Dialysis and Kidney transplants lecture Flashcards
In what groups of people is CKD most prevelant
- 60 yrs or older
- African Americans
- Native Americans
- More men than women
Most common causes of CKD
- Diabetes
- HTN
Risk factors for CKD
- Diabetes
- HTN
- HLD
- Smoking
- Recreational drugs
- NSAIDs
- Obesity
- Glomerulonephritis
- Lupus
- Atherosclerosis
Artificial process for removing waste and water from the body when the kidneys no longer function
Renal Replacement Therapies or RRT’s, dialysis
Name some RRT’s
- Hemodialysis (HD)
- Peritoneal Dialysis (PD)
- CRRT
Hemodialysis (HD) uses what?
an artifical membrane
Peritoneal dialysis (PD) uses what?
A Permanent Tenckhoff indwelling catheter
Continuous RRT is used to treat what?
- Short term for ARF unstable - fluid volume overload (oliguric phase)
- Does not produce rapid shifts like hemodialysis
VV
RRT
Venovenous
AV
RRT
Arteriovenus
Goals of dialysis
- Remove end-products of protein metabolism (Cr & BUN)
- Maintain and correct electrolyte levels (elevated potassium)
- Correct acidosis
- Remove excess fluids
Neuro changes such as lethargy, AMS, and cognitive changes can indicate what?
excess build up of urea
What kinds of patients require dialysis?
AKI or ESRD with the following:
* Severe F/E imbalances
* Elevated creatinine and/or potassium
* acidosis
* uremic symptoms
* patients with GFR less than 10mL/min
Types of access for HD
Central Venous Catheter
Fistula
Graft
What type of HD access is this
For short term use or until long term AV fistula or graft
Central venous catheter
What type of HD access is this
Created by surgery with the artery & vein anastomosed and requires maturation of weeks to months
Fistula
What type of HD access is this
Created by inserting a prosthetic graft between the artery and vein
Graft
What needs to be monitored/checked before a patient goes to dialysis and after they return?
- Vitals (BP)
- Weight
- HD Access site
What type of dialysis is this?
- usually 3 times a week
- Sessions last 3-5 hrs
- duration of sessions, and number of sessions per week change as pt’s status changes
- Can be done outpatient, in the hispital, or at home
Hemodialysis
Complications associated with HD
- Hypotension
- Muscle cramps
- Headaches
- N/V
- Dizziness
- Malaise
- Systemic infection is a concern
- Dialysis dementia
- Localized AV fistula/graft complication
A dialysis patient is complaining of Light-headedness, N/V, seizures, vision changes, and chest pain what do you suspect?
Hypotension
S/S of Hypotension
- Light-headedness
- N/V
- Seizures
- Vision changes
- Chest pain
If hypotension is suspected during HD what needs to be done
Fluid removal rate needs to be decreased and NS therapy needs to be added
If a patient recieving HD is experiencing
- muscle cramps
- headaches
- N/V
- dizziness
- malaise
What needs to be done?
Filtration rate needs to be slowed
or
NS Bolus
HD patients are at higher risk for what?
- Hep B
- Hep C
- HIV
What is this complication of HD
- Progressive, potentially fatal neurological complication from long-term dialysis
- May be d/t aluminium present in phosphate binders
Dialysis dementia
What is this called?
Happens d/t very rapid changes in the composition of the extracellular fluid (why first HD runs slower)
Disequilibrium syndrome
All of the following are S/S of what?
- N/V
- Confusion
- Restlessness
- Headaches
- Decreased LOC
- Twitching
- Jerking
- Seizures
Disequilibrium syndrome
S/S of dysequilibrium syndrome
- N/V
- Confusion
- Restlessness
- Headaches
- Decreased LOC
- Twitching
- Jerking
- Seizures
How to treat dysequilibrium syndrome
- HD can be slowed down or stopped
- Infuse hypertonic saline solution, albumin, or mannitol to pull fluid off brain
What type of RRT is this?
- Indicated for acutely ill with AKI or severe fluid overload
- Limit risk of complications that happen in intermittent HD
- Slow and continuous, can be adjusted hourly depending how patient tolerates
Continuous Renal Replacement Therapy
CRRT
If a patient has vascular access issues or responds to HD poorly what is the second option?
Peritoneal dialysis
What type or RRT is this?
- Offers more control and flexibility
- Preforms independently or by a family member
- Greater mobility and fewer dietary restrictions
- Clearance of metabilic wastes are slower but more continuous
- Avoid rapid fluctuations in the extracellular fluid composition and associated symptoms
- Indicated in those with vascular access problems or those who respond to HD poorly
Peritoneal Dialysis
PD
Name the three phases of PD
Fill
Dwell
Drain
What phase of PD is this?
Room temp dialysate instilled
Fill
What phase of PD is this?
Instilled dialysate sits in abd for predetermined hours
Dwell
What phade of PD is this?
Effluent fluid via gravity
Drain
Name the types of PD
- Continuous ambulatory peritoneal dialysis (CAPD)
- Automated peritoneal dialysis
- Intermittent peritoneal dialysis
What type of PD is this?
