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Unit 3 > Fluid and Electrolyte Imbalance - Renal > Flashcards

Fluid and Electrolyte Imbalance - Renal Flashcards

1
Q

Acute kidney injury onset

A

sudden - hours to days

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2
Q

AKI percent of nephron involvement

A

about 50%

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3
Q

AKI duration

A

2-4 wks; less than 3 months

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4
Q

AKI prognosis

A

good for return of kidney function with supportive care; high mortality in some situations

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5
Q

Chronic kidney disease onset

A

gradual - months to years

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6
Q

CKD percent of nephron involvement

A

90-95%

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7
Q

CKD duration

A

permanent

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8
Q

CKD prognosis

A

fatal without renal replacement therapy such as dialysis or transplantation

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9
Q

Prerenal AKI

A

result from conditions that reduce blood flow to the kidneys

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10
Q

Intrarenal AKI

A

result from damage to the glomeruli, interstitial tissue, or tubules

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11
Q

Postrenal AKI

A

result from obstruction of urine flow

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12
Q

Oliguria

A

Less than 400 mL/day

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13
Q

Anuria

A

Less than 100 mL/day

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14
Q

Pressure in kidney tubules > glomerular pressure

A

glomerular filtration stops

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15
Q

General manifestations of intrarenal and postrenal azotemia

A

generalized edema, weight gain

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16
Q

RIFLE Classification

A 
R - Risk,
I - Injury,
F - Failure, 
L - Loss,
E - End-stage kidney disease
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17
Q

R - Risk

A

serum creatinine = 1.5 times above normal;
GFR = decreased by >25% of normal (>90 mL/min);
urine output

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18
Q

I - Injury

A

serum creatinine = 2.5 times above normal;
GFR = decreased by >50% of normal (60-89 mL/min);
urine output

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19
Q

F - Failure

A

serum creatinine = 3 times above normal;
GFR = decreased by >50% of normal (30-59 mL/min);
urine output

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20
Q

L - Loss

A

complete loss of kidney function that persists for >4 wks;
GFR 15-29 mL/min;
no urine output without renal replacement therapy

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21
Q

E - End-stage kidney disease

A

complete loss of kidney function lasting more than 3 mos;

GFR

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22
Q

Prerenal azotemia

A

caused by poor blood flow to the kidneys that leads to ischemia in the nephrons

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23
Q

Causes of prerenal azotemia

A

heart failure, sepsis, shock, PE, anaphylaxis, pericardial tamponade

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24
Q

Reversal of prerenal azotemia

A

correct blood volume, increase blood pressure, improve cardiac output

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25
Q

Intrarenal AKI

A

caused by actual physical, chemical, hypoxic, or immunologic damage directly to the kidney tissue

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26
Q

Causes of intrarenal AKI

A

acute interstitial nephritis, exposure to nephrotoxins, acute glomerular nephritis, vasculitis, acute tubular necrosis, renal artery or vein stenosis or thrombosis, formation of crystals or precipitates in the nephron tubules

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27
Q

Postrenal azotemia

A

develops from obstruction to the outflow of formed urine anywhere within the kidney or urinary tract

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28
Q

Causes of postrenal azotemia

A

ureter, bladder, or urethral cancer, kidney, ureter, or bladder stones, bladder atony, prostatic hyperplasia or cancer, urethral stricture, cervical cancer

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29
Q

Prevention of progression to severe level of kidney injury

A

restore circulating volume, improve cardiac output, increase blood pressure

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30
Q

Manifestations of prerenal azotemia

A

hypotension, tachycardia, decreased cardiac output, decreased central venous pressure, decreased urine output, lethargy

