chronic kidney disease Flashcards
What is the most common cause of end stage renal disease?
Diabetes mellitus combined with hypertension
What are the characteristics of someone with end stage renal disease?
Less than 15% GFR, patient is on dialysis to survive, 90% of nephrons have been destroyed
What are the complications of end stage renal disease?
Hypertension, hyperkalemia, pericarditis, pericardial effusion, and pericardial tamponade, anemia, bone disease
What causes hypertension?
Sodium and water retention, malfunction of the renin angiotensin aldosterone system
What causes hyperkalemia?
Decreased exertion, metabolic acidosis, catabolism, excessive diet intake, medications, IV solutions
What causes pericarditis/pericardial effusion/pericardial tamponade?
Retention of uremic waste products, inadequate dialysis
What causes anemia in ESRD?
Decreased erythropoietin production, decreased RBC lifespan, bleeding in the GI tract from irritating toxins and ulcer formation, blood loss in dialysis
What is the goal with medications for someone with chronic kidney disease?
Maintain kidney function and homeostasis as long as possible
What medications should we give someone with ESRD?
Renagel (sevelamer carbonate), ACE inhibitors, erythropoietin (epogen)
What does Renagel do?
Binding phosphate to prevent hypocalcemia
How is erythropoietin administered?
SQ Shot in the abdomen weekly
What meds should someone with ESRD avoid?
NSAIDS (all except acetaminophen) , aminoglycosides (broad spectrum abx)
How much protein should someone on dialysis receive?
1.2-1.3 g/kg/day
What type of protein should someone on HD receive?
Biological - dairy, eggs, meat
How much fluid should someone on HD be restricted to?
500-600 more than the previous day 24 hour urine output
When do you take water soluble vitamins (B,C)
Take after HD
What is the diet like for someone with ESRD?
Low potassium, sodium, phosphate
What does HD not compensate for in someone with ESRD?
Loss of endocrine or metabolic activities
How often does someone do dialysis for a week?
3 times/ week 3-5 hours at a time
When at home the time and frequency can be adjusted
Why should you know the patient’s dialysis schedule?
Plan when to give medications
What is the dialyzer and what does it do?
Artificial kidney, acts as the filter for the impaired kidney
what is dialysate?
Solution made up of all the important electrolytes in the ideal extracellular concentration
What does diffusion do in dialysis?
Move waste products from blood to dialysate
What does osmosis do in dialysis?
Excessive water is removed
What does ultrafiltration do in dialysis?
Negative pressure applied to remove water
At what rate must blood be returned to the body?
300-500 mL/min
What types of vascular are used for vascular access in order from shortest to longer term use?
Non cuffed, cuffed, AV fistula
How is a double lumen cuffed catheter inserted?
By surgeon or interventional radiologist into the internal jugular vein
What is the point of the cuff in vascular access?
Reduces the risk of infection, stabilizes the catheter
What veins can be used for vascular access?
Internal jugular, femoral vein
What vein should never be used for access?
Subclavian
How do you make an AV fistula?
Surgically by joining (anastomosing) an artery to vein (best if its the own patients)
How long does it take for an AV fistula to mature?
2-3 months
What makes an AV fistula mature?
The fistula is large enough: there is increased blood flow, can accommodate two large bore needles
How do you make an AV graft?
Subcutaneously interposing a biologic, semi biologic, or synthetic graft material between an artery and vein
Why would someone get an AV graft?
Their vessels aren’t suitable or healthy enough for a fistula (diabetes)
What do we do when a patient has multiple access points?
Ask which one was the most recent, check for bruit/ thrill
What are the complications of someone on hemodialysis?
Clotting of the circuit, air embolism, inadequate/ excessive ultrafiltration, hypotension, cramping, vomiting, blood leaked, contamination of the blood, access complications
How well are fat soluble substances dialyzed out?
Not very
What med would you avoid on the day of HD?
Antihypertensive medications
When can you give once daily medications on days of HD?
After treatment
What’s the goal of nutritional and fluid therapy for a HD patient?
Minimize uremic symptoms and maintain fluid/ electrolyte balance
How much salt should someone on HD have a day?
2-3 g/day
What is a normal interdialytic (time between sessions) weight gain?
Less than 1.5kg
Why would someone go on PD for dialysis?
Those unwilling or unable to undergo HD or transplantation, fewer dietary and fluid restrictions, more compatible with lifestyle
What do you need to do to the dialysate fluid prior to PD?
Warm it to body temperature
What does warming the fluid do to the vessels in PD?
