Exam 3 Renal Saunders Flashcards
creatinine
end product of protein and muscle metabolism
reflects glomerular filtration rate
Kidney disease is the ONLY pathological condition that increases serum creatinine
serum creatinine increases only when at least 50% of renal fxn is lost
creatinine level
0.6-1.3mg/dL
a serum test that measures the amount of nitrogenous urea, a by-product of protein metabolism in the liver and indicate the extent of renal clearance of urea nitrogenous waste products.
BUN 8-25mg/dL
dehydration, poor renal perfusion, hight protein diet, infection, stress, corticosteriod use, GI bleeding, and muscle breakdown
reasons why BUN may be high
1.016-1.022
normal specific gravity
what increases specific gravity?
increased specific gravity is more concentration urine and is caused by dehydration, decreased renal perfusion, and increased ADH
Serum uric acid level
2.5-8mg/dL
What decreases specific gravity?
less concentrated urine results from Diabetes insipidis, increased fluid intake, or may indicate renal disease or the kidney’s inability to concentrate urine
normal GFR
125mL/min
Creatinine clearance test
includes obtaining a blood sample and time urine specimens-usually a 24 urine collection, but can be 8-12. blood is sampled when the urine specimen collection is complete and this is the best indication of GFR
Uric Acid Tests
24 hour urine test to diagnose gout and kidney disease
encourage fluid intake and a reg diet during testing.
VMA test
24 hour urine collection to diagnose pheochromocytoma, a tumor of the adrenal gland.
determines catecholamine levels in the blood
no caffeine, cola, vanilla, cheese, gelatin, licorice, and fruits for at least 2 days before and during urine collection.
ask HCP about prescription meds during test
pt should avoid stress
intravenous urography
NPO after midnight
administer laxatives if prescribed
inform client about possible throat irritation, flushing of the face, warmth or a salty or metallic taste during the test
encourage increased fluid to flush the dye to avoid kidney damage after procedure
Renography (Kidney scan)
an IV injection of radioisotope for visual imaging of renal blood flow, GFR, and tubular fxn and excretion. Consent, allergies, no dietary or activity restrictions, encourage fluids, radioisotope is eliminated within 24h. wear gloves for excretion precaution.
cystoscopy and bladder biopsy
NPO after midnight if biospy planned
if cystoscopy only, no special prep necessary
Renal biospy
assess coagulation studies and notify HCP if abnormal results
withhold fluids and food 4-6 hours before procedure
client is prone with pillow under abdomen during procedure
provide pressure to biopsy site for 30 mins post procedure
pt on bedrest for 2-6 hours
fluid intake of 1500-2000mLs
rapid loss of kidney function from renal cell damage
AKI
leads to cell hypoperfusion, cell death, and decompensation of renal fxn
AKI
intravascular volume depletion, dehydration, decreased CO, decreased PVR, decreased renovascular blood flow, prerenal infection or obstruction
prerenal causes of AKI
within the parenchyma of kidney; caused by tubular necrosis, prolonged rerenal ischemia, intrarenal infection or obstruction, and nephrotoxicity
Intrarenal causes of AKI
between the kidney and urethral meatus, such as bladder neck obstruction, calculi, and postrenal infection
post renal causes of AKI
8-15 days, the longer the duration, the less chance of recovery; sudden decrease in urine output
Oliguric phase of AKI
uremia
anorexia, n/v, pruritis
oliguric phase of AKI
signs of metabolic acidosis
Kussmauls breathing
oliguric phase of AKI
friciton rub, chest pain with inspiration, fevre
signs of pericarditis
oliguric phase of AKI
BUN/Cr elevated
oliguric phase of AKI
decreased urine specific gravity
oliguric phase of AKI
hyperkalemia, hypervolemia, hyperphosphatemia
hypocalcemia
oliguric phase
hypokalemia, hypovolemia, hyponatremia
diuretic phase of AKI
When is it important to restrict fluids in AKI?
during oliguric phase (previous 24 hours output+600mL)
what does excessive urine output in diuretic phase indicate?
that the kidneys are regaining ability to excrete waste
How often do you monitor urine and I&O in AKI?
qhour
What is important to note when monitoring weight?
