Adult Renal Flashcards
How do you assess the patency of a arteriovenous (AV) graft in the forearm ?
auscultate the site for a bruit
What are the functions of the kidney ?
- regulate the volume and composition of extracellular fluid
- excrete waste
- control BP
- produce erythropoietin (building block of RBCs, decreased kidney function can lead to anemia)
- activate vitamin D (important to absorb calcium)
- regulate acid-base balance
What is Azotemia ?
loss of renal function/ increase of metabolic waste products
- aka buildup of waste products
What is Oliguria ?
decrease in urinary output
- < 400 mL/day
How suddenly does acute renal failure (injury) occur ?
develops over hours/days
- with elevation of BUN & serum Creatinine
What will the lab values in acute renal failure look like ?
- decreased glomerular filtration rate
- increased serum creatinine
- increased creatinine clearance (24 hr urine)
- increased BUN
What is the best indicator of renal failure ?
serum creatinine
- represents how much irreversible damage has already occured
What lab value do we use to diagnose chronic kidney disease/ implementation of dialysis ?
glomerular filtration rate
What is the best indicator of renal function ?
creatinine clearance (24 hr urine)
- represents the degree of seriousness and how well the kidneys are functioning
What does the BUN measure ?
the amount of urea nitrogen in the blood
- represents an indirect measurement of renal function and the GFR
What is the best indicator for fluid balance ?
daily weights
What does Prerenal causes of acute renal failure mean ?
factors that reduce the systemic circulation/perfusion
- heart and blood vessels
- anything that causes decreased perfusion of kidneys and blood flow
- causing reduction in renal blood flow and leading to hypotension/hypovolema
- Ex.) severe blood loss, low BP, sepsis, injury, dehydration,
What does Intrarenal causes of acute renal failure mean ?
conditions that cause direct damage to the renal tissue
- kidney
- resulting in impaired nephron function and tubular necrosis
- problem with the kidney itself
- Ex.) med toxicity ischemia, prolonged dehydration/sepsis, nephrotoxic meds (NSAIDS, metformin, vancomycin)
What does Postrenal causes of acute kidney failure mean ?
causes involve mechanical obstruction of urinary outflow
- ureters and bladder
- some blockage or injury to downstream flow of kidney
- body detects that the urine isn’t going down so the kidneys will just stop producing that waste
- Ex.) prostatic hypertrophy (enlarged prostate which is very common in older men
What are the 4 phases of Acute Renal Injury (ARI) ?
- initiating (whatever caused the injury)
- oliguric (kidneys have no perfusion so they stop/decrease urine production until there is enough perfusion)
- diuretic (tx which is giving fluids or maybe diuretic so kidneys start working again)
- recovery (can be months and its when the kidneys and labs stabilize)
How long does the oliguric phase last of ARI ?
1-7 days
What are some characteristics of the Oliguric phase of ARI ?
- <400 mL/day of urine
- metabolic acidosis (kidneys can’t excrete acid products of metabolism)
- hyperkalemia (kidneys can’t excrete potassium) and hyponatremia
- increased BUN and creatinine
- hematologic disorders (anemia)
- fatigue and malaise (sick feeling)
What are some characteristics of the Diuretic phase of ARI ?
- gradual increase in urine output (1-3 L/day to 3-5 L/day)
- hypovolemia, dehydration
- hypotension
- nephrons are still not fully functioning
- uremia may still be severe, as seen in labs (may look bad for about a few days but should get better gradually)
- BUN and creatinine begins to normalize
- persistent S&S
What are some characteristics of the Recovery phase of ARI ?
- begins when GFR increases
- BUN and creatinine levels plateau (even out) and then decrease
- renal function can take up to 12 months to stabilize
What causes the hyponatremia in the oliguric phase of ARI ?
the damaged tubules can’t conserve sodium
- if left uncontrolled or water excess then it can lead to cerebral edema
Why are hematologic disorders associated with ARI ?
impaired erythropoietin production and platelet abnormalities leading to bleeding
Why may a pt have low serum Ca+ in the oliguric phase of ARI ?
inability of the kidneys to activate Vitamin D
- may be on Ca+/Vita. D supplement
- when hypocalcemia occurs the parathyroid secretes PTH which stimulates bone demineralization which releases Ca+ from the bones
Why may a pt have elevated serum Phosphate levels in the oliguric phase of ARI ?
phosphate is also released when the parathyroid secretes PTH
- pt may be on phosphate binders
How long does the diuretic phase of ARI last ?
