Advanced Renal Concepts and TPN Flashcards
Factors which decrease GFR: Afferent
Vasoconstriction d/t NSAIDS
Factors which increase GFR: Afferent
Vasodilation d/t Prostaglandin or ANP (Atrial Natriuretic Peptide)
Factors which decrease GFR: Efferent
Vasodilation d/t prostaglandin
Factors which increase GFR: Efferent
Vasoconstriction d/t ANP (Atrial Natriuretic Peptide), Angiotensin 2, Norepinephrine
What are the 9 major functions of the kidney?
Regulate body fluid/fluid volume Regulate elimination of Na, K, Ca, P04 Regulate osmolality of ECF (extra cellular fluid) by action of ADH (anti-diuretic hormone) BP regulation Maintain pH Eliminate metabolic waste Eliminate drugs Activate Vitamin D Produces erythropoietin
What is BUN and the normal range?
Urea is the product of protein metabolism
Readily filtered out by the kidneys, some may be reabsorbed
Range: 62-102 in male and 53-97 in females
What is Creatinine and the normal range?
Byproduct of of muscle function
Readily filtered out by the kidneys, some may be reabsorbed
Range: 2.1-7.1
BUN/Creatinine Ratio
10:1- 20:1
BUN is higher than creatinine as more is reabsorbed
Glomerular FIltration Rate
125ml/minute
Uses Creatinine clearance, collected via 24 hour urine
Not considered reliable as creatinine filtration is variable
eGFR
an estimate of GFR based on sex, gender, race, and weight
Normal Urine Output
1500ml/day = 30ml/h
Normals for Urinalysis
pH, protein, glucose, ketones, specific gravity, casts, leukocyte esterase, bilirubin, urobilinogen
pH: 5.0-6.5
protein :
Stage 1 Kidney Failure: GFR
90-120
Stage 2 Kidney Failure: GFR
60-90
Stage 3 Kidney Failure: GFR
30-60
Stage 4 Kidney Failure: GFR
15-30
Stage 5 Kidney Failure: GFR
0-15
What is the RIFLE Criteria for GFR?
Risk: No damage to kidney yet, only risk. Increased creatinine X1.5 or GFR decrease>25%
Injury: Some damage to kidneys, may be repairable, may not be. Increased creatinine X2 or GFR decrease>50%
Failure: Definite failure, injury, may be repairable, may not be. Increased creatinine X3 or GFR decrease >75%
Loss: The damage will affect the entire body and will not be regained. Persistent ARF = complete loss or renal function >4 weeks
ESRD: The damage will affect the entire body and will not be regained. End stage renal disease
1st Stage of Renal Failure: Prodromal Phase
Early symptoms, beginning of renal failure, may not have any symptoms yet. Injury has occurred, normal or decreased urine output , increased BUN and creatinine
2nd Stage of Renal Failure: Oliguric Phase (a few)/Anuric (none) [1-2 weeks]
Oliguria/anuria, volume overload, hyperkalemia, azotemia/uremia, metabolic acidosis, high potassium, decreased sodium, decreased hemoglobin (Not making erythropoietin), Not making bicarb
3rd Stage of Renal Failure: Recovery Phase (Up to 1 year)
Fluid volume deficit, labs begin to normalize, kidneys not functioning properly
Acute Renal Failure Types: Pre-renal
R/t blood and 02 content not reaching the kidney. Caused by transient renal hypoperfusion due to :
Hypotension: decreased cardiac output
Decreased effective arterial blood volume
Acute Renal Failure Types: Post-renal
Due to obstruction of the urinary tract.
Urine backs up into the kidney and it cannot make more urine
Acute Renal Failure Types: Intrinsic. 3 Types.
Acute glomerulonephritis
Acute interstitial nephritis
Acute Tubular necrosis
What is Acute glomerulonephritis?
Immune mediated inflammation of the glomerulus- can be autoimmune or r/t an infectious agent
Can be caused by group A B-streptococci
Associated with hypertension, end stage renal failure, and diabetes
What are the signs and symptoms of Acute glomerulonephritis?
Variable hematuria, proteinuria, oliguria, azotemia, edema and hypertension
immune system infiltrates the glomerulus, triggering the clotting cascade
smokey or tea colored urine from hematuria, proteinuria, casts, and increased circulatory volume
‘Coke colored urine’
What is Acute Pyelonephritis?