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31
Q

Renal manifestations of intrarenal and postrenal azotemia

A

oliguria or anuria

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32
Q

Cardiac manifestations of intrarenal and postrenal azotemia

A

hypertention, tachycardia, JVD, increased ICP, tall T-waves on ECG

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33
Q

Respiratory manifestations of intrarenal and postrenal azotemia

A

SOB, orthopnea, crackles, pulmonary edema, friction rub

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34
Q

Gastrointestinal manifestations of intrarenal and postrenal azotemia

A

anorexia, nausea, vomiting, flank pain

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35
Q

Neurologic manifestations of intrarenal and postrenal azotemia

A

lethargy, HA, tremors, confusion

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36
Q

General manifestations of intrarenal and postrenal azotemia

A

generalized edema, weight gain

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37
Q

Serum sodium

A

136-145 mEq/L; remains normal, increases, or decreases

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38
Q

Serum potassium

A

3.5-5 mEq/L; increases in kidney disease

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39
Q

Serum phosphorus

A

3.0-4.5 mg/dL; increases in kidney disease

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40
Q

Serum magnesium

A

1.3-2.1 mEq/L; increases in kidney disease

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41
Q

Serum bicarbonate

A

23-30 mEq/L; decreases in kidney disease

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42
Q

Arterial blood pH

A

7.35-7.45; decreases in metabolic acidosis, or remains normal

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43
Q

Arterial blood HCO3

A

21-28 mEq/L; decreases in kidney disease

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44
Q

Arterial blood PaCO2

A

35-45 mm Hg; decreases in kidney disease

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45
Q

Hemoglobin

A

12-18 g/dL; decreases in kidney disease

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46
Q

Hematocrit

A

37-52%; decreases to 20% in kidney disease

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47
Q

Blood osmolarity

A

285-295 mOsm/kg; increases in volume depleted states

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48
Q

X-rays

A

check the size of the kidneys; may show stones

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49
Q

Renal ultrasonography

A

diagnosis of urinary tract obstruction; dilation of the renal calyces and collecting ducts, and visualization of stones; shows kidney size and patency of ureters

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50
Q

CT scans without contrast dye

A

identifies obstruction or tumors

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51
Q

Continuous arteriovenous hemofiltration with dialysis (CAVHD)

A

dialysate delivery system removes waste products in addition to plasma water; used in pts with limited CO, severe hypotension, those who don’t respond to diuretic therapy

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52
Q

Renal scan

A

determine whether blood flow to the kidneys is sufficient

53
Q

Cytoscopy/retrograde pyelography

A

identify obstructions of lower urinary tract

54
Q

Kidney biopsy

A

performed if the cause of AKI is uncertain, immunologic disease is suspected, or if the reversibility needs to be determined

55
Q

Diuretics (furosemide)

A

administered to pt without fluid overload; discontinued if diagnosed with oliguric kidney injury; monitor for signs of fluid overload

56
Q

Calcium Channel Blockers

A

used to treat AKI resulting from nephrotoxic acute tubular necrosis; prevents the movement of Ca into the kidney cells, maintain kidney cell integrity, and improves the GFR by improving kidney blood flow

57
Q

Vitamins/minerals (folic acid, FeSO4)

A

when on dialysis essential vitamins and minerals are removed from the blood; replacement is needed to prevent deficiencies; teach to take after dialysis, take iron with meals and to take stool softeners with iron

58
Q

Synthetic erythropoietin (epoetin alfa, darbopoetin alfa)

A

prevents anemia by stimulating RBC growth and maturation in bone marrow; teach to have Hgb monitored weekly

59
Q

Phosphate binders (aluminum hydroxide gel, aluminum carbonate gel)

A

high blood phosphate levels cause hypocalcemia and osteogystrophy; lowers serum phosphate by binding phosphorus present in food; teach to take with meals, separate digoxin by 2 hrs, take stool softeners, and report muscle weakness, slow or irregular pulse, or confusion

60
Q

Cardiac glycosides (digoxin)

A

used when heart failure induces kidney injury/disease or makes it worse; improves ventricular contraction, increasing stroke volume and cardiac output; teach to check HR daily and not to take antacids within 2 hrs of digoxin

61
Q

Dialysis therapy

A

used for pts with L and E levels of AKI; indications include uremia, persistent high K+, metabolic acidosis continued fluid overload, uremic pericarditis, and encephalopathy

62
Q

Hemodialysis lasting several weeks vascular access

A

subclavian, internal jugular vein or femoral vein (for 1 or 2 treatments)

63
Q

Subclavian vascular access for HD

A

inserted at the bedside; covered with sterile dressing; monitor for pneumothorax and subcutaneous emphysema; checked by X-ray before use