1-3 weeks
How long does the recovery phase of ARI last ?
3-12 months
What are some indications for Renal Replacement Therapy/Dialysis ?
- volume overload
- elevated serum Potassium level
- metabolic acidosis
- BUN level >120 mg/dL (43 mmol/L)
- significant change in mental status
- pericarditis, pericardial effusion, or cardiac tamponade
- clinical status of patient
Why may someone in the recovery phase of AKI need therapy or counseling ?
it’s because this phase takes 3-12 months so it can be mentally draining and can cause financial hardships
- also if your kidneys never recover you will need dialysis which is a significant lifestyle change
What is a common cause of AKI ?
acute tubular necrosis
What is a common cause of CKD ?
diabetic nephropathy
How much urine should you excrete per hour ?
80 mL per hr
What is Chronic Kidney Disease (CKD) ?
progressive, irreversible loss of kidney function
What is the main diagnostic value when wanting to diagnose CKD ?
Glomerular Filtration Rate (GFR)
What are the leading causes of CKD ?
- diabetes (50%)
- HTN (25%)
Can Vancomycin cause Nephrotoxicity ?
yes because if you have impaired kidneys, it can cause delayed and decreased elimination which can lead to accumulation of drugs and the potential for drug toxicity
- doses and frequency have to be adjusted according to severity of kidney disease
Why does pruritus happen in CKD ?
the buildup of urea causes the itchiness
When on dialysis, do all patients still produce urine ?
after being on dialysis for a while it’s not uncommon for the pt’s to develop anuria/no urine output
What are some S&S of CKD ?
- uremia
- oliguria (as CKD worsens) & anuria
- metabolic acidosis (breathe may have uric scent to it because they are trying to breathe it off)
- anemia
- infection
- respiratory system
- pleural effusion
- predisposition to respiratory infection
- dyspnea
- pulmonary edema
How do we stage chronic kidney disease ?
based on decrease in the Glomerular Filtration Rate (GFR)
- normal is 125 mL/min which is reflected by urine creatinine clearance
What is the GFR for the last stage of kidney failure ?
End-Stage Renal Disease (ESRD) is when GFR <15 mL/min
- needs dialysis
How do we diagnose CKD ?
- renal biopsy
- renal ultrasounds
- renal scan
- CT scan
What are the most accurate indicators of kidney function ?
serum creatinine and 24-hr urine creatinine clearance
AS GFR decreases what happens to BUN and serum creatinine ?
they will both increase
How is carbohydrate metabolism affected by CKD ?
have altered carbohydrate metabolism
- pt’s with diabetes who develop uremia may requires less insulin then before onset of CKD
- excretion of insulin is dependent on kidneys
How are the triglycerides affected by CKD ?
elevated due to alteration of lipid metabolism
How are Potassium levels affected by CKD ?
hyperkalemia is most prevalent
- will cause fatal dysrhythmias and will want to put on a heart monitor
What is the most serious electrolyte disorder in kidney disease ?
Hyperkalemia
How are Sodium levels affected by CKD ?
can be elevated, normal, or low
- because of impaired excretion, Na with water is retained
- dilutional hyponatremia can occur (low sodium due to excess water): S&S are edema, HTN and heart failure
How are Calcium levels affected by CKD ?
decrease in Vitamin D which causes a decrease of Calcium to be absorbed from the intestine which means there is a decrease of serum Ca+ levels
- Ca must be present for activation of Vita. D to occur
How are Phosphate levels affected by CKD ?
it builds up in the blood cause of kidney failure
- leads to musculoskeletal disorders
How are Magnesium levels affected by CKD ?
elevated levels aren’t a problem unless they ingest Mg containing products
- like milk of magnesia, magnesium citrate, antacids with Mg
What are some S&S of hypermagnesemia ?