Presents as urinary Tract infection and fever
Caused by bacteria from the gut
Higher incidence in females, and uncircumcised males under the age of 2
A chronic infection will result in scar tissue
What are the signs and symptoms of Cute Pyelonephritis?
Urgency, frequency, dysuria-burning, pain over kidneys, chills, anorexia, pyreia, flank pain,
Leukocytosis, cloudy urine, odor fishy, and bacteria present on UA
What is Acute Tubular Necrosis? and what are the causes?
Most common cause of intrarenal AKI
Characterized by necrosis of the renal tubular cells
Causes:
Hypoperfusion of the kidneys, tubular damage from ischemia, exposure to nephrotoxic drugs/chemicals, tubular obstruction, toxins from massive infection
Tubular injury is frequently irreversible.
What are the three types of Acute Tubular Necrosis?
Ischemic ATN, Nephrotoxic ATN, Intratubular ATN
What is Ischemic Acute Tubular Necrosis? What are the causes?
Injury happens due to alerted glomerular epithelial cells and decreased glomerular capillary permeability
Caused by major surgery, severe hypovolemia, overwhelming sepsis, trauma, burns (fluid flows elsewhere, decreased to kidneys, capillary/integ trauma)
What is Nephrotoxic Acute Tubular Necrosis? What are the causes?
Occurs as a result of a toxin, causes renal inury through combinations of renal vasoconstriction, direct tubular damage and intratubular obstruction.
Eg. Penicillin, ciprofloxacin, NSAIDs (These drugs do not usually cause harm, but can in some people)
What is Intratubular Acute Tubular Necrosis? What are the causes?
Obstruction of the renal tubules
Causes:
1. Myoglobinuria (bi-product of muscle fibers): muscle trauma, extreme exertion, hyperthermia, sepsis, prolonged seizures, Potassium or phosphate depletion or substance abuse.
2. Hemoglobinuria: blood transfusion reactions and other hemolytic crises (blood given forms a compound with patient blood and forms a compound, eventually filtered where blood products being broken down)
3. Uric Acid crystal deposits: Those with widespread cancer or massive tumor destruction by chemotherapy (usually predicted and treatment is started)
Acute Tubular Necrosis Signs and Symptoms?
Oliguria, anuria elevated serum BUN and creatinine dry skin, mucosal membranes confusion, disorientation, lethargy, ataxia tachycardia and arrhythmias weakness r/t hyperkalemia S&S of infection edema (if heart failure is present) varying fluid volume status coughing, spitting frothy fluid
ATN Treatment
Fluid Bolus to correct hypovolemia and flush out toxins and casts Diuretics to encourage urine formation PRBCs to correct anemia (02 carrying) Antibiotics for infection Correct hypokalemia or hyperkalemia hemodialysis (last step)
ATN Nursing Care
Strict fluid balance record Monitor hydration monitor lab work daily weights strict infection control procedures May need calcium gluconate (If the kidneys are not maining calcium, the body needs it to avoid a bad rhythm, maintain myocardium)
Nutrition r/t Kidney Failure
Those in renal failure are prone to wasting and hyperglycemia due to increased insulin resistance
Nutritional support- restriction of K, Mg and P04
High Calorie (20-30 kcal/kg/day) with vitamins and minerals
Prevent negative nitrogen balance and depletion of energy reserves (if negative, could be r/t muscle balance and protein and muscle break down=BAD)
Restrict protein, unless on dialysis
May require eternal feeding (TPN or PPN)
What is uremia and what are the signs and symptoms?
Uremia is the accumulation of nitrogenous waste.
Symptoms are nausea and vomiting, increased bleeding, confusion (d/t excess nitrogen), irritability and twitching, skin and mouth-care ulcers, hyperkalemia, oliguria, metabolic acidosis, observe for deterioration of pericarditis, Need proper vital signs**
What is rhabdomyolysis and what are the signs and symptoms?
The breakdown of muscle fibers, this releases myoglobin and other proteins into circulation
Myoglobin causes obstruction of the renal tubules and has a cytotoxic effect
Symptoms are fatigue, muscle pain, weakness, urine dark reddish in color, high RBCs in urinalysis but low on microscopy (d/t myoglobin relaxes at same agent that indicates RBC presence in urine)
Elevated serum creatinine kinease (enzyme released with damage to muscle tissue)
What are the causes of rhabdomyolysis?
Muscle injury, ischemia, medications/drugs, toxins and metabolic myopathies (hypo/hyperthermia)
What is the treatment for rhabdomyolysis?
