ARF and AKD Flashcards
What are the two major causes of ESRD?
DM and HTN
With HTN keep b/p controlled at?
130/80
With DM prevent?
proteinuria and microalbuminuria
Renal failure leads to?
F/E problems and acid-base problems.
Renal failure results in?
- azotemia
- acid-base problems
- electrolyte imbalances
What is azotemia?
excess nitrogenous waste in the blood.
What lab do you check for azotemia?
BUN, it was begin to rise
Is acute renal failure reversible?
yes, with prompt intervention.
CKD/CRF slowly develops is it reversible?
no, and it will require dialysis eventually.
GFR should be?
125 mL/min - this decreases with age, but should always be no less that >100 mL/min
with ARF urinalysis may show?
protein and blood in the urine.
True or False
The filtering process can be alter by blood flow and pressure?
TRUE
What are the different types of failure?
- pre renal
- intra renal
- post renal
______ _______ is lack of blood flow (hypoperfusion) to the kidney caused by a severe injury or severe problem.
pre-renal failure
MAP for good kidney CO?
60 - 65 mm Hg
Causes of pre-renal failure?
- volume depletion: hemorrhage, renal losses (diuretics), GI losses (V/D/NG suctioning)
- impaired cardiac efficiency
- vasodilation: sepsis and anaphylaxis and meds that cause vasodilation.
_______ _______ is damage to kidney tissues (parenchyma) and/or nephrons.
Intra-renal failure
Causes of intra-renal failure?
- caused by inflammatory process
- nephrotoxins (NSAIDS, VANC, Genamicin)
- infectious processes such as acute pyelonephritis and glomerulonephritis
______ ______ is outflow of urine being obstructed.
post-renal failure
Causes of post renal failure?
- calculi/stones
- tumors
- BPH
- Blood clots
- Strictures
Causes of AFR differ, but the end results are?
the same
If the kidneys can’t filter the blood excess water and electrolytes build up where?
in the blood
What are the four phases for ARF?
initiation phase > oliguric phase > diuretic phase > recovery phase
________ ______ begins at the time of injury and continues until s/s appear (hrs to days) - result of cellar injury. Oliguria develops (<500 mL/day)
Initiation phase
_______ _______ begins to see increase in serum concentration of wastes (creatinine, urea, electrolytes). Decrease in GFR occurs w/in 1 - 7 days and last up to 14 days. Urine output <400mL/24hrs. Often dialysis is needed until kidney function returns.
Oliguric phase
______ ______ last 1 - 3 weeks in which you see an increase in urine output. This means GF has started to recover, but is still healing. Your pt. may excrete large amount of urine. MONITOR CAREFULLY for signs of dehydration. Lab values should plateau during this phase and then begin to decline.
Diuretic phase
_______ _____ kidneys are recovering and signs of improvement are noted: increase urine output, BUN normalize, lasts up to 12 months.
Recovery phase
True or False:
Patients in ARF have a low specific gravity due to the kidneys inability to concentrate the urine?
True
Stage 1 of CKD:
GFR > 90mL/min; kidney damage w/normal or increased GFR
Stage 2 of CKD:
GFR 60 - 89 mL/min; diminished renal reserve
Stage 3 of CKD:
GFR 30 - 89 mL/min; renal insufficiency
Stage 4 of CKD:
GFR 15 - 29 mL/min; severe decrease in GFR
Stage 5 of CKD:
GFR < 15 mL/min
What meds are used to slow the progression of renal failure?
ACE inhibitors or ARBs
CKD is caused by other chronic illnesses what are they?
- Diabetes: damages small blood vessels that control blood flow to kidneys
- HTN: leads to sclerosis of nephrons
Stick blood glucose control has been show to?
slow the progression of CKD.
GFR < 60 mL/min for 3 months or longer is a sign of?
CKD
Nephrons are slowly destroyed by?
CKD
Final stage kidney disease kidneys have too few?
nephrons
ESRD means?
end stage renal disease
S/S of: renal mass is reduced - >90% of nephrons are destroyed - GFR < 15 mL/min transplant needed!
ESRD
Are manifestations of renal failure the same for ARF and CKD?
Yes, except AFR patients recover and CKD stay in the oliguric phase.
waste products that accumulate during CRF:
- uremia/azotemia
- GFR decreases, BUN and creatinine increases
- urea breakdown occurs increases
- Urea breakdown occurs in the intestinal tract
- Metallic taste in mouth
- Odor of urine on the breath
CRF causes a build up of toxic waste levels as they increase neurologic disorders occur?
Neurologic disorders occur:
- depression of CNS: weakness, leathery, *seizures, stupor, coma, *confusion
- peripheral neuropathy: restless leg syndrome, paresthesias, motor involvement, asterixis
What causes muscle twitching in CRF?
decreased ca+
Metabolic disturbances of CRF:
- defective carbohydrate metabolism: insulin resistance
- elevated triglycerides
- metabolic acidosis
Electrolyte imbalances in CRF:
- sodium (LOW)
- potassium (HIGH)
potassium levels > 6mEq/l can cause?
dysrhythmias
How do you help manage conversation of Na+ in CKD?
fluid administration, dietary restrictions, and meds.
respirations which are a result of the respiratory system compensating for excess CO2 that are rapid and deep in an attempt to blow off CO2 and restore body pH are called?
