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N361: Pathophysiology II > Module 12 - Dialysis > Flashcards

Module 12 - Dialysis Flashcards

1
Q

Hemodialysis

A

process of separating elements in a solution by DIFFUSION across a semi permeable membrane DOWN a concentration gradient

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2
Q

Hemodialysis does the job of …

A

the kidneys

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3
Q

Hemodialysis allows for what 2 processes?

A
  1. Process for removing end products of nitrogen metabolism (urea, creatinine, uric acid)
  2. Process for repletion of bicarbonate deficit associated with metabolic acidosis in CRF
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4
Q

What moves things around in hemodialysis

A

pressure moving down a concentration gradient via diffusion

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5
Q

How much blood is circulated through the dialyzer

A

100-250 mL in the dialyzer at one time moving through a semipermeable membrane

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6
Q

___ and ___ never mix in hemodialysis

A

blood and dialysate

*they are separated by a semi permeable membrane

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7
Q

How long does a hemodialysis treatment take

A

3 to 6 hours with an average of 4 hours

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8
Q

All the movement of hemodialysis is done by what kind of pressure

A

positive hydrostatic pressure

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9
Q

Hemodialysis can remove what from blood ata rate of 1 L/hr with a flow rate of 200-300 mL/hr?

A

Sodium and Water - goes across the membrane

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10
Q

Why is heparin administered into hemodialysis

A

when removing blood there is a greater chance of clotting so heparin is put into the extra corporeal blood as it is removed

The amount is determined by clotting times like PT and PTT

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11
Q

What sort of intravenous access is available for Hemodialysis

A
  1. Subclavian Catheter
  2. internal Jugular Catheter
  3. Aterio-Venous Fistula
  4. Arterio-Venous Graft
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12
Q

what IV accesses are more temporary for hemodialysis

A
  1. subclavian catheter
  2. internal jugular catheter
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13
Q

What do we need to do to check for the arterio-venous fistula or aterio-venous graft access?

A

palpate to feel a thrill and auscultate to hear a whooshing bruit indicating pressure going from high to low (that means the fistula is working)

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14
Q

__ is much better than using a vein for IV access

A

fistula

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15
Q

What is the basic way hemodialysis works?

A

Blood removed –> waste products removed, electrolytes balanced, excess water removed, blood filtered –> Returned to body as cleaned balanced blood

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16
Q

How many times a week does hemodialysis occur

A

2-4 times a week

done in an open room with other patients

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17
Q

Why does dialysate not have to be sterile

A

because bacteria is too large to cross the semipermeable membrane

but machines are cleaned after use

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18
Q

Dialysate

A

fluid with concentrations of products like IV fluids would have but does not have to be sterile

has a lower pressure than the blood to allow movement

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19
Q

How does Na, K, and Cl levels compare between the blood and dialysate

A

Blood and Dialysate have about the same Na and Cl but there is less K in the dialysate to allow pulling of it out of blood

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20
Q

Why is Na about the same in dialysate and blood

A

because we pull off fluid rather than sodium

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21
Q

How does Bicarbonate and Acetate concentrations compare between blood and dialysate

A

Bicarbonate and Acetate is higher in dialysate since the person does not have enough in the blood - it will move into the blood then to correct metabolic acidosis

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22
Q

Why is acetate moved to blood in hemodialysis

A

it metabolized into bicarbonate and can fix metabolic acidosis once shifted

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23
Q

How do Mg and Ca concentrations compare between dialysate and blood

A

they are about the same concentration but can be altered depending on the person

this is why its important to draw water blood levels to check to see if changes are needed

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24
Q

how much creatinine and urea is in the initial dialysate

A

none so that way it can be pulled off and removed

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25
Q

What is a physiological issue with hemodialysis

A

there is a fair amount of loss of cells in the process which contributes to anemia

also the lysis of cells means there more K potentially getting back in

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26
Q

What could mitigate the effect of lysis of cells releasing K in hemodialysis

A

use of a large bore needle with filters to prevent cell breaking and large specific tubing to prevent cell breakage

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27
Q

Why is there dextrose in the dialysate

A

to maintain oncotic pressure but it will not cross the membrane

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28
Q

What is movement of particles across a semi permeable membrane dependent on in diffusion