- absence of reflexes
- decreased mental status
- cardiac dysrhythmias
- hypotension
What are some neurological manifestations of CKD ?
neurologic system starts to deteriorate when the nitrogenous waste products increase
- restless leg syndrome
- muscle twitching
- irritability
- decreased ability to concentrate
- peripheral neuropathy
- altered mental ability
- seizures
- coma
What are some GI issues caused by CKD ?
every part of GI is affected
- mucosal ulcerations
- stomatitis (mouth ulcerations)
- uremic fetor (urinous odor to breath due to metabolic acidosis)
- GI bleeding
- anorexia, N/V
What are some skin issues caused by CKD ?
- pruritus (dry skin, calcium-phosphate deposition in skin, sensory neuropathy) due to urea levels
- itching can be so intense that it can lead to bleeding or infection secondary to scratching
- uremic frost (crystalized urea deposits that can be found on the skin of those affected by chronic kidney disease)
What are some musculoskeletal manifestations in CKD ?
mineral and bone disorders
- decreased activation of Vita. D so impaired calcium absorption in the gut
- causes decreased serum Ca which causes a increase in PTH (parathyroid hormone)
- PTH causes bone demineralization to occur which causes the a increase of Ca and also phosphate
What is collaborative care measures for CKD ?
- correction of extracellular fluid volume overload or deficit
- nutritional therapy
- erythropoietin therapy
- calcium supplementation, phosphate binder
- antihypertensive therapy
- measures to lower potassium
- adjustment of drug dosages to degree of renal function
What is a pharmacologic therapy method for Hyperkalemia ?
IV insulin
- IV glucose to monitor hypoglycemia
- the IV insulin will help draw K+ into the cells when it’s given & the IV glucose is given concurrently to prevent hypoglycemia
- when effects of insulin diminish the K+ shifts back out of cells
What is some HTN therapy methods ?
- weight loss
- lifestyle changes
- Na and fluid restriction
- Antihypertension Meds like Diuretics- Lasix
What is some information about the medication Lasix ?
loop diuretic
- can cause electrolyte imbalances like hypokalemia (can cause dysrhythmias) and dehydration (increases urine output)
- if given IV push fast then it can cause ototoxicity (ringing in ears or hearing loss)
- monitor I&Os, BP, K+ levels
What is a side effect of EPO therapy ?
development of iron deficiency resulting from increased demand for iron to support erythropoiesis
What are some side effects of Iron supplement ?
- gastric irritation, constipation
- may make stool dark in color
What is the goal of Dyslipidemia ?
- lowering LDL (bad cholesterol) below 100 mg/dL
- triglyceride level below 200 mg/dL
What is nutritional therapy for sodium, potassium, phosphate for CKD ?
- Na: restrict from 2-4 g depending on degree of edema, and HTN
- K: 2-3 g and high Potassium foods should be avoided
- Phosphate (dairy) : 1000 mg/day
What foods are high in Potassium ?
- bananas
- spinach
- potatoes and tomatoes
- oranges
Why do CKD pt’s go on a protein restriction ?
when protein is ingested then it’s broken down and it creates creatinine
- the unhealthy kidneys lose the ability to remove protein waste and it builds up
- based on stage of kidney disease, nutrition status, and body size
What are some conditions that put you at risk for CKD ?
- hx of renal disease
- HTN
- DM
- repeated UTI
Which serum laboratory value indicates to the nurse that the client’s CKD is getting worse ?
decreased calculated glomerular filtration rate (GFR)
What is dialysis ?
movement of fluid/molecules across a semipermeable membrane from one compartment to another
- used to correct fluid/electrolyte imbalances and to remove waste products in renal failure
- tx drug overdoses
What is diffusion ?
movement of solute from an area of greater concentrations to an area of lesser
What is osmosis ?
movement of fluid from an area lesser to an area of greater concentration of solute
Why does a pt get dialysis ?
when pt’s uremia can no longer be adequately managed conservatively
- when GFR <15 mL/min
What are the 2 types of dialysis ?