Kausmauls respirations.
True or False:
The kidneys can excrete H+ ions when in CRF.
FALSE they cannot.
hyperkalemia (K+ > 5.5 mEq/L): because the kidney cannot filter out K+ it leads to protein catabolism and acidosis which causes?
release of K+ into the blood worsening kyperkalemia.
when pt has hyperkalemia monitor and treat for?
- telemetry
- s/s: weakness, diarrhea, dysrhythmias, cardiac arrest
- monitor for other sources of K+ the pt could be receiving and stop them.
- restrict food high in K+
Hematologic disorders of CRF:
- anemia
- defect in platelets
- changes in leukocyte function
Why do pt’s with CRF develop anemia?
the kidneys produce the hormone erythropoietin, which stimulates the bone marrow to produce RBCs
hgb is a great indictor of oxygen transport and will determine if the pt. will need a?
blood transfusion
what are the signs and symptoms of anemia?
- fatigue
- general malaise
- SOB
what may pts in renal failure with low hgb receive to stimulate the production of RBCS?
recumbent erthropoietin
if hgb get to high you are at risk for?
blood clots
a decrease in _______ makes you more prone to bleeding?
platelets
changes in leukocyte function alter the immune redone and make you more prone to?
infection
CRF effect on the cardiovascular system:
- HTN
- CHF
- DYSRHYTHIMAS
CFR effects on the respiratory system:
- Kussmauls respirations
- pleural effusion
- pulmonary edema
HTN due to?
FVE (Na+ and H2) retention due to activation of the renin-angiotensin-aldosterone system)
CHF occurs due to?
FVE causing pulmonary edema.
With pulmonary edema what might you hear?
crackles
Dysrhythmias occur due to?
hyperkalemia
CRF effects on the Gi system:
- stomatitis, ulcerations
- metallic taste
- odor of urine on breath
- anorexia
- Diarrhea/ constipation
CRF effects on the musculoskeletal system:
- renal osteodystrophy
The GI tract takes over breaking down _____ since the kidneys cannot do it resulting in ______ _____.
- urea
- excess urea
GI tract signs and symptoms of excess urea:
- belching
- N/V
- ulcer formation and bleeding
- metallic taste and odor of urine on breath ** meticulous oral care **
- ammonia odor on breath
Musculoskeletal changes from alterations in _______ and _______ ;which have an inverse relationship, making bone fracture easily
- phosphorous
- calcium
Hyperphosphatemia results in?
hypocalcemia.
A decreased serum calcium will cause secretion of ______ to leave the bones, resulting in _____ leaving the bones.
- parathormone
- calcium
Vit D is produced by the ______ and will fail to be made as renal failure progresses this impairs absorption of ______.
- kidneys
- Ca+
CRF effects on the integumentary system:
- uremic skin color
- dry, flaky
- pruritus
- petechiae and ecchymosis
- uremic frost
uremic skin color:
yellow/tan
pruritus:
weeping of waste onto skin
decreased platelet function leads too?
petechiae and ecchymosis
Uremic frost will not occur if?
THEY ARE ON DIALYSIS
CRF psychological effects:
- personality and behavioral changes
- significant changes in lifestyle
personality and behavioral changes of CRF:
withdrawal, depressed, angry, fatigue, decrease in ability to concentrate
Lifestyle changes of CRF:
family responsibilities altered.
Diuretic phase of ARF:
- urine output increases
- hypovolemia, hypotension, dehydration
- BUN, creatinine levels are still elevated
- loss of electrolytes
- near end of phase acid-base, electrolyte, BUN and creatinine levels begin to normalize
The urine output increase during the diuretic phase of ARF:
1 - 3 L/day can reach 5L/day; which can lead to fluid volume deficits
Diuretic phase of ARF: Kidneys can excrete waste but cannot?
concentrate urine. Thus you lose a lot of fluid. (hypovolemia, hypotension, and dehydration)
Diuretic phase of ARF: Kidneys excrete?
wate and electrolytes
Recovery phase of ARF:
- GFR increases
- BUN, creatinine levels plateau then decrease
- Can take 12 months to stabilize
Management for renal failure:
- avoid things that increase workload of kidneys
- prevent complications
- focus on fluid balance, nutrition, electrolyte balance and prevention of infection
drug therapy:
- maintenance drug doses adjusted.
- avoid nephrotoxic drugs
Drugs to give:
- Diuretics
- Antihypertensives - ACE inhibitors
- Recombinant human erythropoietin
Target levels of HgB:
11 -12 g/dL
when levels of HgB rise above 12 risk of:
death and serious thromboembolic and cardiovascular events
Expected outcomes of erythropoietin?
increased energy levels decreased level of fatigue and improved exercise tolerance.
renal replacement therapy is initiated beginning in stage?