A

molecular weight and configuration of molecules

pore size of semi permeable membrane

solute concentration on both sides

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29
Q

Which way does Na, K, Cl, and HCO3 move in hemodialysis

A

in both directions to equalize concentrations

typically K goes into dialysate and bicarbonate moves to blood though

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30
Q

Which way does urea and creatinine move in hemodialysis

A

move from the blood into the dialysate solution from the concentration gradient

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31
Q

How does blood, cells, and plasma proteins move in hemodialysis

A

they stay on the blood side as the molecules are too large

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32
Q

Osmosis

A

movement water molecules from an area of higher concentration of osmotically active particles to a lower one

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33
Q

Which way does osmosis move in hemodialysis

A

pulls water from the blood into the dialysate solution

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34
Q

What helps osmosis occur for moving water to dialysate in hemodialysis

A

glucose/dextrose - osmotic pressure (pull)

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35
Q

Hydrostatic Pressure

A

fluid on the high pressure side of a semi permeable membrane moves to the lower pressure side

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36
Q

How does hydrostatic pressure work in hemodialysis

A

pressure (push) is applied to the blood which results in filtration of water from the blood into the dialysate

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37
Q

How does Temperature impact dialysis

A

as temperature increases, rate of diffusion and osmosis also increase

so the dialysate should be the same temperature as blood or slightly higher to speed things up, but not too high and too fast

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38
Q

Fresh Dialysate pumped through the machine is always…

A

coming in contact with blood that is constantly moving through the system

but they never mix

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39
Q

Why may more venipuncture occur with hemodialysis and what may it cause

A

lots of blood draws if health is unstable and they need custom dialysate (stable health can get regular dialysate and less venipuncture)

this contributes to pain and anemia

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40
Q

Potential Complications of Hemodialysis

A

Hypervolemia

Hypovolemia

Hemolysis

Dialysis Disequilibrium Syndrome

Transfusion Hazards

Physical Discomforts

Blood leaks, air embolisms, and clotting in the dialyzer

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41
Q

Why may hemodialysis cause hypervolemia

A

from accidental infusions of saline into the patient

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42
Q

why is hypervolemia particularly bad for hemodialysis patients

A

often they have a cardiac history so the hypervolemia is very bad as water follows salt for their heart

this can cause a cardiac event quickly

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43
Q

Why may hemodialysis cause hypovolemia

A

excessive ultrafiltration too rapidly or efficiently

removal of excess water and electrolytes too fast can mean the body cannot adapt quickly and hypovolemic shock occurs

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44
Q

Why may hemodialysis cause hemolysis

A

wrong dialysate concentration or high temperature

once they are lysed the person can become more hypovolemic

the wrong concentration can also increase K levels and contribute to anemia as well

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45
Q

Dialysis Disequilibrium Syndrome

A

may occur with the initiation of dialysis

High levels of urea and creatinine in the blood and CSF are not removed quickly causing an osmotic gradient which pulls water into the CSF

this results in cerebral edema, increased ICP, N/V, convulsion, and coma

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46
Q

What are some transfusion hazards available from hemodialsysi?

A

if they need transfusions they are at risk for:

Reactions
HIV
Hepatitis
Excess K+

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47
Q

Why may physical discomforts occur with hemodialysis

A

chest pain and muscle cramps from rapid dialysis

repeated venipuncture pain with large needles

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48
Q

What are some psychological dysfunctions from Hemodialysis

A

Body image issues like incorporating the machine into their body image

Grief from loss of kidney functions

Frustration from basic drives like hunger and thirst from restricted diet and decreased sex drive changing relationships

Fear of life and death, the future, QOL

Dependence on healthcare and inability to do other life actions

Denial

Powerlessness Despair Hopelessness

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49
Q

How does suicide attempt rate compare in ESRD patients

A

it is 400x more than normal

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50
Q

Peritoneal Dialysis

A

another dialysis option

this dialysis uses the many capillaries of the peritoneum and the peritoneum itself as a semipermeable membrane for dialysis

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51
Q

What is the number one risk of peritoneal dialysis

A

Peritonitis

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52
Q

What is a huge difference and consideration for peritoneal dialysis compared to hemodialysis

A

in peritoneal dialysis the dialysate must be sterile as the peritoneum is a sterile cavity and bacteria could get in and cause peritonitis

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53
Q

What are signs of peritonitis with peritoneal dialysis

A

cloudy drainage and rebound tenderness

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54
Q

How often does peritoneal dialysis occur

A

3-5 times in 24 hours while awake

55
Q

Will more peritoneal dialysis drainage come out or go in

A

come out

56
Q

Why is peritoneal dialysate warm

A

to dilate blood vessels and improve urea clearance

another benefit is that it contributes to client comfort

57
Q

CAPD - Continuous Ambulatory Peritoneal Dialysis

A

a continuously running peritoneal dialysis bag

it gives more independence and ability to take vacations

it does require cognitive ability and manual dexterity to use though and has a higher risk of infection