increase of 0.5-1 lb in a day could indicate fluid retention
What is a typical AKI diet
low protein and high carbs, restricted sodium and potassium
the retention of nitrogenous wastes in the blood
azotemia
> 90mL/min
normal GFR, but at risk for CKD
60-89mL/min
mild CKD GFR
30-59 mL/min
moderate CKD GFR
15-28 .L/min
severe CKD GFR
<15mL/min
ESKD GFR with uremia
a slow, progressive irreversible loss in kidney function, with a GFR less than or equal to 60 mL/min for 3 months or longer
CKD
why could either hypervolemia or hypovolemia occur in CKD?
hypervolemia due to to kidney inabililty to excrete sodium and water
hypovolemia due to kidneys inability to conserve sodium and water
asterixis, ataxia, tremors, twitching or jerky mvmts
neurological manifestations of CKD
cardiac tamponade, cardiomyopathy, HF, HTN, pericardial effusion, pericardial friction rub, peripheral edema, uremic pericarditis
cardiovascular manifestations of CKD
crackles, deep signing, yawning, depressed cough reflex, kussmaul’s respirations, pleural effusion, pulmonary edema, SOB, tachypnea, uremic halitosis, uremic pneumonia
respiratory manifestions of CKD
abnormal bleeding and bruising
hematological manifestations of CKD
anorexia, changes in taste acuity and sensation, constipation, diarrhea, metallic taste in mouth, nausea, stomatitis, uremic colititis, uremic fetor, uremic gastritis (poss GI bleed), vomiting
GI manifestations of CKD
diluted, straw colored urine, hematuria, oliguria, anuria, polyuria, nocturia (early), proteinuria
urinary manifestations of CKD
decreased skin turgor, dry skin, ecchymosis, pruritis, purpura, soft tissue calcifications, uremic frost (late, premorbid), yellow-grey pallor
integumentary manifestations of CKD
bone pain, muscle weaknes and cramping, pathological fractures, renal osteodystrophy
musculskeletal manifestations of CKD
CKD meds
epogen, procrit for anemia due to decreased erythropoietin
folic acid (B9), iron and vit C, but not at the same time as the phosphate binders
stool softeners due to constipating effects of iron
blood transfusion
What is the cautionary advice about blood transfusions and CKD?
blood transfusions may cause the development of antibodies against human tissues, which can make matching for organ transplant difficult
why is there gastric bleeding in CKD?
urea is broken down by the intestinal bacteria to ammonia, which irritates the GI mucosa, causing ulceration and bleeding
Why cant you give asa to CKD pt?
Aspirin is secreted by kidneys–> aspiring toxicity and prolong bleeding time due to diseased kidney
tall, peaked t waves ,flat p waves, widened qrs complex, and prolonged PR interval
hyperkalemia
Why do you give Kayexalate to CKD patients?
Kayexalate binds to potassium to avoid hyperkalemia
Why would you give 50% dextrose and insulin to a CKD pt?
50% dextrose and insulin may be prescribed to shift potassium into the cell.
Why would you give calcium gluconate to a CKD pt?
calcium gluconate IV may be prescribed to reduce myocardial irritabilility from hyperkalemia.
why would you give an IV of bicarb?
to correct acidosis
drowsiness, lethargy, bradycardia, peripheral vasodilation and hypotension
hypermagnesemia
why is hyperphosphatemia a problem in CKd?
as phosphorus increases, calcium drops, stimulating PTH which leads to bone demineralization
when do you adminsiter phosphate binders?
with food and with stool softener or laxative b/c phosphate binders are constipating
Why does hypocalcemia occur in CKD?
high phosphorus and kidney’s inability to activate vit D which causes poor calcium absorption from intestines
why does metabolic acidosis occur in CKd?
kidneys are unable to secrete hydrogen and manufacture bicarb
why does peripheral neuropathy occur in CKd?
due to buildup of uremia on peripheral nerves
watch for Restless leg syndrome
presence of protein, RBCs and casts in urine
elevated levels of urea, uric acid, potassium, and magnesium in urine
uremic syndrome (result of either AKI or CKD) causes stomatitis
what is important to know about dialsylate for hd?
the dialsylate need not be sterile bc bacteria and viruses are too large to pass through the pores of the semipermeable membrane, however the dialsylate must meet specific standards, and water is treated to ensure a safe water supply.
