Renal Flashcards
what is an inflammatoryreaction in the glomerulus
Glumerulonephritis
Glumerulonephritis patho/causes:
A. Inflammatory reaction in glomerulus
B. Antibodies lodge in the glomerulus causes scarring and ↓ filtering
* main cause → filtering issue
Glomerulonephritis signs and symptoms:
a. Flank pain ( costovertebral angle tenderness - CVA tenderness)
b. Urinary output ↓ (oliguria)
c. Hematuria (blood in urine)
d. Proteinuria
e. Periorbital edema (eye swelling) which progresses to other areas of the body
f. ↑ bp
g. Fluid volume excess (FVE)
h. ↑ urine specific gravity
i. Azotemia → abnormally high BUN and creatinine***
j. Malaise and headache (due to toxins)
Glumerulonephritis treatment
A. Get rid of the STREP or the cause
B. Input and output (I&O)
C. Diuretics
D. Monitor blood pressure
E. Restrict fluids → fluid replacement = 24 hour fluid loss + 500 ml
F. Balance activity with rest
G. Dietary needs: ↑ carbs, ↓ sodium (Na), ↓ protein
H. Dialysis
Older clients and atypical symptoms with glomerulonephritis
A. Older clients - may experience fluid overload with dyspnea, enlarged neck veins, cardiomegaly and pulmonary embolism
B. Atypical symptoms - confusion, somnolence, and seizures (often confused with symptoms of primary neurologic disorders)
Glomerulonephritis client teaching:
A. Dieresis begins 1-3 weeks after onset
B. Blood and protein may stay in the urine for months
C. Teach signs and symptoms of renal failure
* malaise, headache, anorexia, N/V, ↓ urinary outputput and weight gain (notify PCP if signs and symptoms are present)
What is nephrotic syndrome?
A kidney disorder that causes the body to excrete too much protein in the urine (often caused by damage to small blood vessels in the kidneys)
Nephrotic syndrome patho:
- Inflammatory response in the glomerulus
- Big holes form
- Protein starts leaking in the urine (proteinuria)
- Hypoalbuminemic (↓albumin)
- Without albumin you can’t hold on to fluid in the vascular space
- Fluid from the vascular space goes to the tissues
- Edema
- ↓ amount of circulating blood volume
- Kidneys sense ↓ volume and want to replace it
- Renin-angiotensin system (RAS) ricks in
I1. Aldosterone is produced - Causes retention of sodium and water
- But since there’s no protein (albumin) to hold on to the fluid
- It goes into the tissues
- may lead to anasarca
What is anasarca?
Total body edema
What problems are associated with protein (albumin) loss
• Blood clots (thrombosis):
→ losing proteins that normallypreventblood from clotting; without these proteins blood can clot and put client at risk for thrombosis
• high cholesterol and triglycerides
→ liver compensates by making more albumin causing an increased release of cholesterol and triglycerides
Causes of nephrotic syndrome
Idiopathic but has been related to:
A. Bacteria or viral infections
B. NSAID’s
C. Cancer
D. Systemic diseases like lupus or diabetes
Signs and symptoms of nephrotic syndrome
A. Massive proteinuria
B. Hypoalbuminemia (low albumin)
C. Edema (anasarca)
D. Hyperlipidemia
Nephrotic syndrome treatment
A. Diuretics
B. Ace inhibitors to block aldosterone secretion
C. Prednisone to ↓ inflammation
D. Cyclophosphamide to ↓ the body’s immune response
• shrink holes so protein can’t get out
• immunosuppressed
• infection→ major complication *
E. Diet:
• moderate protein: 1-2 g/kg/day
• client can become malnourished fast
• ↓ sodium/salt (Na)
F. Lipid lowering drugs for hyperlipidemia
G. Anti-coagulation for up to 6 months
H. Dialysis
You should always limit protein with kidney problems except for…
Nephrotic syndrome
Nephrotic syndrome nursing considerations:
A. Daily weights
B. I&O
C. Measure abd. Girth or extremity size
D. Good skin care
What is an acute kidney injury (AKI)
