Exam #1 Renal Flashcards
Renal
1
Q
How much do the Kidneys Filter?
A
Equivalent to all the bodys ECF ( 15 L ) every 100 mins
2
Q
Kidneys are able to make?
A
Adjustments to fluid volume
Electrolyte Composition
Acid Base Balance
3
Q
Kidneys secrete what hormone?
A
Renin, which plays a role in regulating blood pressure
Erythropoitentin which stimulates RBC production
4
Q
Kidneys are responsible for the production of
A
Calcitriol, the active form of Vit D which allows us to absorb calcium from our diet
5
Q
Blood enters the nephrons through the?
A
Large renal arteries and is filtered through the glomerulus, a specialized capillary. —> Bowmans Capsule and then –> proximal tubule
5
Q
Once in the nephron the fluid is called?
A
Filtrate, what will eventually become Urine
6
Q
Proximal Tubule –>
A
Loop of Henle —> Distal Tubule –> Common Collecting Ducts –> Kidney
7
Q
Should protein be in urine?
A
NO
8
Q
Water Soluble Drugs
A
Are easily excreted by the kidneys
9
Q
Charged / ionized substances
A
Also easily excreted ( K+, Mg+, Cl-, Na+, Ca+ )
10
Q
How does the liver help with excretion?
A
By making lipid soluble drugs more water soluble so they can be removed by the kidneys.
11
Q
Kidneys also filter into urine…
A
Excess amino acids, glucose, bicarbonate ions, hydrogen ions
12
Q
Normal Blood Glucose Level
A
70-130 mg/dl
13
Q
Proximal Convoluted Tubule
A
A loop like structure of the kidney, reabsorbs 98% of glucose back into blood.
- Only when blood glucose level is normal
14
Q
At blood glucose levels beyond 300 mg/dl
A
The proximal tubule fails to reabsorb the filtered glucose and the glucose will start spilling into the urine.
15
Q
When kidneys are damaged…
A
Reabsorption and secretion mechanisms are impaired and serum drugs levels may be affected. ( Reduce dosage and frequency )
16
Q
Normal pH level
A
7.35-7.45
17
Q
If the serum level is too acidic then the pH number will be
A
Low
18
Q
If the serum level is too alkaline then the pH number will be
A
High
19
Q
Causes of Metabolic Acidosis
A
GI bicarbonate losses ( diarrhea )
Lactic Acidosis ( Sepsis, Hypoperfusion, metformin overdose )
Renal Failure leading to Uremia
20
Q
Causes of Respiratory Acidosis
A
COPD
Asthma Attack
Cardiac Arrest ( CO2 Build Up )
Depression of respiratory center
21
Q
Causes of Metabolic Alkalosis
A
Vomiting
NG Suction
Too much sodium bicarbonate
22
Q
Causes of Respiratory Alkalosis
A
Hyperventilating
23
Q
2 mechanisms to remove acid:
A
- The CO2 produced during body metabolism is an acid efficiently removed by the lungs during exhalation
- The kidneys remove excess acid in the form of hydrogen ions by excreting them in the urine. Kidneys can retain bicarbonate from the renal tubules
24
If retained in the body, CO2 and H+ would
Lower body ph thus the lungs and kidneys collaborate in the removal of acids to maintain normal acid base balance
25
Lungs play a vital role in...
Acid-Base Balance
- CO2 and acid is removed by the lungs during exhalation.
- When CO2 elimination is inadequate the retained CO2 will drive the release of acid hydrogen ions, the arterial blood becomes more acidic and this is called respiratory acidosis.
26
When hyperventilation occurs, and more CO2 is eliminated than normal... arterial blood becomes
Alkalotic, known as respiratory alkalosis.
27
Kidneys play a vital role in...
Acid-Base Balancing
- They excrete hydrogen ions and retain bicarbonate ions when hydrogen ions become too high.
- They retain hydrogen ions and excrete bicarbonate when hydrogen levels fall below norma.
28
When the excretion of hydrogen ions and retention of bicarbonate ions is not enough to eliminate the excess hydrogen ions in the body...
