient with ARF?
regain and maintain normal fluid and electrolyte balance
comply with treatment regimen
experience no infectious complications
have complete recovery
What is chronic kidney disease?
progressive, irreversible loss of kidney function
presence of kidney damage
GRF<15ml/min
What are the clinical manifestations of chronic kidney disease that relate to the urinary system?
decreased urine output
edema
What are the clinical manifestations of chronic kidney disease that relate to metabolics?
acidosis carbohydrate intolerance hyperlipidemia nutritional deficiencies gout
What are the clinical manifestations of chronic kidney disease that relate to electrolyte imbalances?
high potassium
high BUN
high creatinine
anemia
what are the clinical manifestations of chronic kidney disease that relate to hematologic studies?
decrease hemoglobin and hematocrit
anemia
bleeding
infection
What are the clinical manifestations of chronic kidney disease that relate to the reproductive system?
difficulty conceiving amenorrhea infertility sexual dysfunction azoospermia
What are the clinical manifestations of chronic kidney disease that relate to the endocrine system?
diabetes
hyperparathyroidism
thyroid abnormalities
What are the clinical manifestations of chronic kidney disease that relate to the cardiovascular system?
dysrhythmias - hypertension heart failure atherosclerotic heart disease pericarditis myocardiopathy pericardial effusion
What are the clinical manifestations of chronic kidney disease that relate to the respiratory system?
congestive heart failure shortness of breath uremic lung pulmonary edema uremic pleuritis pneumonia depressed cough reflex
What are the clinical manifestations of chronic kidney disease that relate to the GI system?
low motility anorexia nausea/vomiting uremic fetor gastrointestinal bleeding peptic ulcer stomatitis gastritis
What are the clinical manifestations of chronic kidney disease that relate to the neurological system?
pain confusion lethargy somulance fatigue headache sleep disturbances muscular irritability seizures coma
What are the clinical manifestations of chronic kidney disease that relate to the musculoskeletal system?
weakness
What are the clinical manifestations of chronic kidney disease that relate to the integumentary system?
pallor pigmentations changes pruritus ecchymosis excoriations CaPO4 deposition uremic frost dry, scaly skin
What are the clinical manifestations of chronic kidney disease that relate to the psyche?
denial
anxiety
depression
psychosis
What are the clinical manifestations of chronic kidney disease that relate to the ocular
hypertensive retinopathy
What are the clinical manifestations of chronic kidney disease that relate to peripheral neuropathy?
paresthesias
motor weakness
restless legs syndrome
What are the electrolyte imbalances when related to chronic kidney disease?
Potassium Sodium Calcium and phosphate Magnesium Metabolic acidosis
What are the diagnostic studies done for chronic kidney disease?
urine analysis for protein and microalbuminuria
GFR
Serum Creatinine
What is chronic kidney disease?
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
What does the GFR have to do in relation to chronic kidney disease?
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
What are the leading causes of end-stage renal disease?
diabetes
hypertension
What is the appropriate diet for patients receiving hemodialysis?
low potassium (apple juice) high protein (scrambled eggs) avoid milk of magnesia and fleet enema if calcium and phosphate levels are high
In the nursing process for a patient with chronic kidney disease what does the nursing assessment entail?
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)
In the nursing process for a patient with chronic kidney disease what are the nursing priorities/diagnoses?
Excess fluid volume Risk for injury Imbalanced nutrition: less than body requirements Grieving Risk for infection
In the nursing process for a patient with chronic kidney disease what dose planning entail?
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.
In the nursing process for a patient with chronic kidney disease what are the type of interventions that are implemented?
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.
n the nursing process for a patient with chronic kidney disease what type of evaluations can we expect?
Maintenance of ideal body weight, Acceptance of chronic disease, No infection, No edema, Hematocrit, hemoglobin, and serum albumin levels in acceptable range.
What are the goals of conservative treatment for patients with chronic renal disease?
preserve existing renal function
treat clinical manifestations
prevent complications
provide patient comfort
With a patient with chronic kidney disease how do you pharmacologically treat hyperkalemia
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.
With a patient with chronic kidney disease how do you pharmacologically treat hypertension?
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.
With a patient with chronic kidney disease how do you pharmacologically treat renal osteodystrophy?
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.
With a patient with chronic kidney disease how do you pharmacologically treat anemia?
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.
With a patient with chronic kidney disease how do you pharmacologically treat dyslipidemia?
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.
With a patient with chronic kidney disease how do you pharmacologically treat complications?
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.
What is dialysis?
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)
What is peritoneal dialysis?
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)
What types of peritoneal dialysis are there?
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
What are complications of peritoneal dialysis?
exit site infection peritonitis hernias low back problems bleeding pulmonary complications protein loss
What are the nursing interventions/ patient responsibilities for a patient with chronic renal failure receiving peritoneal dialysis?
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
What does the dialysate (dialysis solution) for PD contain?
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
What do you have to look at with hemodialysis?
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
What are the types of vascular access for hemodialysis?
shunts
arteriouvenous grafts
AV fistula
Temporary vascular access
What are complications of hemodialysis?
hypotension
muscle cramps
blood loss
hepatitis
What is an arteriovenous fistula?
it is created by anastomosing an artery and vein
What are the tyoe of vascular access used in patients with chronic renal failure?
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
What drugs shoul a patient avoid if they are doing dialysis?
antacids containing magnesium laxatives containing magnesium or phosphorus phenytoin protein bound drugs (give lower doses) glucophage - risk of lactic acidosis
What should a patient be cautious about taking if they are undergoing dialysis?
heparin is used during dialysis - no invasive procedures for 4-6 hours after dialysis
Nitrates - can cause fatal hypotension
What are the advantages of kidney transplant compared to dialysis?
reverses many of the pathophysiologic changes associated with renal failure
eliminates dependence on dialysis
less expensive than dialysis after the first year
How is a recipient selected for kidney transplantation?
candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers
What are contraindications to transplantation when it comes to the recipient of a kidney transplant?
disseminated malignancies untreated cardiac disease chronic respiratory failure extensive vascular disease chronic infection unresolved psychosocial disorders
How do you find donors when it comes to kidney transplantation?
compatible blood type deceased donors blood relatives emotionally related living donors altruistic living donors paired organ donation
What is the surgical procedure for a living donor in kidney transplantation
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
What is the surgical procedure for a kidney transplant recipient?
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
What are the goals of immunosuppressive therapy in kidney transplantation?
adequately suppress the immune response
maintain sufficient immunity to prevent overwhelming infection
In kidney transplantation what are the different types of rejection?
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
WIth kidney transplantation complications what are the most common types of infections
Most common infections observed in the first month Pneumonia Wound infections IV line and drain infections Fungal infections Candida Cryptococcus Aspergillus Pneumocystis jiroveci
In kidney transplantation what are the complications having to do with cardiovascular disease and malignancies
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.
In kidney transplantation what type of complications signal a reoccurrence of the original renal disease
Glomerulonephritis, IgA nephropathy
Diabetes mellitus, Focal segmental sclerosis
What are the corticosteroid- related complications related to kidney transplantation?
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
What are the evaluations in nursing management for kidney transplants?
Maintenance of ideal body weight Acceptance of chronic disease No infection No edema Hematocrit, hemoglobin, and serum albumin levels in acceptable range