A sudden episode of renaldamage; kidneys suddenly can’t filter the waste from the blood
• dev. Rapidly from hours to days and may be fatal
What is the goal of treatment for an acute kidney injury
To reverse it and prevent chronic renal failure
AKI causes:
A. Pre-renal failure : blood can’t get to the kidneys
• hypotension
• ↓HR (arrhythmia)
• hypovolemic
• any type of shock
B. Intra-renal failure: damage has occurred inside the kidney
• glomerulonephritis or nephrotic syndrome
• malignant HTN - uncontrolled hypertension and diabetes mellitus
• acute tubular necrosis - damage to the filtering bodies of the kidneys
. caused by hypotension, sepsis, or drugs that damage the kidneys
• dyes used in tests such as heart cath, and CT scan cause damage to the kidneys
• drugs (amino-glycosides are nephrotoxic)(‘mean’‘to kidneys)
• NSAID’s
C. Post-renal failure: urine can’t get out of the kidneys
• enlarged prostate
• kidney stones
• tumors
• urethral obstruction
• edematous stoma (ileal conduit)
4 phases of AKI:
- Initiation phase (when injury occurs)
- Oliguria/anuria phase (output may be <400 ml or even <100 ml in 24hr) (anuria is no urine output)
- Diuretic phase (kidney recovering)
- Recovery phase (3-12 months)
Signs and symptoms of an AKI:
A. ↑ creatinine and BUN
B. ↑ specific gravity
• fixed specific gravity: may lose abilityto concentrate and dilute urine
C. HTN (retaining fluid)
D. Heart failure (retaining fluid)
E. Anorexia, nausea/vomiting →retaining toxins!
F. Itching frost (uremic frost) →good skin care
G. Retaining phosphorus =↓ serum calcium (calcium pulled from bones) (calicium have and phosphorus an inverse relationship)
H. Anemia can occur with kidney injury → not enough erythropoietin
I. Hyperkalemia can cause lethal arrhythmias*
J. Metabolic acidosis → unable to filter or retain hydrogen or bicarb. *
What is erythropoietin?
A hormone secreted by the kidneys that stimulates red blood cell production
Treatment of AKI:
A. Goals:
1. Prevent complications
2. Manage signs and symptoms
3. Eliminate the cause of the injury
B. Nursing measures:
1. Bedrest to ↓ metabolism and caloric needs
2. TCDB
3. Monitor I&O
4. Daily weights
5. Monitor VS closely
C. Meds:
• loop diuretics or osmotic diuretics
• treat hyperkalemia with IV glucose and insulin
• IV calcium gluconate (dysrhythmias)
• polystyrene sulfonate to ↓ vitamin K
• phosphate binding drugs to prevent hypocalcemia
• give IV meds in the smallest volume allowed
Treatment of AKI part 2:
D.nutrition:
• ↑ carbs and fats
• low phosphorus diet
• avoid foods or fluids high in protein
• avoid food high in potassium (K+) like bananas, citrus, and coffee
E. Prevent infection:
• use aseptic technique
• meticulous skin care
• prevent pressure ulcers
• mouth/oral care
• no catheter, if possible
• protect from others who may have infectious disease
F. Renal replacement therapy (RRT) may be needed
G. Client and family support
H. Oliguric phase = 10-14 days
I. Diuretic phase: begins when output ↑
• fluid and electrolyte replacement based on labs
J. Recovery phase:
• client on ↑ protein and calories
• resume activity as tolerated
Renal replacement therapy (rrt) take over or replace the kidney function when…
*BUN and creatinine can’t be decreased
* FVE is compromising the heart and lungs
* hyperkalemia and metabolic acidosis can’t be treated successfully
What is hemodialysis
• The machine is the glomerulus (filter)
* done 3-4x/week → client must watch what they eat and drink between treatments
* anticoagulant given during hemodialysis to prevent blood clots → usually heparin → implement bleeding precautions
* depression → suicide
* before dialysis begins assess fluid status
** electrolytes and BP are watched constantly
*** unstable cardiovascular systems cannot tolerate hemodialysis
Clients must have ___________________ for hemodialysis
