Fluid and electrolytes, Kidney Disease and Dialysis Flashcards
Hypovolemia and how to treat it
> 5% weight loss, decreased skin turgor, dry mucous membranes, low BP, increased Hg/HCT, decreased UOP, Elevated Na, Increased SG
Treatment includes IV fluids + NSS
Hypervolemia and how to treat it
> 5% weight gain, edema, crackles, SOB, JVD, decreased Hg/HCT, Decreased Na, Decreased SG
Treatment includes diuretics, fluid restriction, salt restriction, dialysis
Hyponatremia and how to treat it
nausea, lethargy, change in mental status, headache, seizures
Treat with NSS/ Hypertonic saline (fluid overload- diuretics)
Hypernatremia and how to treat it
Thirst, dry mucous membranes, weakness, change in mental status
Treatment includes sodium restriction, increasing fluids, change in mental status
Hypokalemia and how to treat it
muscle weakness/ cramping, EKG changes, lethargy
Treatment includes oral/ IV replacement, dietary supplementation
Hyperkalemia and how to treat it
Nausea and diarrhea, muscle weakness, EKG changes
Treatment includes Kayexalate, diuretics, IV insulin and glucose, calcium chloride, sodium bicarb, dialysis
AKI
sudden and rapid loss of renal function (decreased blood flow, nephrotoxicity, obstruction)
AKI characteristics + goals of treatment
increased creatine, decreased GFR, azotemia, oliguria
Goals of treatment include minimizing risk of lethal and long-term complications
Azotemia
increased BUN
Prerenal- definition and causes
decreased blood flow, caused by hypoperfusion, hypovolemia, dehydration, GI losses, hemorrhage, hypotension, low CO, sepsis, burns, thrombosis
Intrarenal- definition and causes
damage to nephrons, caused by ATN, rhabdomyolysis, nephrotoxic meds, IV contrast, autoimmunes, infection
Postrenal- definition and causes
obstruction of urine flow, caused by renal calculi, strictures, thrombus, BPH, prostate cancer, bladder cancer, trauma to strictures
4 Phases of AKI
Initiation, oliguria, diuresis, recovery
Symptoms of AKI
Lethargy, Weakness, Headache, Muscle twitching, Tremor, possible seizures, Nausea, vomiting, anorexia, SOB, pulmonary edema, HTN, Dysrhythmia
Assessment of AKI
elevated BUN and crea, decreased GFR, hematuria, low SG, hyperkalemia, hyperphosphatemia, anemia, metabolic acidosis
AKI management
eliminate underlying cause, optimize renal perfusion (fluids and dopamine), maintain fluid balance (fluids and diuretics), correct chemical abnormalities (fluids, diuretics, dialysis), minimize further risk
AKI monitoring
fluid balance, daily weight, I&O, IV fluids, electrolyte balances
AKI assessing
edema, lung sounds, JVD, HR and rhythm, EKG
AKI prevent
infection, hyperkalemia, fluid volume overload, CKD
AKI pt ed
disease process, diagnostic testing, meds and treatments, self-care, follow up
Glomerulonephritis
acute inflammation of glomerular capillaries, 2nd to strep A, Epstein Barr, varicella, Hep B, HIV
AB antigen complexes deposit in glomeruli, may progress to CKD
symptoms of GN
hematuria, edema, decreased UOP, elevated BUN & creat, HTN, flank pain (cola colored urine)
treatment of GN
steroids, control HTN, treatment of infection, dietary protein restriction w/ increase in carbs
CKD definition
decreasd GFR >3 months, decreased quality of life, may progress to ESRD, significantly increases risk of CV disease
CKD risk factors
HTN, diabetes, cv disease, obesity, 60+, family history, use of nephrotoxic drugs, african americans
CKD Causes
Diabetes, HTN, chronic GN, PCKD, hereditary diseases, congenital diseases, renal artery stenosis/ thrombosis, cancer, nephrotoxic agents
Diabetic nephropathy
Glomerular damage & enlargement
Kidney filtration decreased due to
hyperglycemia
Blood proteins leak into urine
Affects afferent & efferent arterioles
Affects 30% of diabetics
Kidney disease is reduced when glucose levels are controlled
People at high risk for diabetic nephropathy
african americans, native americans and hispanics with T2DM
Diabetic nephropathy assessment
proteinuria, anasarca, HTN, acidosis
Diabetic nephropathy treatment
Control HTN
* Ace Inhibitors