64
Q

Femoral vascular access for HD

A

avoided for more than 1 or 2 HD treatments d/t restrictions of mobility, hematomas, and infection

65
Q

Internal jugular vascular access

A

segment of catheter within the subcutaneous tissue before the jugular vein reduces risk of infection; placed in the radiology dept

66
Q

Hemodialysis catheter

A

has 2 lumens (inflow/outflow); 3 lumen is available for drawing venous blood or giving drugs and fluid without interrupting HD

67
Q

Peritoneal dialysis

A

uses the peritoneum as the dialyzing membrane; dialysate is infused through a catheter implanted in the peritoneum; fluid stays in cavity for specified time; fluid drains into a drainage bag; repeated as physician prescribes

68
Q

Continuous Renal Replacement Therapy (CRRT)

A

better tolerated than HD for critically ill pts because it avoids rapid shifts of fluids and electolytes

69
Q

Continuous venovenous hemofiltration (CVVH)

A

used with critically ill pts; powered by a pump; pump increases risk for air embolus; requires the use of anticoagulants; used in critical care units; pts require more continuous nursing care

70
Q

Continuous venovenous hemodiafiltration (CVVHD)

A

uses infusion pump, hemodialysis membrane, and dialysate solution; adds the dialysis membrane and dialysate soln instead of just filtering the blood; increases the efficiency of removing waste products; less efficient than CVVH; fewer adverse changes in blood volume and blood pressure

71
Q

Continuous arteriovenous hemofiltration (CAVH)

A

for pts with fluid volume overload, resistant to diuretics, have unstable BP and CO; placement of arterial and venous catheters; MAP must be at least 60; continuously removes plasma water, wastes, and electrolytes; risk for bleeding caused by anticoagulants used to prevent membrane clotting

72
Q

Continuous arteriovenous hemofiltration with dialysis (CAVHD)

A

dialysate delivery system removes wast products in addition to plasma water; used in pts with limited CO, severe hypotension, those who don’t respond to diuretic therapy

73
Q

Chronic kidney disease

A

progressive, irreversible disorder and kidney function does not recover

74
Q

Azotemia

A

buildup of nitrogen-based wastes in the blood

75
Q

Uremia

A

azotemia with clinical symptoms (metallic taste, anorexia, n/v, muscle cramps, “frost” on skin, itching, fatigue, lethargy, hiccups, edema, dyspnea, paresthesias)

76
Q

Main causes of ESKD

A

hypertension and diabetes mellitus; infection and genetic kidney disease

77
Q

Appearance of urine

A

note any changes in color, clarity, or odor

78
Q

Change in frequency or volume of urine passage

A

more or less frequent voiding not associated with changes in fluid intake may signal potential problems

79
Q

Discomfort or distress

A

pain, burning, urgency, aching, or difficulty with initiating urine flow or complete bladder emptying is of concern

80
Q

Carbonated soft drinks

A

decrease intake

81
Q

Kidney function

A

periodically ask for provider to measure your kidney function with a serum creatinine and urinalysis

82
Q

Hx of kidney disease, DM, HTN, or family hx of kidney disease

A

know serum creatinine level and 24-hr creatinine clearance

83
Q

If identified as having decreased kidney function

A

ask about whether drugs, diet, diagnostic tests, or therapeutic procedure will present risk to kidney function

84
Q

Neurological manifestations of CKD

A

lethargy, inability to concentrate, seizures, coma, slurred speech, asterixis, tremors, twitching, or jerking movements, myoclonus, ataxia, paresthesias

85
Q

Cardiovascular manifestations of CKD

A

cardiomyopathy, HTN, peripheral edema, heart failure, uremic pericarditis, pericardial effusion or friction rub, cardiac tamponade

86
Q

Respiratory manifestations of CKD

A

uremic halitosis, tachypnea, deep sighing, yawning, Kussmaul respirations, uremic pneumonitis, SOB, pulmonary edema, pleural effusion, depressed cough reflex, crackles

