NURS 444 week 11 Flashcards
CKD
- kidney damage:
` pathologic abnormalities
` markers of damage
blood urine, imaging test - OR glomerular filtration rate (GFR) < 60 mL/min for >3 months.
5 stages of CKD based on GFR
- normal GFR 125 mL/min
`urine creatinine clearance test (24 hr urine)*** - end-stage renal disease (ESRD) occurs when GFR <15 mL/min
Gold standard for CKD
24 hr urine test
- creatinine < 100 not normal for anyone
Leading causes and CKD risk facors
HTN and DIABETES
risk factors:
- age> 60
- cardiovascular disease
- ethnicity
- exposure to nephrotoxic drugs
- family hx
Clinical Manifestations of CKD
itching
mental status change (main reason for dialysis) irritability
trouble sleeping
- alterations in potassium, phosphate and calcium, sodium, MG
- metabolic acidosis
- anemia
- bleeding tendencies
- infections
Clinical manifestations of CKD: urine
Polyuria:
- due to inability of kidneys to concentrate urine
- most often at night
- specific gravity fixed around 1.010
Oliguria:
- occurs as CKD worsens (<400 mL/24 hr)
Anuria:
- urine output <40 mL/24 hr
Uremia:
- syndrome in which kidney function declines to the point that symptoms develop in multiple body systems
- occurs when GFR < or equal to 10mL/min
Metabolic Acidosis
- headache
- decreased BP
- hyperkalemia
- muscle twitching
- warm, flushed skin (vasodilation)
- nausea, vomiting, diarrhea
- changes in LOC (^drowsiness)
- ## Kussmaul’s
CKD diag. studies
> H&P
dipstick evaluation/ UA
albumin-creatinine ratio (first morning void)
GFR/ creatinine clearance (preferred measure of kidney function)
renal US
renal scan
CT scan
renal biopsy
** rule out tumor or congenital problem
CKD nursing management & Health promotion
- prevention and early identification
- reg. checkups
- report changes in urinary appearance, frequency, and volume
- identify individuals at risk
historyhtn
` DM
` repeated UTI
CKD goals
- preserve existing kidney function
> Treat CV disease
prevent complications
provide patient control
Conservative management CKD
- extracellular fluid correction
- nutritional therapy
- erythropoietin
- calcium supp., phosphate binders**
- antihypertensive therapy
- lower potassium
- adjustment of drug doses
- ambulatory and home care
phosphate binders to rid body of phosphate
restrictions for CKD
^ protein
^ water
^ sodium
^ potassium
^ phosphate
ACUTE care: nursing management for CKD
daily weight
daily BP
identify s&s of fluid overload
identify s&s of hyperkalemia
strict dietary adherence
med. education
motivate in patients management of their disease
Dialysis
- initiated when GFR (or creatinine clearance) < 15 mL/min
- used to correct fluid and electrolyte imbalances
- remove waste products
- treat drug overdose
Principles of Dialysis
Diffusion: greater to lesser
Osmosis: lesser to greater solute
Ultrafiltration: water and fluid removal. results when an osmotic gradient occurs across a membrane
Peritoneal dialysis:
solutions and cycles
- Dialysate
- available in 1-2 L plastic bags
- glucose concentrations of 1.5%, 2.5%, 4.25%
- electrolyte composition similar to plasma
- solution warmed to body temp.
- three phases of PD cycle:
called an exchange
1. inflow
2. dwell
3. drain
Peritoneal Dialysis complications
!! exit site infection
!! peritonitis
!! hernias
!! lower back problems
!! bleeding
!! pulm. complications
!! protein loss
Types of hemodialysis grafts
- arteriovenous fistulae
- AV grafts
- temporary vascular access
Nursing Management:
Before Tx hemodialysis
- complete fluid status assessment
- condition of access
- temperature
- skin condition
- medications
Nursing management:
During Tx hemodialysis
> alert for changes in condition
VS q 30 to 60 min. (or more frequent depending on patients condition)
HD complications
!! hypotension
!! muscle cramps
!! loss of blood
!! hepatitis
HD and peritoneal dialysis considerations
- cannot fully replace hormonal and metabolic functions of kidneys
- can ease many symptoms
- can prevent certain complications
- patient/family need clear explanations of dialysis and transplantation
Kidney transplantation
B and O types have the longest waiting times
Types of Renal Transplants
- Cadaver
` need heart beating
` HLA and ABO matched
` national ntwrk UNOS - living-related
- living-unrelated
preferred to be ABO compatible but not necessary (paired organ donation)preferable to have HLS match
` careful emotional and physical eval. of donor
Contraindications for kidney transplant
^ advanced malignancies
^ untreated cardiac disease
^ chronic resp. failure
^ extensive vasc. disease
^ chronic infection
^ unresolved psychosocial disorders
Nursing management: preoperative kidney transplant
kidney transplant recipient
- emotional and physical preparation
- immunosuppressive drugs
- ECG
- CXR
- lab studies
nursing management: before incision in kidney transplant
- urinary cath placed
- antibiotic solution instilled
distends the bladderdecreases risk of infection - crescent-shaped incision
- surgery 3-4 hours
nursing management”
post-op kidney transplant
liver donor:
- care is similar to laparoscopic nephrectomy
- close monitoring of renal function
- close monitoring of hematocrit
- pain management Post-op care
nursing management: post-op care
Recipient
- maintenance of fluid and electrolyte balance is first priority*** ex. output is 200 mL so we replace with 200
- large vol. of urine soon after transplant
- urine output replaced with fluids mL by mL hourly
200mL out > 200 in - acute tubular necrosis (ATN) can occur
(may need dialysis) - maintain catheter patency
**we maintain graft of fistula just in case.
Hyperacute kidney transplant rejection
occurs minutes to hours after.