Prevent further damage/treat the cause
Fluid resuscitation (correct hypovolemia to prevent further renal hypoperfusion and hyperkalemia. ++fluids to flush out toxic metabolites).
Mannitol (osmotic diuretic) -(big bulky sugar which the body will try to dilute by putting water into the cells to flush it out, increased urine production)
Assess/monitor coagulopathies
What is hemodialysis?
Movement of fluid and molecules across a semipermeable membrane from one compartment to another
Machine pumps blood, creating pressure across a dialysis membrane, the waste products and fluids are filtered out.
Works via diffusion and other methods
Hemodialysis access types
- Arteriovenous Fistula (AVF): surgical anastomosis of an artery and vein. takes 1-3 months to mature
The vein thickens and pulsates(bruits)-avoid BP/IV here
Synthetic graft is also used, arteriovenous Graft - Hemocatheter: dual lumen synthetic catheter is tunneled under the skin, accessing a major vein.
Can be left in place for years
Placement is confirmed by x-ray prior to use
Pre-dialysis nursing care
Usually done 3x/week, usually for life once kidneys are damaged.
Assess VS, fluid status, weight, lung sounds, peripheral edema, vascular access status, review meds (especially anti-coags)
Check is pre blood work is required
Post-dialysis nursing care
Re-assess the patient!
Check for post dialysis orders or blood work
Any post dialysis medications?
What are complications of hemodialysis?
Hypotension (d/t shift of blood), muscle cramps, seizure
cardiac ischemia
disequilibrium syndrome (from rapid changes in electrolytes in extracellular fluid)
Bleeding or damage to fistula
What is TPN?
Total parental nutrition (TPN) is the practice of nourishing a patient intravenously, bypassing the usual process of eating and digestion. It is a form of specialized nutrition,
What is 2 in 1TPN composed of?
Dextrose, amino acids, electrolytes, vitamins/minerals Lipid emulsion (as a separate infusion)
How is TPN administered?
It is administered intravenously and can be administered through a peripherally inserted central catheter (PICC), a central venous line (CVL) or a large peripheral line. In order to administer it carefully, TPN is ALWAYS administered with an infusion pump.
What are the common indications for TPN?
Intolerance to oral feeds and the patient is NPO for 3 or more days.
Non functional GI tract (massive GI surgery, paralytic ileus, severe malabsorption)
Extended bowel rest (inflammatory bowel disease, severe diarrhea, moderate to severe pancreatitis)
Pre-operative TPN (pre-op bowel rest, Tx for comorbid severe malnutrition, Severe catabolic patients)
Increased Metabolic Needs (sepsis, cancer, burns, severe anorexia nervosa)
What is 3 in 1 TPN composed of?
More common in adults.
Dextrose, amino acids, electrolytes, vitamins/minerals plus an intravenous lipid emulsion
What is central TPN?
Formula specifically designed to be administered into a central line (PICC or CVL), contains 20-50% dextrose (hypertonic), must be infused via a large central vein so that rapid dilution can occur
What is Peripheral TPN?
Peripheral
o Formula specifically designed for administration into a peripheral intravenous line, contains 10% dextrose or less but is still hypertonic
Peripheral PN is usually only used when:
-nutrition support will only be needed short-term
-patient does not have high protein/calorie requirements
-risk of inserting a central line is too high
-patient is allowed oral intake, but requires supplementation
What is TFI?
TFI identifies the total fluid volume to be infused from ALL sources. A TFI order requires the nurse to calculate the patient’s fluid administration from all sources and to adjust the peripheral IV rate accordingly to allow the TPN to be administered as prescribed, while not exceeding the TFI amount.
What is involved in the planning stage of TPN administration?
Serum glucose will be within normal limits, IV line will remain patent, free of pain, redness or inflammation, explain purpose of TPN support
What assessments are required before TPN administration?
Assess electrolytes, renal, hepatic function, and inform physician of abnormalities
Assess skin turgor, evidence of edema, weight
Assess Blood glucose level, VS, auscultate lungs
Verify physician’s orders from volume, frequency and rate
Verify Total fluid intake ordered by physician
What complications are associated with TPN therapy?
Infection/sepsis, pneumothorax, embolism, catheter occlusion, fluid excess or pulmonary edema, refeeding syndrome,
Nutritional imbalance,
Hypo/hyperglycemia, electrolyte imbalance,
metabolic imbalance