* ARB’s
* Calcium channel blockers
* Eat moderate amount of protein
* high quality
* Low sodium & potassium diet
* Control HgAIC
Nephrosclerosis
hardening of renal arteries, secondary to HTN and diabetes (decreased renal blood flow) major cause of CRF
Malignant nephrosclerosis
DBP >130, More common in young adults, Men > women, 50%»_space; death if untreated
Benign nephrosclerosis
more common in adults 50+, BP >160/110
Treatment of nephrosclerosis
ACE inhibitors/ ARBs
Polycystic kidney disease
Fluid-filled cysts in kidneys»_space;> destroy
nephrons, Kidney enlargement, Can also occur in: liver, brain, heart
Symptoms of PCKD
HTN, abdominal/ flank pain, hematuria, constipation
Treatment of PCKD
BP control, pain control, antibiotics for infection, dialysis may be needed
Renal artery stenosis
Fibromuscular changes and atherosclerosis (thrombosis or renal aneurysm)
Assessment of Renal Artery Stenosis
difficult to control HTN, elevated creat, abd bruit, renal bruit, flank or upper abd pain
Renal Vein Thrombosis
Increased fibrinogen levels + increased platelet aggregation
»> hypercoagulation
* Serious risk for thrombus & emboli formation
* Renal vein = common site for thrombi
* PE may occur in 40% of patients
Treatment of renal vein thrombosis
anticoagulants, thrombolytics, surgical intervention
Kidney cancer
Renal cell carcinoma
* 5% of all cancers in U.S.
* 25% metastasize to lungs, liver, bone, brain
Risk factors include smoking, obesity, native americans
Symptoms of kidney cancer
often asymptomatic but may have palpable mass, hematuria, flank pain, weight loss, anemia
Treatment of kidney cancer
nephrectomy, radiation, chemotherapy, immunotherapy, renal artery
embolization (for pts. w/ mets)
CKD has how many stages?
5
Clinical manifestations of CKD
Increased Creatinine
* Decreased GFR
* Anemia
* Hyperphosphatemia
* Hypocalcemia
* Secondary Hyperparathyroidism
* Hyperkalemia
* Hypervolemia
* HTN
* Metabolic acidosis
CKD Assessment
fatigue, weakness, headaches, trouble concentrating, pruritis, increased BP, decreasing UOP, edema, nausea, decreased appetite, anemia, restless legs
CKD Treatment goals
Early referral to nephrologist
* Early referral for RRT planning
* BP < 130/80
* Control hyperglycemia
* Management of anemia»_space;
* epoetin (Procrit) injections
* Management of
hyperphosphatemia >
* Phosphate binders
* Reduced phos. diet
* Reduced Na diet
* Reduced K+ diet
* Fluid restriction
* Reduced alcohol use
* Smoking cessation
* Weight control & exercise
ESRD
end stage renal disease, GFR <15 ml/min, CKD stage 5
ESRD symptoms
inability to concentrate, confusion, tremor, asterixus
* dry skin, pruritis
* SOB, crackles
* edema, HTN, hyperkalemia
* nausea, decreased appetite, metallic taste, halitosis
* muscle cramps, restless legs
ESRD Assessment findings
Increased BUN, Creatinine
* Decreased GFR <15ml/min
* Decreased or absent UOP
* Hyperkalemia
* possible dysrhythmia
* Hypernatremia
* Hyperphosphatemia, Hypocalcemia,
Vitamin D deficiency, Elevated PTH
* bone disease
* Metabolic acidosis
* Decreased Hg, HCT, RBC’s
* Anemia of Chronic Disease
* HTN, edema, increased weight
* Pericarditis, pericardial effusion
ESRD Treatment
dialysis, renal transplant, diet (protein, restriction of sodium, potassium, phosphorus, uric acid, fluid restriction of <1L/day), use of phosphate binders, anti HTNs, Vitamin D, anti- anemics
Nursing Management of CRF and ESRD
Monitor
* Fluid Balance
* Daily weight
* I&O
* Electrolyte Balance
* Na, K, Phos, Calcium, Mg
* IV Fluids ≠
Assess
* Edema
* Lung sounds
* JVD
* Heart rate & rhythm
* EKG changes
Prevent Infection
* Venous access care
* CVC care
Patient Education
* Disease process
* Diagnostic testing
* Medications & Treatments
* Diet
* Fluid intake
* Self-care
* Follow up
Hemodialysis
removes excess fluid and waste products, individualized to pt needs, uses heparin to reduce clotting, is not curative
Complications of hemodialysis
bleeding, hypotension, muscle cramping, air embolism, weakness
Hemodialysis options
Incenter and home
How does hemodialysis work?