87
Q

Hematologic manifestations of CKD

A

anemia, abnormal bleeding and bruising

88
Q

Gastrointestinal manifestations of CKD

A

anorexia, n/v, metallic taste, changes in taste acuity and sensation, uremic colitis, constipation, uremic gastritis, uremic fetor, stomatitis

89
Q

Urinary manifestations of CKD

A

polyuria, nocturia (early), oliguria, anuria (late), proteinuria, hematuria, diluted straw-colored appearance (early), concentrated cloudy appearance (late)

90
Q

Integumentary manifestations of CKD

A

decreased skin turgor, yellow-gray pallor, dry skin, pruritis, ecchymosis, purpura, soft tissue calcifications, uremeic frost

91
Q

Musculoskeletal manifestations of CKD

A

muscle weakness and cramping, bone pain, pathologic fractures, renal osteodystrophy

92
Q

Reproductive manifestations of CKD

A

decreased fertility, infrequent or missed menses, decreased libido, impotence

93
Q

Psychosocial assessment of CKD

A

ask about pts understanding of diagnosis, assess for anxiety and coping styles; requires ongoing psychosocial assessment

94
Q

FOC: fluid overload

A

r/t inability of diseased kidneys to maintain body fluid balance; monitor input/output, hydration status, and fluid overload, daily weight; diuretics; fluid restriction

95
Q

FOC: potential for pulmonary edema

A

r/t fluid overload; assess for s/s of pulmonary edema; high fowlers; loop diuretics; morphine sulfate; monitor serum electrolytes, ECG tracings, and O2 sat

96
Q

FOC: decreased cardiac output

A

r/t reduced stroke volume, dysrhythmias, fluid overload, and increased peripheral vascular resistance; ACEI, ARBs, CCBs; teach to measure BP daily, weigh daily; monitor for manifestations of decreased cardiac output, heart failure, and dysrhythmias

97
Q

FOC: inadequate nutrition

A

r/t inability to ingest, digest food, or absorb nutrients as a result of physiologic factors; protein, sodium, potassium, and phosphorus restriction, vitamin supplementation; collaborate with dietitian, give written examples of diet

98
Q

FOC: potential for infection

A

r/t skin breakdown, chronic disease, or malnutrition; provide meticulous care where skin is not intact, provide preventative skin care where skin is intact, inspect vascular access site every shift, monitor VS

99
Q

FOC: potential for injury

A

r/t effects of kidney disease on bone density, blood clotting, and drug elimination; use lift sheet, observe ROM, unusual surface bumps, depressions over bones; get detailed drug history, assess for drug toxicity

100
Q

FOC: fatigue

A

r/t kidney disease, anemia, and reduced energy production; avoid vitamin/mineral supplementation before HD; anemic pt is treated with erythropoietin

101
Q

FOC: anxiety

A

r/t threat to or change in health status, economic status, relationships, role function, situational crisis, threat of death, lack of knowledge, loss of control, or disrupted family life; coordinate health care team, perform ongoing assessment of pts anxiety level, observe cues indicating anxiety, evaluate the support system; explain all procedures, tests, and treatments, provide education; encourage pt to discuss current problems, concerns, questions, and fears

102
Q

Most pts require about 12 hrs/week of total dialysis time

A

usually divided into 3 4-hr treatments

103
Q

Prevention of blood clots within the dialyzer

A

anticoagulation therapy; heparin is most common; pts receiving erythropoietin may need add’l heparin

104
Q

Heparin during dialysis

A

remains active in body for 4-6 hrs after HD tx; pt is at risk for hemorrhage during this time; avoid invasive procedures for 6 hrs; protamine sulfate is antidote

105
Q

AV fistula

A

long-term vascular access formed by surgically connecting an artery to a vein; most often used are the radial or brachial artery and the cephalic vein of non-dominant arm; need maturation time of up to 4 months before use

106
Q

AV fistula access

A

cannulate by inserting two needles (one toward venous, one toward arterial)

107
Q

AV graft

A

long-term vascular access used when the AV fistula does not develop or when complications limit its use; synthetic material

108
Q

Precautions of AV fistula/AV graft

A

assess for circulation; check distal pulses and cap refill; palpate for thrill; auscultate for bruit; skin stretching increases risk for injury in area

