Renal Flashcards
What do the kidneys do?
Maintain body fluid volume and composition and create urine for waste
filter in order to balance fluids & electrolytes
help make RBCs
help regulate BP
What do the kidneys help regulate?
Blood pressure, acid-base balance (produce erythropoietin for RBCs synthesis and convert Vitamin D to an active form)
What does aldosterone do?
Increases kidney reabsorption of sodium and water which restore BP, blood volume and blood sodium levels.
-Promotes excretion of potassium
-promoted the reabsorption of sodium in the DCT
What does vasopressin do?
increases tubular permeability to water, allowing water to leave the tube & be reabsorbed by the capillaries
-increases arteriole constriction
What happens to the kidney with age?
Loses cortical tissue and nephrons and gets smaller with age
-reduces ability to filter blood and excrete wastes
What can suggest kidney disease in patient’s older than 50?
Sudden onset of hypertension
What do you ask when assessing the function of the kidney?
-Changes in appearance (odor, color, clarity)
-ability to initiate or control
-changes in pattern
-changes in amount
-pain (flank, lower aBd, pelvic region, perineal area)
Symptoms of uremia
Anorexia, N/V, muscle cramps, pruritus, fatigue and lethargy
60.1- When obtaining a health history and physical assessment from a 68 year old male client who has a history of an enlarged prostate, which finding does the nurse consider?
A. distended bladder
B. absence of bruit
C. frequency of urination
D. dribbling urine after voiding
E. chemical exposure in the workplace
What pathologic conditions increase serum creatinine levels?
Just kidney disease!!!
What does it mean when serum creatinine levels double?
50% reduction of GFR
What happens with liver and kidney dysfunction
BUN is decreased
-this is due to the liver failure limiting urea production
What does it mean when both serum creatinine & BUN increase?
Kidney dysfunction
-not related to poor perfusion or dehydration
What happens when glomerulus filtration decreases?
Cystatin-C increases
(predictor of CKD)
High specific gravity indicates
-dehydration, decreased kidney blood flow, excess vasopressin: SIADH, stress, surgery, anesthetic agents, certain drugs
Low specific gravity indicates
high fluid intake, diuretic drugs or DI
Normal specific gravity
1.005 - 1.030
Normal microalbumin levels
less than 2.0 mg/dL
What indicates microalbuminuria
levels greater than 80mcg/24hr
CKD
gradual decline of kidney function
AKI
sudden onset of kidney function
(higher mortality rate)
Problems related to kidney function loss
waste elimination, fluid & electrolyte balance, disturbances in acid-base balance, build up of nitrogen-based wastes and loss of kidney hormone function
What lab value defines an AKI?
Increased serum creatinine by 0.3mg/dL or 1.5 times the baseline
or
urine volume less than 0.5mL/kg/hr for 6 hours
-creatinine can be used but too slow
Causes of AKI
reduced perfusion
damage to kidney tissues
obstruction of urine outflow
Risk factors for AKI
shock, cardiac surgery, hypotension, prolonged mechanical ventilation and sepsis
RF for AKI if hospitalized
older adults, DM, HTN, PVD, liver disease and CKD
Prerenal AKI
Source outside the kidneys creating conditions that impair renal perfusion
Intrinsic AKI
Inside of the kidney by disorders that directly effect the renal cortex or medulla
Causes of prerenal AKI
shock, dehydration, burns and sepsis
Causes of intrinsic AKI
allergic disorders, embolism or thrombosis of the renal vessels & nephrotoxic agents
Postrenal AKI
A urine flow obstruction
Causes of postrenal AKI
tumors, kidney stones or strictures
Pre & Postrenal compensations and what it does to the kidneys?
constricts kidney blood vessels, activating renin-angiotensin-aldosterone pathway and release of ADH
-increases blood volume and improves kidney perfusion but reduce urine elimination (oliguria and azotemia)
What to do with AKI?
ACT EARLY!
keep track of Is & Os over 2 hours
DW
What labs to monitor for kidney function?
creatinine, BUN, serum potassium, sodium, osmolarity, urine specific gravity, albumin-creatinine ratio, electrolytes
Immunity mediated AKI
Flu, colds, gastroenteritis & sore throats
What is prerenal?
Reduced perfusion
What happens during prerenal?
Shock, hypotension, anything that blocks blood flow to the kidney
What is intrarenal?
kidney damage
What happens during intrarenal?
glomerulonephritis, lupus, drugs that damage kidney, toxins, ischemia
What is postrenal?
obstruction
What happens with postrenal?
bladder cancer, kidney stones, prostate cancer or BPH
How do kidneys compensate in prerenal and postrenal?
-Activating the RAAS manifests in high BP
-constricting kidney blood vessels
-releasing ADH- holds onto fluid, holds onto more water so less urine
What happens to blood volume and kidney perfusion in prerenal and postrenal?
both increase
What do prerenal and postrenal cause?
oliguria and azotemia (build up of nitrogenous wastes)
What is included in a history assessment for AKI
drugs/toxins, DM, HTN, lupus, infection, dehydration, IV contrast, current condition
Assessment findings for AKI
history
oliguria
fluid overload
pulmonary crackles
increased oxygen demand/ RR/ dyspnea
edema
N/V
confusion
Diagnostics of AKI
increased serum creatinine
increased BUN levels
abnormal electrolytes
urine Na levels
metabolic acidosis
urine specific gravity
ultrasound
CT scans (no IV contrast)
MRI
xray/KUB
What are interventions for AKI
Intervene early (low UOP, edema, rising creatinine)
maintain MAP above 65
monitor Is& Os
fluid replacement or restriction
medications
central venous pressure
CCB
Nutrition
Renal replacement therapy
What are the nutrition interventions for AKI?