combo of diffusion of toxins, osmosis and ultrafiltration of fluids (uses the pressures)
Two different types of vascular access for HD
AV fistula, AV graft
complications include stenosis, thrombus formation, infection, aneurysm development
Nursing care for AV fistula
assess for bruit and thrill, infection, clotting, no venipuncture, torniquets, BP cuffs or restrictive clothing
Catheter use in HD
double lumen, tunneled, subclavian or IJ
assess for infection, sterile technique, occlusive, transparent dressing, do not use for IV fluids or blood draws
Nursing care before HD
Weigh patient
* Obtain labs before HD ??? **Often done during HD
* Early breakfast & morning care
* Routine assessment of fistula, graft, or catheter
* Medications:
* Give daily drugs after HD
* CV and HTN meds usually not administered before HD
* Most antibiotics after HD
Nursing care after HD
Vitals
* Routine access care
* Observe for disequilibrium after patient stands
* Monitor for bleeding – heparin was most likely administered during
dialysis & LARGE needles used
CVVH
common with AKI
* especially patient’s w/ hypotension and hemodynamic
instability
* requires double-lumen CVC
* usually temporary
* Intensive Care Unit
* UF = continuous & slow fluid removal
CVVHD
added dialysate to filter out waste products
Peritoneal dialysis
Uses peritoneal membrane
* Permanent PD catheter inserted
* Interventional Radiology
* Strict sterile technique
* No heparin use
* Multiple exchanges (cycles) daily
* Requires independence
* Increases freedom
3 stages of Peritoneal Dialysis
Infusion
* 2-3 liters
* 10-15 minutes
* Dwell
* 3-4 hrs.
* Diffusion & osmosis occur
* Drainage
* 10-20 minutes
* uses a closed system
* colorless or straw-colored fluid
Peritoneal Dialysis options
Continuous Ambulatory- most common, at home, gravity
Intermittent- hospitalized and hemodynamically unstable
Continuous Cyclic- overnight, computer based cycler, pt or caregiver
Nursing care during PD
Vital signs
* Warm dialysate — DO NOT MICROWAVE
* Hook dialysate bag to peritoneal catheter – sterile technique
* “Fill” - allow fluid to flow by gravity
* approx.10 min. for 2 liters
* patients may c/o abdominal pain & cramping (may radiate to shoulder)
* slow the rate to make patient more comfortable
* Disconnect & start “dwell” - time depends on MD orders
* “Drainage” – at end of dwell, connect drainage bag
PD education
Dietary education
* higher protein diet
* Increased fiber
* Less restriction of Na & K
* Fluid restriction
* Less restrictive than HD
* May produce urine
* Support services
* Prevention of infection
* sterile technique
* catheter care
* Awareness of complications
* peritonitis
* rupture of membrane
Care of Hospitalized Dialysis pt
Protect vascular access
* assess site for patency
* assess for signs of potential infection
* do not use catheter for BP or blood draws
* Carefully monitor
* fluid balance - IV therapy, accurate I&O, daily weight
* cardiac & respiratory status
* Lab results
* Assess for:
* signs of uremia
* signs of electrolyte imbalance
* pain & discomfort
Care of hospitalized dialysis pt continued
Medications:
* Hold CV & HTN meds prior to dialysis
* Antibiotics at end of dialysis
* Monitor all medications and dosages carefully
* Dietary considerations:
* sodium, potassium, protein
* sugar-free candy, lemon (to decrease thirst)
* Skin care:
* pruritus, moisturize skin, hygiene, trim nails, avoid scratching
* CAPD catheter care
* Stringent infection control measures
Kidney transplant
compatible ABO and human leukocyte antigens, donor can be related, unrelated or cadaveric
Recipient contraindications
malignancy, infection, COPD, severe PVD,
inoperable CAD, BMI >35, current substance abuse, history of non-adherence
Tesio catheter
catheter that allows pts to recieve dialysis w/o needing a surgical shunt, it is placed under radiological guidance
Donor contraindications
same as recipient plus HTN, DM
Hyperacute rejection
immediate to 24hrs, thrombosis, necrosis, requires removal
Acute rejection
2-14 days, tenderness at site, fever, malaise, possible reversal
Chronic rejection
several months/ years, possible reversal
Signs of rejection
edema, oliguria, fever, tenderness at site, weight gain, HTN, elevated
creatinine (≥ 20% rise = sign of rejection)
90% remain functioning at 1 year, treatment plan is individualized