- first 24-48h
!! temp. >100
!! nausea
!! headache
!! pain
!! no BUN/ creat. improvement
** take kidney out
Acute
kidney transplant rejection
occurs days to months after transplant
** we increase amount of immunosuppressant drug which will usually resolve the problem
chronic
kidney transplant rejection
process that occurs over months or years
- irreversible
- immunosuppressants won’t work
- go back to conservative care
Goals of immunosuppressive therapy for kidney transplant
- adequately suppress immune response
- maintain sufficient immunity to prevent infection
Immunosuppressive med classes
+ cyclosporine
+ corticosteroid
+ monoclonal antibodies
Most common infection complications in the first month:
Kidney transplant
~ pneumonia
~ wound infection
~ IV line and drain infections
Fungal infections with kidney transplant
~ Candida***
~ cryptococcus
~ aspergillus
~ pneumocystis jiroveci
Viral infections with kidney transplants
~ CMV*** (one of most common)
~ Epstein-barr virus
~ herpes simplex virus
Kidney transplant: Complications
!! cardiovascular disease
!! malignancies
!! recurrence of original renal disease
!! dyslipidemias are also something to manage
!! regular screening is important**
Kidney transplant complications: Cardiovascular disease
- immunosuppression can worsen htn and hyperlipidemia
- adhere to antihypertensive regimen
main cause for malignancies in kidney transplant
immunosuppressive therapy
Risks for BPH
- family hx
- obesity
- physical activity level
- alcohol consumption
- smoking
- DM
BPH: obstructive symptoms
> due to urinary retention
decrease in calliber of force in urinary stream
difficulty initiating
intermittency
dribbling at end of voiding
BPH: irritative symptoms
associated w/ infection/ inflammation
< urinary frequency/ urgency
< dysuria
< bladder pain
< incontinence
BPH: Diagnostic studies
- H&P
- dig. rectal exam DRE
- UA w/ culture
- PSA levels
- serum creatinine
- TRUS scan
- uroflometry
- cystoscopy
BPH: goals
restore bladder drainage
relieve symptoms
prevent/ treat complications
BPH: collaborative care
- goals
- watchful waiting
- dietary changes
- timed voiding schedule
BPH: invasive therapy indications
+ decrease in urine flow sufficient to cause discomfort
+ persistent residual urine
+ acute urinary retention
+ intermittent cath. can reduce symptoms and bypass obstruction
Transurethral microwave therapy (TUMT)
+ outpatient procedure
+ microwaves directly to prostate through trans.urethral probe
+ heat causes death of tissue
- post-op urinary retention is common
- sent home w/ cath 2 to 7 days
- antibiotics, pain meds, and bladder antipasmodics
***NOT APPROPRIATE WHEN RECTAL PROBLEMS EXIST - SE: bladder spasms, hematuria, dysuria, retention
BPH: Transurethral needle ablation (TUNA)
> ^temp . of tissue for necrosis
low-wave frequency used
affects only tissue in contact with needle
majority show improvement of symp.
outpatient: local anasth. and sedation
lasts 30 min w/ little pain and quick recovery
some require cath
hematuria up to a week
COMPLICATIONS: urinary retention, UTI, irritative voiding symptoms
BPH: laser prostatectomy
- laser transurethrally to cut or destroy parts of the prostate
- visual laser ablation (VLAP)
` takes several weeks for results
` urinary cath. inserted - contact laser techniques
minimal bleeding during and afterfast recovery time
` patients may take anticoags. - photovaporization of the prostate
transurethral resection (TURP)
resectoscope through urethra to remove prostate
80 - 90% excellence
relatively low risk
hospital stay: spinal or general anesthesia
bladder irrigated first 24 hr to prevent mucous and blood clots
patients must stop anticoagulants before therapy
TURP complications
!! bleeding
!! clot retention
!! dilutional hyponatremia
!! retrograde ejaculation
TURP: nursing pre-op care
+ use aseptic technique when using urinary cath.
+ administer antibiotics preoperatively
+ provide opportunity to discuss sexual dysfunction problems
+ inform of possible compications
TURP: nursing post-op care
+ bladder irrigation to remove clots and ensure drainage
+ admin. antipasmodics
+ teach Kegel
+ observe for infection signs
+ dietary intervention
+ stool softeners
Discharge instructions after TURP
~ cath. care
~ managing incontinence
~ 2-3 L fluid intake
~ s&s of UTI, wound infection
~ prevent constipation
~ avoid heavy lifting
~ refrain from driving, sex as directed