Interventions pertaining to dialysis?
monitor vitals before, during, and aftr
client may have a slight fever due to warmed blood
assess for fluid overload before and fluid volume deficit after (weigh before and after), assess patency of access before, during, after, monitor for bleeding, heparin is added to dialysis bath to prevent clots from forming in the tubing of the dialysizer. hypovolemia and shock may occur during due to too much fluid/electrolyte removal
withhold antiHTN, water soluble vitamins, certain antibiotics, and digoxin bc they will be removed by dialysis anyway.
external AV Shunt care
dont get shunt wet
keep cannula clamps at bedside or attached to the AV dressing for use in case of accidental disconnection
notify HCP immediately is s/s clotting, hemorrhage or infection
access of choice for a pt with CKD requiring dialysis due to lowered risk for clot, bleeding, and infeciton
Internal AV fistula
the flow of arterial blood into the venous system causes the vein to become engorged (matured or developed)-this takes 4-6 weeks-hand flexing exercises help fistula to mature
Internal AV fistula disadvantages
cant be used immediately-need to mature
needle insertions necessary for dialysis
infiltration of the needles during dialysis can occur and cause hematomas
an aneuryism can form in the fistula.
HF can occur from the increased blood flow in the venous system
arterial steel syndrome
when would you use an internal AV graft?
when clients do not have adequate blood vessels for fistula
can be used 2 weeks after insertion
internal AV graft complications
clotting, aneuryisms, infection
too much blood is diverted to the vein and arterial perfusion to the hand is compromised
arterial steel syndrome
air embolus disequilibirum syndrome electrolyte alterations encephalopathy hemorrhage hepatitis hypotension sepsis shock
complications of hemodialysis
what do you do if your patient develops an air embolus?
stop hemodialysis
turn pt to left side, with head down (trendelenburg’s)
notify HCP
administer oxygen
assess vitals and pulse ox
document the event, actions taken, and client’s response
dyspnea, tachypnea, chet pain, hypotension, reduced oxygen saturation, cyanosis, anxiety, and changes to sensorium
signs of air embolus
a rapid change in the composition of the ECF occurs during dialysis, and solutes are removed from the blood faster than from the CSF and brain-fluid is pulled into the brain–> cerebral edema
disequilibrium syndrome
n/v, ha, htn, restlessness and agitation, muscle cramps, confusion, seizures
disequilibrium syndrome-stop HD-notify hcp-reduce environmental stimuli-prepare to administer a hypertonic IV solution like albumin or mannitol-prepare to dialysize patient for a shorter period of time at reduced flow rates next time
an aluminum toxicity from dialysate water sources containing aluminum. Also can occur from ingesting aluminum containing antacids (phosphate binders)
dialysis encephalopathy
progressive neurological impairment mental cloudiness speech disturbances dementia muscle incoordination bone pain seizures
dialysis encephalopathy-notify hcp-administer aluminum chelating agents as prescribed
peritonitis
abdominal surgery
abdominal adhesions
diverticulitis
contraindications to PD
dialysate soluiton for PD
sterile
higher glucose means more fluid will be removed during tx
what should be reported to HCP during PD?
outflow greater than inflow, frank bleeding or cloudiness in the outflow
fever, cloudy outflow, rebound abdominal tenderness, abdominal pain, general malaise, nv
peritonitis-obtain a sample for culture and sensitivity
what needs to be done before kidney transplant?
HD 24 hours before
immunosuppressive meds started 2 days before
treatment for trichomonas infection
flagyl or mycelex
treatment for yeast infections
mycostatin or diflucan
treatment for chlamydial infections
doxycyclin or azithromycin
flank pain and costovertebral angle tenderness, cloudy, foul smelling urine
pyelonephritis
Findings indicative of __________ are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to __________.
multiple myeloma
Hypercalcemia caused by bone destruction is a priority concern in the client with _________. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules.
priority of care in multiple myeloma
what is the most common symptom of bladder cancer?
