Beth - Week 11 - Exam 4 Flashcards
what is CKD?
chronic kidney disease
- presence of kidney damage defined by structural or functional abnormalities
- with or without ↓ GFR
- manifested by pathological abnormalities in blood, urine, or imaging
what is the etiology of CKD?
the presence of GFR < 60mL/min/1.73 m2 for three months, with or without other signs of kidney damage
what is the epidemiology of CKD?
- 26 million Americans have CKD
- 1 out of 9 Americans are at risk
- 1/2 million are receiving tx
- Approx 435,000 have ESRD
- Annual mortality rate for ESRD: 24%
- 90,000 die each year `
Review: how does the kidney relate to regulating BP?
- Hypovolemia/Na+ depletion triggers release of
Renin (enzyme) which converts angiotensin to
A-I (ACE) which converts to A-II in the lungs.
A-II causes adrenal cortex to secrete
Aldosterone (secrete K+ & absorb Na+ & H20—
water balance)
Look at review slide
REVIEWED
what are the causes of CKD?
- glomerulonephritis
- nephrotic syndrome
- hypercalcemia
- multiple myeloma
- chronic UTI
- disease - (leading cause)
what diseases cause CKD?
HTN and diabetes
what are the stages of CKD?
- Stage 1*: GFR >= 90 mL/min/1.73 m2 - Normal or elevated GFR
- Stage 2*: GFR 60-89 (mild)
- Stage 3: GFR 30-59 (moderate)
- Stage 4: GFR 15-29 (severe; pre-HD)
- Stage 5: GFR < 15 (kidney failure-uremia)
TEST: what are the general sxs of CKD?
- General (fatigue, malaise, edema)
- ophthalmologic (loss of •vision)
- respiratory (pleuritis, pulmonary edema)
- cardiac (HTN, HF, pericarditis, CAD)
- GI (A + N + V, GI bleed)
- Skin (pruritus, pallor)
- Neuro (MS changes, seizures, neuropathy)
- Metabolic (hyperglycemia)
what is the management/tx of CKD?
** ID and treat factors associated with progression of CKD **
t
how are the factors associated with the progression of CKD treated?
- dialysis (hemodialysis (permanent/temp) or peritoneal or continuous veno-venous hemofiltration CVVH)
- transplant
what are the factors ID’d that are associated with CKD?
- HTN
- proteinuria
- metabolic changes (↑ glucose)
- anemia
- hyperlipidemia
what is the target BP for someone with CKD?
< 130/80 mmHg
- <125/75 mmHg for pts with proteinuria
what should pts with HTN consider for medications?
- consider several anti-HTN meds with different mechanisms of activity
- ACEs/ARBs
- Diuretics
- *HCTZ (less effective when GFR < 20)
_____ is the single best predictor of disease progression
proteinuria
what are the 4 stages of proteinuria?
• Normal albumin excretion - <30 mg/24 hours • Microalbuminuria - 20-200 µg/min or 30-300 mg/24 hours • Macroalbuminuria - >300 mg/24 hours • Nephrotic range proteinuria - >3 g/24 hours
what are the metabolic changes with CKD?
- ↓ H+H
- ↓ calcium **
- ↑ phos **
- ↑ PTH
- ↑ triglycerides
what can the metabolic changes result in??
- acidosis
- ↑ K+
- ↓ Na+
***BUN and Cr may also be ↑
what are the metabolic and hematologic changes within the CKD patient?
- anemia (↓ erythropoietin and platelet function)
- leukocyte function
- humoral and cellular responses
- metabolic changes
- mineral metabolism
- dyslipidemia
- nutrition (renal diet)
Test: what is the tx for anemia?
- epoetin alfa (rHuEPO, Epogen)
- darbepoetin alfa (aranesp)
what is the dosing and side effects for epoetin alfa?
- HD: 50 -100 U/kg IV/SC 3x/wk
- Non-HD: 10,000U qwk
- *Side effect is Iron deficiency
- Constipation from Iron treatment
what is the dosing for darbepoetin alfa?
- HD: 0.45 µg/kg IV/SC qwk
- Non-HD: 60 µg SC q2wks
what causes metabolic acidosis and what is the tx?
• Muscle catabolism - decreased albumin synthesis • Metabolic bone disease • Sodium bicarbonate - Maintain serum bicarbonate > 22 meq/L - Watch for sodium loading (Volume expansion + HTN)
•• Acidosis leads to release of bone calcium/phos
what is mineral metabolism and the tx?
- calcium and phosphate metabolism abnormalities associated with:
• renal osteodystrophy
• calciphylaxis and vascular calcification - take CaCO3 or Ca-acetate with meals to bind phos
- ↓ phos intake
what is dyslipidemia and the tx?
abnormalities in the lipid profile
- triglycerides and total cholesterol
- *lipid lowering tx prevention of CV disease
what are the characteristics of a CKD pt’s nutrition (diet)?
- think about uremia (elements normally eliminated in urine) • catabolic state • anorexia • ↓ protein intake • water restriction (limit 1-3 kg between dialysis) • Na+ restriction (2-4g) • K+ restriction (2-3g) • phosphate restriction (1g) - renal dietitian
Read the case study
READ
what are the diagnostics of CKD?
• Blood tests - CBC with diff - BMP - Ca++ - phos - PTH - HbA1c - LFTs - uric acid and Fe2+ study • Urine - urinalysis with microscopy - spot urine for microalbumin - 24 hr urine collection for protein and creatinine • Ultrasound - hydronephrosis, tumors, stones
what are the CKD tx options?