58
Q

Why may CAPD be a preferred choice to hemodialysis

A

lots of urea and fluid builds up between hemodialysis treatment and this has less shock in comparison and less buildup when removing

also some people have fragile cardiovascular systems and need peritoneal dialysis as it is easier on the system

59
Q

How does peritoneal dialysate differ from hemodialysis dialysate

A
  1. Absolutely no K in the dialysate since we want it coming out
  2. Na, Cl, Ca, and Mg are about the same concentrations as blood
  3. In this glucose acts as an osmotic force to pull fluid from the blood and since there is no hydrostatic pressure it is more gentle on the body
60
Q

Benefits of Peritoneal dialysis

A

less stressful than hemodialysis in hemodynamically unstable patients

allow patients to be more flexible in terms of schedule, travel, and employment

there are automatized machines available that work at night and can tell you if it is not working

61
Q

Downfalls of Peritoneal Dialysis

A

it is less efficient that hemodialysis and longer treatment times are needed to get through a cycle

also you are continuously attached to the bag which can get old

you can feel dialysate in the peritoneum and can feel bloated at times

62
Q

How long is a peritoneal dialysis cycle

A

8 hours

63
Q

What in peritoneal dialysate causes osmotic removal of water

A

glucose

64
Q

What can the exchange volume of fluid into the peritoneum in peritoneal dialysis be

A

1-3 Liters

1 liter isnt bad but you can feel distention and bloating with 3

65
Q

Where is peritoneal dialysate infused

A

between the visceral and parietal components of the peritoneum - so the peritoneal cavity where there is abundant capillaries to do exchange

66
Q

Peritoneal Dialysis is infused via a ___ catheter

A

Tenckhoff

67
Q

____ are the membrane for exchange in peritoneal dialysis

A

capillaries

68
Q

How does drainage work in peritoneal dialysis

A

it is periodically drained and replenished in a tidal fashion

some is put in but more is drained out (but not as much as hemodialysis

ex: CAPD does this 4 times a day

69
Q

What is the goal of peritoneal dialysis

A

more drainage than inflow (negative water balance - removal of excess)

70
Q

What is the major complication of peritoneal dialysis

A

Peritonitis

repeated episodes will scar the peritoneum and reduce dialysis surface making poor exchange occur

71
Q

How to prevent peritonitis in peritoneal dialysis

A

Catheter tunneled under the skin exiting caudally with 2 Dacron cuffs to decrease infection risk

strict asepsis

UV radiation treatment to kill anything in the catheter

cap off procedure to prevent bacteria entering

72
Q

Tenckhoff Catheter

A

a catheter with 2 Dacron cuffs so Sub Q tissue grows into the Dacron and prevents bacteria entry

the first cuff is very close to the skin

this catheter can be used for ascites drainage as well

73
Q

Benefits of CAPD

A

need fewer blood transfusions

can eat a normal diet without fluid restriction since its always removing toxins

insulin can be added to dialysate for diabetics

do not spend long periods of times multiple times a week on a hemodialysis machine

also do not get wide variations in H and bicarb or K levels because this is continuous

74
Q

Acute Renal failure (ARF)

A

syndrome characterized by relatively rapid decline in renal function (measured by GFR) over a period of hours to days

develops very fast

75
Q

What is significant ARF associated with?

A

DAILY increases in serum creatinine and urea nitrogen

76
Q

Why is creatinine increases so significant in ARF

A

kidney function has decreased as creatinine increased

so if creatinine jumps from .9 to 1.9 that’s a 50% kidney function loss, triple from .9 to 2.7 means a 75% loss of function

77
Q

What is the most common cause of ARF

A

iatrogenic (we caused it)

50% of cases are iatrogenic with 60% being related to surgery

5% of patients total

78
Q

What sort of urinary output is common in ARF

A

Oliguria with urine flow less than 400 mL a day

Anuria could also occur but is uncommon

79
Q

What are the 3 types of ARF

A

Pre Renal (Before)

Intra Renal (in)

Post Renal (After)