The most common symptom in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also signs of a bladder infection.
more common in children >2 years of age, but can occur at any age. Inflammation of the glomerular capillaries often caused by a strep infection, a viral illness, or SLE
acute glomerulonephritis
kidneys become large, edematous, and congested; PROTEINURIA
acute glomerulonephritis
abnormally high levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood.
azotemia
when do you restrict protein?
when renal insufficiency and nitrogen retention develop (increased BUN)
When do you restrict sodium?
when the patient has HTN, edema, or heart failure (loop diuretics and antiHTN meds may be prescribed to control HTN)
Why are carbs encouraged?
provide energy and reduce catabolism of protein
characterized by proteinuria usually caused by repeated episodes of glomerular injury that results in renal destruction
chronic glomerulonephritis can progress to ESRD
Will someone with chronic glomerulonephritis have hypo or hyperkalemia?
Hyperkalemia due to decreased potassium excretion, acidosis, catabolism, and excessive potassium intake from food and medications
Why will someone with chronic glomerulonephritis have metabolic acidosis?
Metabolic acidosis from decreased acid secretion by the kidney and inability to regenerate and reabsorb bicarbonate
Will someone with chronic glomerulonephritis labs reflect hyper or hypoalbuminemia
Hypoalbuminemia with edema secondary to protein loss through the damaged glomerular membrane.
What happens to serum phosphorus and calcium in chronic glomerulonephritis? What is the cause of changes to mental status? Why is nerve conduction impaired?
Increased serum phosphorus level due to its decreased renal excretion
Decreased serum calcium level (calcium and phosphorus exist in an inverse ratio in the body) and decreased vitamin D activation
Mental status changes due to build up of nitrogenous wastes
Impaired nerve conduction due to electrolyte abnormalities and uremia
renal disease characterized by massive edema and albuminuria; disorder causes structural changes in glomerulus resulting in renal loss of protein, hypoalbuminemia, hyperlipidemia, and edema
nephrotic syndrome-confirm diagnosis with a needle biopsy of the kidney
occurs when kidneys cannot remove the body’s metabolic wastes or perform regulatory functions
renal failure
a sudden loss of kidney function caused by failure of renal circulation or damage to tubules or glomeruli
acute renal failure
prerenal failure
hypoperfusion of the kidney
intrarenal failure
renal parenchyma or nephron is damaged
postrenal failure
outflow of urine is obstructed
4 phases of renal failure
- initiation (initial insult of cellular injury an oliguria develops)
- Oliguric ( watch for dehydration
- Recovery may take 6-12 mos
progressive and irreversible deterioration in renal function taking place over months to years (characterized by GFR <20% or normal)
chronic renal failure
renal diet
limit protein, fluids, sodium, potassium, and phosphorus
Why would someone in chronic renal failure have a Risk for decreased Cardiac Output diagnosis?
: Risk factors may include: fluid imbalances affecting circulating volume, myocardial workload, and systemic vascular resistance; alterations in rate, rhythm, and cardiac conduction (electrolyte imbalances, hypoxia); accumulation of toxins (urea).
when is dialysis necessary?
hyperkalemia, fluid overload, impending pulmonary edema, acidosis, pericarditis, or severe confusion/encephalopathy
Pts. with diabetes or cardiovascular disease, many older pts., and those who may be at risk for adverse effects of systemic heparin are likely candidates for _____. Additionally, severe hypertension, heart failure, and pulmonary edema not responsive to usual treatment regimens have been successfully treated with _____.
periotoneal dialysis-monitor for peritonitis
is used with pts. demonstrating hemodynamic instability, such as hypotension, or in those who cannot tolerate rapid fluid shifts.
CRRT circulates the blood outside the body through a filter similar to the hemodialysis filter. A pump is used to assist blood flow
stones in ureter
stenting or ureteroscopy
large stones in kidney
percutaneous nephrolithotomy (PNL); small incision with a endoscope and stones are removed with forceps
small stones in kidney
lithotripsy; shock waves break up stone in ureter
urinary diversion pre op steps
administer antibiotics for 24 hrs before surgery, bowel pre beings 4 days prior to surgery, administer enema on night before surgery to clear fecal matter from bowel