Arterial blood becomes acidic known as metabolic acidosis.
Eg; Renal Failure
29
If hydrogen ions are not maintained in the normal range ( too low ) or too abundant
Metabolic alkalosis occurs
Eg; Vomiting
30
What to do for acidotic patients?
To infuse sodium bicarbonate
( neutralizes acid in blood )
- BUT need to find cause! Just a "band-aid"
31
What to do for alkalotic patients?
Infusions of normal saline, concurrently with potassium chloride.
- Increases renal excretion of bicarbonate ions, which increases the acidity of blood by eliminating the acid buffer from blood.
32
For patients who can't tolerate extra fluid?
Fluid overload patients -->
Hydrochloric acid and ammonium chloride are 2 drugs that can quickly lower pH in patients.
33
ABG
Arterial Blood Gases
A clinical test that involves measurement of the pH of arterial blood and the amount of oxygen, CO2, and bicarbonate dissolved in arterial blood.
- Monitored in critically/acutely ill patients.
34
In the presence of respiratory acidosis
( retaining CO2 )
The kidneys compensate by excreting H+ ions and retaining bicarb ions.
- pH levels become normal and bicarb ions rise.
35
Compensation by the kidneys...
Is not quick, may take several hours for compensation to become noticeable and up to 4 days to be complete.
36
In the presence of respiratory alkalosis
The kidneys compensate for the increase in pH by retaining hydrogen ions and excreting bicarb ions.
37
In the presence of metabolic acidosis
Ventilation of the lungs increases through stimulation of central chemoreceptors in the medulla of the brain and peripheral chemoreceptors in the carotids and aortic arch- the CO2 levels fall and the equation is pushed to the left and the hydrogen concentration falls.
38
Metabolic Alkalosis
Is hypoventilation in which CO2 rises above normal- but respiratory compensation of metabolic alkalosis is variable and unpredictable. it is unlikely that a conscious patient will hyperventilate.
39
CO2 forms
H+ ions when retained by the body, leading to acidosis
40
What causes too much bicarb?
H+ shifting
41
Normal Urine Specific Gravity Range
1.003-1.030
- High = dehydration
42
Renal Failure is a
Decrease in the kidneys ability to maintain electrolyte and fluid balance and to excrete waste products
43
Primary treatment goal for a patient with renal failure is to
1. Maintain blood flow through kidneys.
2. Adequate urine output
44
Serum Creatine
Specific and sensitive indicator of renal function
45
BUN
Gross index of glomerular function and production / excretion or urea.
46
GFR ( Glomerular Filtration Rate )
It is the volume of filtrate passing through Bowmans Capsule per min
- Progressive decline = decline in number of functioning nephrons
47
Acute Renal Failure
Requires immediate intervention because retention of nitrogenous waste products such as urea and creatine can result in death
48
Acute Tubular Necrosis
Medical condition involving the destruction of epithelial cells. Common cause of ANF
49
Most common cause of ATN and ARF is
Renal Hypoperfusion
- And nephrotoxic drugs ( NSAIDS, IV contrast dye )
50
IV Iodinated Contrast Dye
( Iohexol )
Used for CT scan or cardiac catherization can cause kidney injury. ( Contact induced nephropathy ) so before a patient gets this dye we need a creatine level within previous 30 days and after procedure we either give 0.9% NaCl or we encourage fluids to flush out kidneys
51
Side effect of Metformin
- Lowers blood glucose level
Is lactic acidosis
52
What to discontinue before IV contrast dye procedure?
Metformin: then restart 48 hours later after stable kidney function has been documented
53
Cardiac Alterations with Renal Failure
CV is the leading cause of death for ESRD
- Hypertension
- CHF
- Pericarditis: Membrane that surrounds the heart becomes inflamed/ irritated because of waste build up.
54
Renal Alterations with Renal Failure
Abnormal Electrolyte accumulation in the bloodstream because anuric.
( why you do not supplement electrolytes with someone who was ESRD )
Anuria: Can't get rid of excess water, no extra fluid
Metabolic Acidosis: Waste is acidic and we can't get rid of it if we don't pee.