Dilates the peritoneal vessels to increase urea clearance
How should you warm the fluid in PD?
Dry heating machine, never microwave or warm water
What technique is necessary for PD?
Aseptic
What is the exchange in PD?
Infuse, dwell, and drain
How is the dialysate infused in PD?
Gravity, 5-10 minutes to infuse 2-3 L of fluid
How long does it take to drain the peritoneal fluid?
10-20 minutes
What are the complications of peritoneal dialysis?
Peritonitis, leakage, and bleeding, hypertriglyceridemia, abdominal hernias, hemorrhoids, low back pain
What is the most common complication of peritoneal dialysis?
Peritonitis
How would we know someone has peritonitis?
Cloudy dialysate drainage fluid, diffuse abdominal pain, rebound tenderness, lose protein through the peritoneal cavity, acute malnutrition and delayed healing
How do we treat peritonitis?
Intraperitoneal antibiotic 14-21 days
How do you educate the patient to prevent leakage in PD?
Avoid bending, lifting over 5 pounds, straining in bowel movements (stool softener needed!)
How can the nurse prevent leakage in PD?
Start the rate off slow (500mL) and gradually increase the volume to 2000-3000mL
Who is most likely to have bleeding in PD?
Menstruating women, the fluid pulls blood from the uterus into the peritoneal cavity
When is bleeding during PD normal?
When a new catheter is put in, stops in 1-2 days
How do we prevent blood clots for someone bleeding during PD?
Adding heparin to the dialysate and doing more frequent exchanges
What medications should the patient be on with hypertriglyceridemia in PD?
Beta blockers, ACE inhibitors, aspirin and statins to control blood pressure
Why do patients on PD have abdominal hernias, hemorrhoids, and low back pain?
Increased abdominal pressure
Why would someone go on acute intermittent PD?
Used for those hemodynamically unstable
What is the common routine for someone on acute intermittent PD?
10 minute infusion time, 30 minute dwell time, 20 minute drain time
What should you do if the patient is not draining well during acute intermittent PD?
Turn patient side to side or raise the head of the bed
What should you never do for someone on acute intermittent PD?
Never push the catheter
Why do patients like continuous ambulatory peritoneal dialysis?
Gives reasonable freedom and control of activities, less fluctuation in lab values and electrolyte levels because its so frequent
How often is continuous ambulatory peritoneal dialysis done?
7 days/ week 4-5 times a day
When does a patient on continuous cyclic peritoneal dialysis do their dialysis?
At night, the patient sleeps and the machine does the work. Patient is free from exchange through the day
When would a patient be on continuous renal replacement therapy?
Very sick, clinically unstable
Why is CRRT better than HD for a patient in the ICU?
Does not produce rapid fluid shifts or require machine or personel, does not require arterial access better tolerated and can be done by the critical care nurse
What patients with kidney transplants have better outcomes?
Those who do not have to go through dialysis before hand
What are the nursing management of dialysis?
Protecting vascular access, taking precautions during IV (slow rate), detecting cardiac and respiratory complications (pericarditis), controlling electrolyte levels and diet
How do you protect vascular access to an AV fistula?
Don’t use that arm for BP or blood draw. Prevent tight dressings, restraints and jewelry, assess bruit/thrill every 8 hours
What must a nurse do prior to kidney surgery?
Encourage fluid unless contraindicated, broad spectrum antibiotics if infection, coagulation studies
What are the chief complaints of someone post op kidney surgery?
Hemorrhage and shock
How to treat abdomen distention post op kidney surgery?
NG tube to decompress the abdomen
Why should you listen to bowel sounds post op kidney surgery?
To monitor paralytic ileus
When can we give oral fluids post op?
After the passage of flatus
What are the contraindications of kidney transplant?
Recent malignancy
active/ chronic injection
Severe irreversible extrarenal disease
Active autoimmune disease
Morbid obesity
Current substance abuse
What is an indicator of a successful kidney transplant?
Production of urine
How would we know the organ was rejected?
Oliguria, edema, increasing BP, weight gain, swelling or tenderness over the transplanted kidney or graft, rise in creatine for those taking neoral
How long is the hyperacute phase of rejection and failure?
Within 24 hours
How long is the acute phase of rejection and failure
Within 3-14 days
How do you minimize rejection of the transplanted kidney?
Combo of glucocorticoids and other meds to affect the action of lymphocytes
What are the side effects of these combo of meds?
Nephrotoxicity, HTN, HL, hirsutism, tremors, blood dyscrasias, cataracts, gingival hyperplasia, and several type of cancer