- peritoneal dialysis
- hemodialysis
- kidney transplant
what are the characteristics of peritoneal dialysis?
surgical placement of peritoneal catheter
what are the characteristics of hemodialysis?
• vascular access placed after 14 months
- arteriovenous fistula
- arteriovenous graft
- temporary vascular access
- CVVH
what are the characteristics of kidney transplants?
- live donors
- deceased donors
- only 1/4 ever receive a kidney
- once transplant survival is 90%
- lifetime medications (immunosuppressive)
- life long concern of infection and rejection
what is the risk for diseases for kidney transplant patients?
- CV
- malignancy (basal cell/lymphoma)
- recurrence of original disease into new kidney
- corticosteroid-related complications (↑glu)
- diabetes
what are the physiologic principles of hemodialysis?
- osmosis
- diffusion
- ultrafiltration
what is osmosis?
Movement of fluid from an area of lesser to area of
greater concentration of solutes
what is diffusion?
Diffusive transport across semipermable membrane
(based on countercurrent flow of blood and
dialysate) removal of impurities
what is ultrafiltration?
- water and fluid removal (↓ BP ↑ HR)
- results when there is an osmotic gradient across the membrane
what are the goals of dialysis?
• fluid removal
• osmosis and diffusion across semipermeable membrane
- solute clearance
- diffusive transport (based on countercurrent flow of blood and dialysate)
- conventive transport (solvent drage with ultrafiltration)
what are the nursing assessment/priorities for a pt with CKD?
- complete assessment (heart and lung sounds)
- condition of access
- temperature
- skin condition (itchy, edema)
- weight
- BP
- edema
- labs (renal panel, lytes, CBC)
- CXR
what is a arteriovenous fistula?
- Preferred form of dialysis access
- Typically end-to-side vein-to-artery anastamosis
what are the different types of arteriovenous fistulas?
- Radiocephalic (first choice)
- Brachiocephalic (second choice)
- Brachiobasilic (third choice, requires superficialization of
basilic vein, i.e. transposition) - lower extremity fistulae are rare
what are the assessments for arteriovenous fistulas?
• Look - site, condition, s/s infection
• Feel - look for the Thrill…Pulse is bad
• Listen - bruit, low pitched…high short is
bad
what is a arteriovenous graft?
• Synthetic conduit, usually polytetrafluoroethylene (PTFE, aka Gortex), between an artery and a vein
- Either straight or looped
what are the common sites for AV grafts?
- Straight forearm : Radial artery to cephalic vein
- Looped forearm : brachial artery to cephalic vein
- Straight upper arm : brachial artery to axillary vein
- Looped upper arm : axillary artery to axillary vein
what are tunneled cuffed catheters?
- dual lumen catheters
- most commonly placed in the internal jugular vein, exiting at the upper, anterior chest
- can also be placed in the femoral vein
- subclavian catheters should be avoided given the risk of subclavian stenosis (rise in infection)
what is peritoneal dialysis?
- peritoneal access is obtain by inserting a catheter through the anterior wall
- technique for catheter placement varies
- usually done via surgery
what are the three phases of peritoneal dialysis?
- called an exchange*
- inflow (fill)
- dwell (equilibration)
- drain
what does “inflow” phase consist of?
- Prescribed amount of solution infused through
established catheter over about 10 minutes - After solution infused, inflow clamp closed to
prevent air from entering tubing
what does the “dwell” phase consist of?
- Diffusion and osmosis occur between patient’s
blood and peritoneal cavity - Duration of time varies depending on method
what does the “drain” phase consist of?
- 15 - 30 minutes
- may be facilitated by gently massaging abdomen or changing position
TEST: what is the nursing management of peritoneal dialysis specific patient?
- Skin must be cleaned with antiseptic solution and sterile dressing applied - Must be connected to sterile tubing system - Secured to abdomen with tape - Mask & gloves during connecting and disconnecting - Maintain sterile environment !!!!
what is the nursing management and assessment of a dialysis patient before treatment?
• before tx, RN should
- complete assessment of fluid status, condition of access, temp, skin condition
- weight
- BP
- edema
- heart and lung sounds
what is the nursing management and assessment of a dialysis patient during treatment?
- be alert to changes in condition
- perform VS every 30 - 60 minutes
what is the nursing management and assessment of a dialysis pt post tx?
weight
test: what are the complications of dialysis?
- hypotension
- muscle cramping
- loss of blood (damanged during dialysis)
- hepatitis
- sepsis
- disequilibrium syndrome
what are the possible complications of the dialysis access site?
- thrombosis
- infection (10% for AVG, 5% for AVF, 2%)
- aneurysms and pseudoaneurysms (3% of AVF, 5% of AVG)
- HF (avoid AVFs in pt with severely depressed LVEF)
- local bleeding
- peritoneal dialysis (peritonitis/sepsis, cath clogged or dislodged)
what is the pt education for someone on dialysis?
- understanding of regular scheduled tx
- acceptance of chronic disease
- risk for infections (sxs of infection)
- edema (daily weight)
- dietary restrictions
what is the family education for someone on dialysis?
- same as pt
- understand their role
- risk for infection
- med routine
- maintain healthy lifestyle
T/F it is important to be in collaboration with the dialysis nurse
TRUE
what are the things we should communicate to the dialysis nurse?
- clinical situation (hold meds?)
- meds (BP, ATB, diuretic, pain meds)
- lab results (K, Cl, BUN, Cr, H/H)
- assessment (access device)
- plan of care (ongoing assessment, medicate prn, pt comfort (bedrest), nutrition (hold food d/t N+V), psychosocia support, family education)