- 4-5 exchanges a day with a dwell time of 4-6 hrs w/o machine
- Ambulatory during dwell time and/or sleeping
Continuous ambulatory peritoneal dialysis
or
CAPD
What type of PD is this?
- Uses cycler to preform multiple overnight exchanges
- Typically 30 min cycles, 10 min. Each phase for 8-10 hrs
Automated Peritoneal Dialysis
What type of PD is this?
Short dwell times, 30-40 exchanges a week, 30-60 min per exchange
Intermittent peritoneal dialysis
Contraindications of PD
- Hx of multiple surgeries
- Chronic ABD conditions (pancreatiti, diverticulitis)
- Reoccurent abd wall or inguinal hernias
- Obesity
- Pre-existing back problems or vertebral disease
- Severe COPD
Complications associated with PD
- Catheter infections
- Abd pain and/or distention
- Hyperglycemia and increase in tryglyceride levels r/t glucose in dialysate
- Outflow problems
- Respiratory compromise
- Protein Loss
What complication associated with PD is this?
- Cloudy effluent
- Increased WBC
- Redness
- Swelling
- Drainage
Catheter infection and peritonitis
If a pt recieving PD is suffering from chronic infections what is the next step?
Switching to HD
Dialysate contains glucose therefore it can cause what?
Hyperglycemia and an increase in triglyceride levels
If a PD patient experiences:
* A kinked catheter
* Catheter migration
* Constipation
What does it cause?
Outflow problems
Pt is recieving PD and effluent appears cloudy and WBC’s are increased. PD cath site appears red, swollen, and has some drainage. What do you suspect?
Catheter infection or Peritonitis
If a pt recieving PD is having reoccuent catheter infections and peritonitis what is the next step?
Swithing to HD
Specific assessments for PD
- ABD girth
- monitor outflow > inflow
- clear not cloudy
Nursing assessments specific to HD
- Listen to bruit
- Feel thrill
- Neuro checks
- post dialysis vitals & weight
Nursing assessments specific to CRRT
Frequent hourly VS & assessments
General Assessments for Dialysis
- Vital signs - specifically BP, o2, temp
- Daily weight
- Lab values- specifically renal function, electrolytes, CBC, H&H
- Nutritional intake - Na intake & fluid restrictions
A patient is going down for HD this morning. They are supposed to recieve metoprolol with their morning medications. What should be done? and why?
Metoprolol should be held until after HD. All BP meds should be held until after HD
Care for HD fistula/graft
- Avoid lying on fistula/graft, heavy lifting, procedures, blood draws, IV’s or BP’s in the arm with access.
- pt should preform exercises on access arm
Nursing interventions for CRRT
Requires intensive nursing support to preform and document hourly functions
Medication taken by dialysis patients that frequently experience hypotension with dialysis to try to maintain BP
Midodrine
General dialysis teaching points
- Teach compliance because it is required to sustain life
- Assist with social service and counseling services
- Refer to case management for OP setup
Teaching points for pt’s on PD
- Slow instillation if necessary - if pt exp abd pain
- Check tubing for kinks if intake > OP
- Proper positioning
- Check for abd distension
- Check dressing for dampness and when to chance to prevent infection
- Dialysate should be warmed
- Dialysate should be clear if cloudy call MD
Pt should be taught that if dialysate is cloudy not clear to do what?
CALL MD
Kidney transplant education
- Lifelong treatment no cure
- Requires immunosupressive therapy
Contraindications of a kidney transplant
- Untreated/metastatic cancer
- Refreactory CAD or heard disease
- psychosocial issues
Complications of a kidmey transplant
- Organ rejection
- Ischemia
- Renal artery stenosis
- Thrombosis
- Infection
A kidney transplant patient is experiencing the following:
* Onset 48 hrs
* Malaise, high fever
* graft tenderness
What do you suspect?
Hyperacute post kidney transplant rejection
A patient with a kidney transplant is experiencing the following:
* 1 wk-2 yrs
* oliguria
* fever
* HTN
* Flank tenderness
* lethargy
* increased BUN, K, Creatinine
* Fluid retention
What do you suspect?
Acute post-kidney transplant rejection
A patient with a kidney transplant is experiencing the following:
* Gradual over months to years
* Increase in BUN, creatinine
* imbalances in proteinuria & electrolytes
* Fatigue
What do you expect?
Chronic post kidney transplant rejection
How is Hyperacute post kidney transplant rejection treated?
Organ must be removed to decrease S/S
Most common and treatable form of kidney transplant rejection
Acute rejection
What can be done to treat acute kidney transplant rejection?
MD will increase the dosages of immunosuppression therapy
Nursing management of Kidney transplant patients
- Post-transplant VS and renal function labs
- Assess incision site and manage pain
- Daily weights & monitoring I/O
- Educate to avoid contact sports/injury to kidney and report S&S of infection
- Education on immunosuppression medication compliance