metabolic support
40g/day of protein (more if on dialysis)
potassium restrictions
fluid restrictions
Stages of CKD
Stage 1-5
Stage 1 of CKD
normal GFR/ increased
Stage 2 of CKD
mild disease/ decrease in kidney function/ mild decrease in GFR (60-80)
Stage 3 of CKD
moderate disease/ azotemia present/restriction of fluids/ GFR 30-59
Stage 4 of CKD
severe disease/ cannot maintain A-B & F-E balance/ dialysis may be needed/ GFR 15-29
Stage 5 of CKD
GFR < 15/ dialysis or death/ transplant
Diagnosing AKI (4)
elevated BUN
elevated creatinine
elevated potassium
decreased UOP
Assessment for CKD
fluid volume overload= breathing difficulty
elevated potassium = cardiac arrest
What happens in CKD when 75% of kidney function is gone?
kidneys are unable to
-maintain urine production
-maintain homeostasis
-BUN rises
-urine production decreases
What happens metabolically in CKD
-rise in BUN & creatinine
-increase phosphorus= decreases calcium so weak bones
Kussmaul breathing
renal osteodystrophy
metastic calcifications
vascular calcium deposits
itchy skin
What happens with the heart in CKD
HTN
malfunction of RAAS
hyperlipidemia
HF
pericarditis
cardiomyopathies
What are the hematologic impact of CKD
anemia
damaged platelets
What happens to the GI system with CKD
PUD
uremia leads to stomatitis
colitis
BUN/ creatinine -anorexia
N/V
hiccups
What are the skin changes with CKD
pruritis
bronzed skin
uremic frost
bruises
Assessment for CKD
urinary changes
alterations in taste
weight loss
uremic halitosis
weight loss -> anorexia
N/V
fatigue
drowsiness
confusion-> seizures & coma
neuropathies -> due to uric acid
fluid overload
HTN
dysrhythmias
Kussmaul breathing
signs of anemia
What are the signs of fluid overload?
crackles, JVD, edema
CKD patients should not lose or gain
2lbs overnight
5lbs in a week
CKD patients on dialysis should not gain
3lbs in between dialysis
Pharm therapy for CKD
lasix & antihypertensives
Interventions for CKD
DW
lasix & antihypertensives
fluid restrictions
nutrition
dialysis
When would diuretics be given to CKD
mild to severe (up until stage 3)
no diuretics if on dialysis
What do diuretics do?
increase UOP
decrease fluid overload
decrease BP
*monitor electrolytes & ototoxicity (lasix)
CKD medications
diuretics
antihypertensives
CCB
angiotensin
BB
Amount of protein a CKD patient should have
Less protein until on dialysis
How much potassium for CKD patient
60-70 mEq/dialy (restriction)
** because potassium is typically high in these patients
How much sodium for CKD
restriction
-b/c HTN, edema, HF (1-3 g/day) = early stages
-2-4g after starting dialysis
What is done with phosphorus for CKD
phosphorus binder is given with meals
Interventions/ teaching with CKD
infection prevention (avoid crowds)
injury prevention
be aware of meds processed by kidneys
high risk of fatigue -rest/activity balance
How long does is take AV fistula to mature?
6 months
Rules of fistulas
NO BP
NO venipuncture
feel thrill & listen to bruit Q4
assess distal pulses
assess for signs of infection
avoid pressure on fistula
-when accessed used sterile procedure
makes signs above bed so everyone knows there is a fistula
What is the most common fistula complications
thrombosis
What are the 4 fistula complications?
thrombosis
strictures
infection
ischemia
What are the long term vascular accesses for CKD?
AV fistula
AV graft
What are the short-term vascular accesses for CKD?
Vas cath
perm cath
What is a vas cath?
non-tunneled = higher risk for infection
large bore central line
intended for short-term use
*big risk for clot
What is a perm cath?
tunneled
large bore central line
intended for short term use
less risk for infection
cap with anticoagulants
What is peritoneal dialysis?
utilizes peritoneal cavity for exchange of fluids, wastes and electrolytes
What is lost in peritoneal dialysis?
protein
When is peritoneal dialysis not an option?
extensive abdominal surgery/adhesions
What are the complications of PD
infection
peritonitis
discomfort
bowel perforation
How to avoid peritonitis
sterile technique
ensure the catheter is not leaking
monitor for cloudy outflow/ effluent
check for abdominal tenderness
fever
What is the most commonly prescribed renal replacement therapy?
hemodialysis
What are the signs someone needs dialysis?
no response to diuretics
symptomatic hyperkalemia
calciphylaxis (vascular calcification & skin necrosis)
What are patients at risk for when receiving hemodialysis?
cardiac arrest and seizures - do to large volume shifts
What are patients at risk for when receiving hemodialysis?
cardiac arrest and seizures - do to large volume shifts
What is the care involved in hemodialysis?
warming
monitoring often
What can happen as a result of hemodialysis?
fatigue
changes in LOC
What is used for unstable patients?
continuous renal replacement therapy
What is continuous renal replacement therapy?
hemofiltration- uses a filter with fine pores
-avoids large volume shifts with HD but provides
-runs continuously for 24 hours a day
1:1 nursing
ICU setting