55
Hematologic Alterations with Renal Failure
Chronically anemic because they don't make suffcient amounts of erthyropoietin which is why we give Epoetin alfa SubQ for Hb <10 stop giving if above 11.
- Before giving Epoetin alfa check BP.... can cause HTN and if patient is already hypertensive you need to hold dose and call provider.
56
Psychological Changes with Renal Failure
Labile emotions or personality changes and may exhibit depression or agitation.
- Changes related to uremia and stress.
57
For a patient experiencing AKI r/t dehydration
( demand ischemia )
Administer IVF and try to improve perfusion and help kidneys recover. ( 0.9% NaCL )
Diuretics to increase urine output and decrease fluid retention ( Furosemide ); need patient to make urine.
58
Cardiovascular Drugs
Given to treat HTN and CHF which can exacerbrate renal failure
- Patient is any form of renal failure who reports N/V and HA: CHECK ON THEM RIGHT AWAY, could be hypertensive encephalopathy from uncontrolled hypertension.
- BP bring down after 1 hour of heart,brain and kidney damage can occur.
59
Monitor Electrolytes in Renal Failure
Especially K+, avoid use of potassium supplements or any meds putting at risk for hyperkalemia such as ...
- ACE inhibitors, potassium sparing diuretics
60
For patients who have diabetes and renal failure...
Control blood glucose with intensive insulin therapy
61
Nursing implications renal failure
1. All nephrotoxic drugs should be discontinued
2. Dosage reduction
3. Daily weight *
4. Dialysis
5. Nutrition modification
62
CKD patients are at risk for...
Fluid overload and hyperkalemia.
- Clients should avoid salt substitutes.
63
CKD dietary restrictions
Potassium restriction: bannans, oranges, carrots, tomatos, avocados.
Sodium Restriction: Cured meats, soy sauce, hot dogs.
Fluid Intake monitoring: Include monitoring of liquid based fluids ( popsicles )
Low Protein diet: 0.6-0.8 of protein
Low phosphorus diet ( chicken, turkey, dairy )
64
Safe food for CKD patients
Apples, pears, grapes, pineapple, blackberries, plums
65
Patients with diabetes are at high risk for
Hyperglycemia if they extend the dwell time for longer than prescribed.
66
S/S of peritonitis
Cloudy urine output, low grade fever, tachycardia, abdominal rigidity or tenderness.
67
Insufficient outflow results most often from
Constipation, when distended intestines block the catheters hole.
- Administer stool softners; docusate
68
Poor outflow? Nursing interventions for peritoneal dialysis
1. Reposition
2. Bag below level of abdomen
3. Check for twisting and kinks
4. Assess bowel patters
69
CAPD
Continuous Ambulatory Peritoneal Dialysis
Closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. ( 4-6 X )
- No machinery
- Fewer dietary restrictions
- Can do nightly
70
AVF
Hemodialysis Arteriovenous Fistula
The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken enabling blood flow.
1-4 months for AVF to mature
HD 3-4 runs 3x/week
71
Major complications of AVF
Infection, stenosis, thrombosis, hemorrhage.
72
Preventive Interventions for AVF
Report any numbness/tingling
Do not allow anyone other than dialysis to draw blood or take blood pressure measurements on the extremity to prevent thrombosis
Monitor capillary refill. Less than 3 secs.
Do not use the arm with vascular assess to carry heavy objects ( more than 5 LB ) : You can exercise like squeezing a ball.
73
Other Complications of AVF
Check the function of the vascular access several times a day by feeling for vibration ( thrill ) to assess for patency, stenosis and clotting.
- There should also be a bruit, ( swooshing sound )
- Absence of thrill/bruit = clot formation
Monitor for s/s of infection: purulent drainage from fistula site, red streaking, fever. HIGH RISK ( assessed 3x a week )
Sterile technique needed.
Monitor for excessive bleeding
74
Arterial Steal Syndrome
Results from vascular insufficiency after creation of an AV fistula.
Pallor, diminished pulse, pain
Can lead to necrosis.