- peritoneal dialysis: peritoneal membrane is a filter
- hemodialysis: goes through the blood and it goes through a external filter and clean blood goes back in
Where does the catheter go into in Peritoneal dialysis ?
into the peritoneal cavity
- usually done via surgery
What is the solution/concentrations of the peritoneal dialysis liquid ?
- 1 to 2 L bags with glucose concentrations of 1.5, 2.5, and 4.25%
- electrolyte composition similar to plasma
- solution is warmed to body temp to prevent cramping and pain
What are the 3 phases of peritoneal dialysis cycle ?
an exchange
- inflow (flow)
- dwell (equilibration)
- drain
What happens in the inflow phase of PD ?
- prescribed amount of solution infused through established catheter over about 10 mins
- after solution infused, inflow clamp closed to prevent air from entering tubing
What happens in the dwell phase of PD ?
- diffusion and osmosis occur between pt’s blood and peritoneal cavity
- duration of time varies, depending on method
What happens during the drain phase of PD ?
- 15 to 30 mins
- may be facilitated gently by massaging abdomen or changing position
- Goal is to take fluid off (should have more out than put in)
- like urine, output should be clear and yellow with no cloudiness or dark
What is Automated Peritoneal Dialysis ?
- cycler delivers the dialysate
- times and controls fill, dwell, and drain
- at night
What is continuous ambulatory peritoneal dialysis (CAPD) ?
manual exchange
- during the day
What are some peritoneal dialysis (PD) complications ?
- exit site infection & peritonitis (can lead to sepsis)
- hernias
- lower back problems
- bleeding
- pulmonary complications
What are the best places to put a fistula or graft ?
- upper arm or forearm
- leg is the last resort
What is a Arteriovenous (AV) fistula ?
directly connecting an artery to a vein
- fistula causes extra pressure by increasing the blood flow into the vein, making it grow larger and stronger and providing easy access to the blood vessels.
What is a Arteriovenous (AV) graft ?
synthetic tube implanted under the skin that connects between the artery and the vein
- providing needly placement access for hemodialysis
Why is a AV fistula the “gold standard” ?
- less likely to clot
- reduces infection risk
- lasts longer
- need to palpate for a thrill and listen for a bruit at the site
What are some risk factors of AV fistulas ?
can cause distal ischemia (no perfusion to peripheral body parts) and aneurysms
- can lead to tissue death, loss of function or loss of limb
- S&S: pain distal to access site, numbness or tingling of fingers, poor capillary refill
Why don’t we want to put pressure on AV fistulas or grafts ?
can cause it to clot
- no BP, IV lines, or venipunctures on that arm
Where is a temporary vascular access port for hemodialysis usually ?
internal jugular or femoral vein
- double lumen
- for blood removal and return
- risks: high infection, dislodgement, and malfunction
Why do regular RN’s not mess with the dialysis catheters ?
- only for Dialysis RN’s
- in these catheter’s they put large amounts of heparin after hemodialysis to prevent clotting
- if you were to flush this catheter then all this Heparin enters their body and it can cause bleeding
- Dialysis RN’s pull the Heparin out before they use the lumen’s
In what direction does dialysate flow in hemodialysis ?
in the opposite direction of the blood
How is Hemodialysis done ?
2 needles placed into fistula or graft
- 1 needle is closer to fistula or red cath lumen pulls blood from pt
- it’s moved through the dialyzer by a blood pump (Heparin is infused as a bolus to prevent clotting)
- dialysate is pumped in and flows in the opposite direction of the blood
- the dialyzed blood is returned to the pt through a 2nd needle or blue cath
- old dialysate is drained and discarded
- needles removed and light pressure
Once they come back from hemodialysis, what is the most important vital sign ?
Blood pressure
- take lots of fluid from body and want to ensure they didn’t take too much
What are some complications from hemodialysis ?
- Hypotension: result from rapid removal of vascular volume (hypovolemia), decreased cardiac output, and decreased systemic intravascular resistance
- Muscle Cramps: associated with hypotension, hypovolemia, high ultrafiltration rate, and low sodium dialysis solution
- Blood Loss: blood not being completely rinsed from the dialyzer with saline, accidental separation of blood tubing, dialysis membrane rupture or bleeding after the removal of needles at the end of dialysis