80
Q

Pre Renal ARF

A

cause before the level of the kidneys

often it is hypovolemia causing this but there are other reasons

81
Q

Intra Renal ARF

A

cause is in the level of the kidneys itself like anything that kills nephrons

82
Q

Post Renal ARF

A

cause is after the level of the kidney

so something like an obstruction after this level causing retention or backup

83
Q

Pre Renal ARF Causes

A

Hypovolemia (The main one)

Cardiovascular Disorders

Peripheral Vasodilation

Renovascular Obstruction

Severe Vasoconstriction

84
Q

How does Pre Renal causes lead to ARF

A

it decreases the effectiveness of perfusion of the kidney parenchyma (nephron)

85
Q

What are some causes of Pre Renal ARF Hypovolemia

A

hemorrhage

burns

dehydration

GI losses like diarrhea and vomiting

diuretics and osmotic diuresis

third spacing like in peritonitis and burns

premature separation of the placenta

trauma

86
Q

What are some causes of Pre Renal ARF Cardiovascular Disorders

A

arrhythmias

cardiac tamponade

cardiogenic shock

heart failure

MI

anything that causes decreased kidney flow

87
Q

What may cause peripheral vasodilation that leads to Pre Renal ARF

A

antihypertensive drugs

sepsis

leads to lack of perfusion and circulating blood volume

88
Q

What may cause Renovascular Obstruction that leads to Pre Renal ARF

A

arterial embolism

arterial or venous thrombosis

tumor

blocks flow to the kidney

89
Q

What may cause Severe vasoconstriction leading to Pre Renal ARF

A

DIC

eclampsia

malignant HTN

vasculitis

prevents flow to the kidney

90
Q

Vasculitis

A

inflammation of the vasculature (constricts)

91
Q

Post Renal Causes for ARF

A

Ureteral Obstruction

Bladder Obstruction

Urethral Obstruction

92
Q

Examples of Ureteral Obstruction Post Renal Causes of ARF

A

blood clots

calculi

edema or inflammation

necrotic renal papillae

surgery - accidental ligation

tumors

uric acid crystals

93
Q

Examples of Bladder Obstruction Post Renal Causes of ARF

A

anticholinergic drugs

ANS dysfunction

infection

tumor

94
Q

Examples of Urethral Obstruction Post Renal Causes of ARF

A

1 is BPH

prostatitis

tumors

urethral stricture

95
Q

Hydroureter

A

enlargement of the ureter from backflow to the kidney

96
Q

What is the number one type of post renal cause of ARF in males

A

Urethral Obstruction from BPH

97
Q

Why does obstruction cause post renal ARF

A

because the back pressure can kill nephrons and lead to not enough blood getting to the kidneys

98
Q

Intra Renal (Renal) Causes of ARF

A

Acute tubular necrosis

obstetric complications

pigment release

parenchymal disorders

anything that kills the kidney itself

99
Q

What are some examples of acute tubular necrosis intra renal causes for ARF

A

ischemic damage to nephrons from poorly treated or unrecognized pre renal failure

nephrotoxins like analgesics, anesthetics, antibiotics, heavy metals, radiographic contrast media and organic solvents

100
Q

What are some examples of OB complications leading to intra renal ARF

A

eclampsia

postpartum renal failure

septic abortion

uterine hemorrhage

101
Q

What causes pigment release leading to intra renal ARF

A

crush injury

myopathy

sepsis

transfusion reaction

102
Q

Other Parenchymal Disorders that can cause Intra Renal ARF

A

Acute glomerulonephritis
Acute interstitial nephritis
Acute pyelonephritis
Bilateral renal vein thrombosis
Malignant nephrosclerosis
Papillary necrosis
Peri-arteritis nodosa
Renal or multiple myeloma
Sickle cell disease
Systemic lupus erythematous
Vasculitis

sometimes something liek MI, CPR< or transfusion reaction can cause damage yet it does not involve the kidney directly itself

103
Q

What are the main reasons for Pre Renal, Post Renal, and Intra Renal ARF?

A

Pre Renal - Lack of perfusion / Hypovolemia

Post Renal - Obstruction

Intra Renal - Direct Organ Damage

104
Q

What are the stages of ARF

A
  1. Oliguric Phase
  2. Diuretic Phase
  3. Recovery Phase
105
Q

What signals the Oliguric Phase of ARF

A

decreased urinary output 50-400 mL/day and increased BUN and creatinine daily

106
Q

Complications of the Oliguric Phase of ARF

A

infection

HF from hypervolemia

PE

hyperkalemia

metabolic acidosis

GI bleeding (stress ulcers)

107
Q

How to manage infection in the oliguric phase

A

prevention of infection via NO indwelling catheter and good mouth care and pulmonary hygiene

108
Q

How should fluid management be done in the oliguric phase

A

daily weight should be taken with expected loss of .5 to 1 kg per day from catabolism

fluid replacement is then based on these weights

109
Q

In the oliguric phase it is important to avoid what?