75
Disequalibrium Syndrome
May be caused by rapid removal of solutes from the body during hemodialysis. Can cause cerebral edema
- Common to older adults and children, in their first few HD runs, especially when their BUN is high.
76
Disequalibrium Syndrome s/s
HA, N/V, HTN -->
AMS, tremors, seizures, coma
77
Disequalibrium Syndrome treatment
Early s/s may be treated with anticonvulasants
( lorazepam, diazepam ) because there is risk of seizures.
Reducing cerebral edema --> osmotic diuretics called mannitol ( sugar that pulls water out of the swollen brain cells and blood vessels )
78
Ways to prevent Disequalibrium Syndrome
Decrease length of HD.
- Patients new to HD will have shorter run times ( 1-2 hrs ) for a number of consecutive days ( 2-4 days ) to help the body adjust.
79
Complication of HD
Muscle Cramps!!!!!!!
Anemia
Bleeding
80
HD vs PD
Hemo: Better clearance, short time for treatment, have to leave home 3x a week, disequallibrium syndrome, muscle cramps, hemorrage, restricted diet
Peritoneal: Easy access, fewer hemodynamic complications, infections, less effective, protein loss, peritonitis, uses intra abdominal catheter
81
Medication timing for patients with ESRD
- Antihypertensives held before dialysis to prevent hypotension
- Checking all VS before dialysis
- Water soluable vitamins ( B,C ) , antibiotics and Digoxin all held before dialysis
- Client SHOULD take phosphurs before dialysis: Clients with ESRD have high phosphurs levels so dialysis does not filter enough to keep with body.
- Includes: Calcium, calcium carbonate, calcium acetate, non calcium containing= Sevelamer; blocks absorption of ingested phosphate, Aluminum Hydroxide = phosphate binder
- ^ watch for s/s of toxicity; AMS, bone pain
82
Always Weight a patient
Before / after dialysis
- Most accurate indicator of fluid loss/ gain
83
Drugs that increase K+ or are Nephrotoxic use w caution for ESRD
Potassium sparing diuretics ( spironolactone, triamterene, eplerenone )
ACE inhibitors ( lisinopril )
Angiotensin blockers ( losartan ) causes hyperkalemia
Nephrotoxic:
NSAIDS
ACE
Contrast DYE
Immunosuppresants ( Cyclosporine )
Antifungal ( Amphoterecin B )
Antibiotics ( Aminoglycosides .. gentamicin, vancomycin )
84
Lowering K+ w ESRD
1. Insulin 10-15 units w 50% dextrose ( 1st )
2. Bicarbonate infused over 5 min
3. If client has ECG changes like peaked tall T waves = Calcium Gluconate should be given FIRST
85
Lowering K+ Permanent with ESRD
1. Loop Diuretics ( Furosemide ) : Pt needs to make urine
2. Sodium Polystyrene Sulfonate : PO, unless pt has bowel obstruction --> can cause intestinal necrosis
3. Dialysis : last
86
Who experiences Polyuria
( Excess urine )
Diabtes Mellitus
High blood glucose levels --> high glucose levels in filtrate --> pull water into collecting duct and out of body
Diabetes Insipidus
Psychogenic Polydipsia: Urge to drink even in absence of thirst
- Associated with bipolar disorder and schizophrenia over 10 L a day
S/S: HA, behavioral changes, hyponatremia: muscular weakness, twitching, Vomitng, confusion, drowsiness, seizures
87
Potassium Supplementation
Hypokalemia usually creates a risk for life threatening cardiac dysrhythmias therefor clients taking loop diuretics / potassium wasting meds need supplementation
- PO Potassium chloride ( KCI ): Erosive substance that can cause esophagitis. To prevent take with plenty of water at least 4 oz and remain upright for up to 20 mins after ingestion.
- Pill induced esophagitis is also common with tetracyclines and biophosphonates.
88
Potassium Chloride given IV
High alert drug never by IV push, intramuscular or SQ routes. If given IVP can stop heart!