109
Q

Complications of AV fistula/AV graft

A

thrombosis, stenosis, infection, aneurysm, ischemia, heart failure

110
Q

Care for pt with AV fistula/AV graft

A

no BP readings, venipunctures or IV lines in accessed arm; elevate postop; encourage ROM; check for bleeding at needle insertion sites; assess for s/s infections; no heavy objects; sleep on non-accessed side

111
Q

Post-dialysis care

A

Monitor for hypotension, HA, nausea, malaise, vomiting, dizziness, muscle cramps, VS, hemorrhage

112
Q

Dialysis disequilibrium syndrome

A

caused by rapid decrease in fluid volume ad BUN levels during HD; can cause cerebral edema and increased ICP

113
Q

Infectious diseases

A

transmitted by blood transfusion in long-term HD; most common are hepatitis and HIV

114
Q

Continuous ambulatory peritoneal dialysis (CAPD)

A

infusion of 4 2-L exchanges of dialysate into the peritoneal cavity; remains for 4-8 hrs; 7 days/week; no machine necessary; allows constant removal of fluid and wastes; resembles kidney action more closely than HD

115
Q

Continuous-cycle peritoneal dialysis (CCPD)

A

automated cycling machine; exchanges occur at night; final exchange is left to dwell during the day and is drained the next night

116
Q

Automated peritoneal dialysis (APD)

A

uses cycling machine for dialysate inflow, dwell, and outflow according to preset times and volumes; 30-minute exchanges for 8-10 hrs; can be done while pt sleeps

117
Q

Intermittent peritoneal dialysis (IPD)

A

combines osmotic pressure gradients with true dialysis; 30-40 exchanges of 2L 3x/week; can be automated or manual

118
Q

Complication: Peritonitis

A

major complication of PD; common cause is connection site contamination; use sterile technique when caring for, hooking up, or clamping off

119
Q

Peritonitis manifestations

A

cloudy dialysate outflow (first sign), fever, abd tenderness, abd pain, general malaise, n/v; when suspected send specimen for culture and sensitivity, gram stain, and cell count

120
Q

Complication: pain

A

common; no longer occurs after a week or two of PD; warm dialysate bags before instillation (no microwaving)

121
Q

Complication: exit site and tunnel infections

A

difficult to treat and can become chronic; dialysate leakage and pulling or twisting of catheter increase risk; gram stain and culture should be performed when exit sites have purulent drainage

122
Q

Tunnel infection manifestations

A

redness, tenderness, and pain; treated with antimicrobials; deep cuff infection may require catheter removal

123
Q

Complication: poor dialysate flow

A

usually r/t constipation; kinked or clamped connection tubing, pts position, fibrin clot formation, catheter displacement

124
Q

Complication: dialysate leakage

A

clear fluid coming from catheter exit site; may take pts 1-2 weeks to tolerate a full 2L exchange without leakage; occurs more often in obese pts, diabetics, older adults, and long-term steroid therapy

125
Q

Other complications

A

bleeding, bowel perforation (brown effluent), may be blood tinged when PD is first started, bladder perforation (same color outflow as urine and same glucose level), infection (cloudy or opaque effluent)

126
Q

Nursing care for PD

A

mask, wash hands, done sterile gloves, remove old dressing, remove contaminated gloves; assess for signs of infection; use aseptic technique, don sterile gloves, clean around catheter site; apply pre-cut gauze over catheter site and tape edges only

127
Q

Nursing care during PD

A

VS, breath sounds, and weight before; continually monitor during, VS every 15-30 min, signs of resp distress, pain, or discomfort; outflow pattern should be a continuous stream after the clamp is completely open; measure total outflow after each exchange, inflow/outflow records; weigh daily to monitor fluid status

128
Q

Exclusion criteria for kidney transplant

A

advanced uncorrectable cardiac disease, metastatic cancer, chronic infection, alcoholism, chemical dependency

129
Q

Physical criteria for kidney donor

A

absence of systemic disease and infection, no hx of cancer, no htn or kidney disease, adequate kidney function

Unit 3 (4 decks)

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