4 kidney disease
Na+ bicarbonate helps correct?
acidosis
Ca+ carbonate and calcium acetate are binders and help too?
level out these electrolytes
________ - cation resin - bind to K+ so it can be excreted through the intestines.
kayexalate
Insulin moves glucose into the cell, but will also move K into the cells which?
will lower K+ levels
MVA due to?
dietary restrictions and oftentimes malnutrition
Other drugs given:
- sodium bicarbonate (not often used)
- calcium carbonate (Os-Cal)
- Calcium acetate (PhosLo)
- Kayexalate/Insulin
- Folic acid and Fe supplements
- Daily MVA
Folic acid and Fe to treat?
anemia
Fluid balance?
- fluid restrictions
- calculating fluid restrictions
how to calculate fluid restrictions:
- add all loses (output) from previous 24 hrs
- add 600 mL for insensible fluid loss
Calculate this fluid loss restriction:
Patient had 250 mL urine output and 200 mL emesis.
450 + 600 = 1050 - fluid restriction
fluid allowance of approximately?
500-800 mL plus the previous days 24 hour urine output.
ways to control thirst:
sucking on hard candy, chew gum, rinse mouth with water, use small glasses vs. large ones, keeps lips moist
Renal diet/Nutrition:
- increased carbohydrates
- protein restriction
- potassium and sodium regulated according to blood levels
- phosphorous restriction
increased carbs for?
energy and adequate caloric intake
protein is restricted because
when they are broken down it leads to uremia
**Uremia is what makes them symptomatic with N/V etc.
K+ is restricted
citrus, tomatoes, melons, potatoes
Na+ is usually restricted but depends on blood levels of?
Na+ (canned foods, smoked foods, lunchmeat)
Phosphorous is restricted:
dairy, peas, beans, nuts
Nursing Diagnosis for Renal Failure:
FVE r/t decreased urine output, dietary excesses and rententiion of Na+ and H20
Goal for FVE:
maintenance of ideal body weight and fluid balance w/o excess fluid
Interventions for FVE:
- Assessment of fluid status: daily weight, I/O, presence of edema, such as JVD, ascites, pedal edema, changes in respiratory status, V/S changes
- Limit fluid intake
- *encourage frequent oral hygiene
Implementation of nursing interventions:
- monitor fluid balance
- administer medications
- monitor lab values
- mouth care
- skin care
- impact on individual, family, and community
Hemodialysis:
- uses a dialyzing membrane unit
- requires vascular access
Vascular access for dialysis:
- AV shunt or fistula
- Bruit
What does dialysis do?
pumps pt blood through a unit where it cleanses and removes toxic substances and excess water via blood and returns it to the body.
Does hemodialysis prolong life?
yes
Leading cause of death is hemodialysis patients?
CV disease
Patients with a temporary catheter are at risk for?
- hematoma
- pneumothorax
- infection
- thrombosis
AV fistula is a surgical anastomosis of artery and vein in FA protect is by:
no labs or BPs in patients arm with access.
AV graft is subcutaneous synthetic graft between artery and vein and is at risk for?
- infection
- thrombosis
Assess av site for?
- feel thrill
- hear bruit
Complications of hemodialysis:
- hypotension
- muscle cramps
- blood loss
- sepsis
- disequilibrium
hypotension r/t
repaid removal of volume with decreased C.O.
muscle cramps r/t
rapid removal of NA, water or neuromuscular hypersensitivity
blood loss r/t
dialysis and accidental tubing, membrane, needle disconnections
sepsis r/t
poor access technique
disequilibrium syndrome r/t
rapid exchanges from the blood rather than CSF and brain creating an osmotic gradient and fluid shift into brain cells, cerebral edema.
peritoneal dialysis is?
highly vascular and uses the peritoneum area. a warm solution enters into the peritoneal space and excess water and electrolytes move into the solution and then is drained out by gravity. **remember output must be greater than what was put in.
- 3x/week
- vascular access
- effective, rapid clearance
- extensive equipment
- less protein loss
- contributes to anemia
Which dialysis treatment is this?
hemodialysis
- done daily
- peritoneal catheter
- may cause high glucose
- more flexibility
- fewer dietary restrictions
Which dialysis treatment is this?
peritoneal dialysis
complications of which dialysis is this?
- vascular access infection/clotting
- hypotension
- muscle cramps
- blood loss
- sepsis
hemodialysis
complication of which dialysis is this?
- exit site infection
- peritonitis
- abdominal pain
- lower back pain
- bleeding
- protein loss
peritoneal dialysis
Living donors transplant
one kidney
pre-operative care for transplant is?
- emotional and physical preparation
- immunosuppressive drugs
- EKG, CXR, Blood tests
- bring metabolic state to a level as close to normal as possible
- make sure patient is infection free
- give immunosuppressant drug prior to transplant - reduces rejection rate
- complete physical
- antibody screening
- psychosocial evaluation for adjustment to procedure
post-transplant care for transplant is?
- monitor output/fluid retention
- monitor electrolytes, BUN, CBC, creatinine
- observe for s/s of rejection
- monitor for infection
s/s for rejection:
- oliguria
- edema
- fever
- increasing b/p
- weight gain
- swelling or tenderness at site
infection during rejection:
@ least 75% of pmts on iummosuppressants get an infection the first year after transplant.