- Concentration of 10 mEq can be administered though a peripheral vein
- 20 mEq if central / PICC
89
For a patient complaining of burning at PIV site
1. Always check for patency of the PIV. Always check before any new med infusion or before giving IVP med... flush with 7-10 ml of 0.9% NACL
- KCI irritates the vein so some discomfort is expected.
- Slow infusion rate!
90
Nephrotic Syndrome
An autoimmune disease, affects children 2-7 and its charactorized by increased permability of the glomeruls to protiens ( albumin )
- Loss of albumin in urine leads to hypoalbuminemia: this causes decreased plasma oncotic pressure which allows fluid to leak out of vascular spaces.
91
S/S Nephrotic Syndrome
Edema, fatigue, pallor, weight gain, loss of apetite, decreased urine output, loss of immunoglobulins
92
4 classifications of Nephrotic Syndrome
1. Massive proteinuria: Caused by increased glomerular permability
2. Hypoalbuminemia ( excess protein loss in urine )
3. Edema: Periorbital and peripheral edema and ascites: caused by low serum protein causing fluid to be pulled in tissues
4. Hyperlipidemia: increased compensatory protein and lipid production by liver
93
Treatment for Nephrotic Syndrome
1. Corticocosterioids / immunos
2. Appetite managment
3. Infection preventions
4. Bed rest when edema is severe
5. Diuretics if fluid overload
6. Salt restriction
94
Renal disease ends in "itic " or "itis"
Caused by inflammation = infection
95
Wilms Tumor
Kidney tumor that usually occurs in children age <5
- Involves only one kidney and the prognosis is good if tumor has not metastisized.
- Unusual contour in abdomen
- DO NOT PALPATE ABDOMEN!
96
Kidney Stones
Formation of stones anywhere in urinary tract; renal calculi.
Causes: Decreased urine volume, increase urine pH, high calcium, UTI, family history
Clinical Presentation: Sudden pain, hematuria, N/V
Complications: Hydrpnephrosis devoleps if stone blocks ureter and urine backs up and dilates and damages kidneys. = Percutaneous nephrostomy tube to drain urine from kidney, URI, renal damage, hypertension
Diagnosis: X ray
Treatment: increase fluid intake, diet mod, lithotripsy (shock wave therapy)
97
Lithotripsy
Noninvasive procedure to use high energy acoustic shock waves to break up kidney stones. Temp ureteral stent may be placed, removed 1-2 weeks.
98
More ways to remove kidney stones
1. Percutaneous Nephrolithotripsy
- Insertion of a needle and sheath through skin into pelvis of kidney.
- Tube may be placed to prevent obstruction; maintain patency is critical.
- If pt expeirencing flank pain on side of body and has no drainage; obstruction of urine flow
- Irrigation
99
Kidney Stones nursing implications
1. Increase fluids
2. Expect some bruising and pain of the back and flank pain.
3. Blood in urine, concerning if bright red for too long >24 hrs
4. S/S of infection report
5. Ambulation
100
UTI
Most common in women!
- Ascending route
- Pyelonephrititis causes flank pain that is in back.
S/S: flank pain, dysuria, frequency
101
Treating UTI
1. Aggressive hydration- 0.9% NACL
2. Cranberry Juice / tablet
3. Vit C
4. Antibiotics ( Trimethoprim Sulfamethoxazole )
5. Analgesics: NSAID/ acetaminophen
- Phenazopyridine Hydrochloride: will turn urine bright orange. Symtomatic relief only. so remain on antibiotics
102
Overeactive Bladder
Oxybutynin: anticholingergic
Side effects: new onset constipation, dry mouth, hyperthermia, blurred vission, drowsiness.
EX others: Tolterodine, Solifenacin
103
How to handle urinary retention?
Occurs most commonly in opiods use, anesthesia, older men due to enlarged prostate or BPH.
- First: Get to stand if safe!
- 2nd/3rd: Assess the suprapubic area and bladder scan.
- CAUTI is a significant hospital aqquired infection can be reduced by using indwelling catheter only when interventions have failed to produce urine.
- 4th intervention: Intermittent catherization if pt is unable to urinate or UR > 300-400 ml