A

negative nitrogen balance

for that reason high biologic value protein should be given for maintenance and repair, protein restrictions, sufficient carbs to stop catabolism of proteins and possible TPN if needed

110
Q

Nephramine

A

a special formula of TPN for ARF patients with fewer amino acids

111
Q

What may vary in Oliguric phase

A

Hyperkalemia levels

112
Q

What can be done to manage mild, moderate, and severe Hyperkalemia

A

Mild - Kayexalate PO or enema

Moderate - GIK insulin

Severe - Calcium gluconate, GIK, dialysis

113
Q

How do we manage and prevent acidosis in the oliguric phase

A

protein restriction

give sodium bicarbonate PO

dialysis if needed

114
Q

How do we prevent GI bleeds in the Oliguric phase

A

there is a chance of GI bleed from ulceration of the wall so we can prevent this with H2 inhibitors like Pepcid and axis

115
Q

Why does anemia occur in the oliguric phase

A

there is decreased production and survival due to azotemia occurring

116
Q

What neurologic manifestations can occur in the oliguric phase

A

convulsions and coma indicating need for dialysis since it is a s/s of encephalopathy

ay change in LOC of mental status indicates dialysis need

117
Q

Diuretic Phase

A

stage 2 lasting 7-14 days

urinary output progressively increases with it double each day until 1-2 L is met in 4-5 days

118
Q

How long does the oliguric phase last

A

for a few weeks - this is a risk for hypervolemia

119
Q

What is important to monitor for in the diuretic phase

A

hypovolemia since UO is increasing

120
Q

Recovery Phase

A

Stage 3 of ARF lasting 3-12 months

it is a convalescent phase where kidneys finish healing

can take up to a whole year to fix and may need dialysis during that time but not after

121
Q

ARF Prognosis

A

good chance for recovery but it takes time

122
Q

Nursing Responsibilities during the Oliguric Phase

A

Administer IV fluids for rehydration and watch for overhydration

Consistently evaluate mental status including anxiety and level of understanding

do accurate I&O

administer kayexalate (PO preferably)

100-150 gm CHO daily to reduce protein catabolism

administration of loop diuretics

restrict proteins to 10-20 gm with high biologic value

know and prevent conditions increasing protein catabolism

prepare for peritoneal or hemodialysis if indicated

123
Q

What fluid replacement is needed usually during the oliguric phase

A

usually 500-600 ccs to cover insensible water losses + whatever the UO was in the last 24 hours + any other measurable losses

124
Q

Hypervolemia in the oliguric phase can lead to PE which can show as what on assessmetn

A

crackles in the lungs

125
Q

Always take daily weights…

A

using the same scale

126
Q

Why do we give Kayexalate in the oliguric phase

A

it can lower serum potassium levels 1-2 mEq every 24 hours

127
Q

Why do we give 100-150 grams of carbohydrates to someone in the oliguric phase

A

to prevent protein catabolism and nitrogenous waste buildup

128
Q

What are some examples of food with proteins of high biologic value

A

milk

eggs

129
Q

Rapid administration or repeated doses of Lasix (loop diuretic) can cause what

A

deafness

130
Q

We administer loop diuretics to work on the loop of Henle. How can we tell if it is ARF or hypo perfusion to the kidney when giving this?

A

A fluid challenge

We give fluid and the diuretic

If it is ARF there will be little UO but if it is hypo perfusion there will be UO

131
Q

What are some conditions that increase protein catabolism that a nurse should know and prevent

A

fever

steroid use

immobilization

infection

necrosis

132
Q

Nursing Responsibilities during the Diuretic Phase

A

Watch for dehydration and salt depletion from UO doubling

Monitor daily electrolytes

Replace fluids (volume lost in 24 hours (UO) + 500-600 cc of insensible loss)

Daily weights on the same scale

protein intake increases as long as the BUN is low

133
Q

What measure of BUN can indicate an increase in protein intake during the diuretic pahse

A

A BUN under 80 mg/dL

134
Q

Nursing Responsibilities during the Recovery Phase

A

Follow up care

self care

teaching if on a special diet or medications / continued temporary dialysis use

N361: Pathophysiology II (20 decks)

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