Vascular access
Types of access
Vascular → AVG or AVF
What happens during hemodialysis
Blood is being removed → cleaned → then returned at a rate of 300-800 ml/min ***
What is vascular access
A site to access a largeblood vessel because very rapid blood flow is essential to hemodialysis
Arteriovenous fistula (AVF)
Placed in the forearm with an anastomosis (surgical connection) between an artery and a vein
Arteriovenous graft (AVG)
A synthetic graft used to join the vessels (looped graft)
Which requires surgery
AVF and AVG both require surgery → the access site takes weeks to mature and be ready for repeated punctures
How many needles are used in dialysis
2 needles are inserted into the vascular access
* one needle will allow blood to be pulled from circulation and sent to the hemodialysis machine
* the arterial end of the access will remove the blood and the return is through the low pressure venous end
What is used for temporary venous access
Internal jugular or femoral vein - often used forcatheter placement;
**surgery is not req. For temporary placement
How do you care for the vascular access
***DO NOT USE FOR IV ACCESS (drawing blood, administering meds, etc.)
* No bp
* no needle sticks
* no constriction
When a client hasan alternativevascular access hat is the assoc. Nursing care for the extremity
*No BP
* No needle sticks
* No constriction
Assessment of access
•Why → ensure patency
** thrill → cat purring sensation (palpate)
** bruit → turbulent blood flow (auscultate)
Feel the _________ hear the __________
Feel the thrill; hear the bruit
Continuous renal replacementtherapy (CRRT)
• Typically done in an ICU setting and is continuous so the client doesn’t have drastic fluid shifts
*NEVER move than 80 ml of blood out of the body at one time being filtered and therefore doesn’t stress the cardiovascular system as much
**CCRT is done on a client with → a fragile cardiovascular status and acute AKI injury (kidney injury)
A fragile cardiovascular status and acute kidney injury (AKI ) client needs what
Continuous renal replacement therapy (CRRT)
What is peritoneal dialysis
- Use peritoneal membrane as a filter
- dialysate is infused into the peritoneal cavity
- takes about 10 min. And remains in the peritoneal cavity for a prescribed amount of time →AKA DWELL TIME
- then the bag is lowered and the fluid, along with the toxins, etc. Are drained
→entire process is called an EXCHANGE - why do we WARM the fluid →cold promotes vasoconstriction
*** want it warm → promotes vasodilation and more blood flow
What color should the drainage be from peritoneal dialysis
Clear, straw colored
* should be able to read a newspaperthroughthe drainage/effluent
* cloudy = infection
What should you do ifall of the fluid doesn’t come out from peritoneal dialysis
Turn client side to side
Which client uses/needsperitoneal dialysis
Someone who can’t tolerate hemodialysis or someone who chooses peritoneal
2 types of peritoneal dialysis
- (CAPD) continuous ambulatoryperitoneal dialysis
- (APD) automated peritoneal dialysis
(CAPD) continuous ambulatory peritoneal dialysis
- Client must have the ENERGY/DESIRE to be active in theirtreatment and then also has the ability to learn and follow instructions
*** 4x/day/7 days a week
*NEVER USE IN CLIENTS with arthritis or disc disease → fluid causes pressure on back
*NO continuous peritoneal dialysis for clients witha colostomy →HIGH RISK for infection
(APD) automated peritoneal dialysis
- Connect their peritoneal dialysiscatheter to a cycle at night and their exchange is done automatically while they SLEEP →disconnected in AM
** allows for more freedom
Complications of peritoneal dialysis
• Exit site infection
** major complication → PERITONITIS
***S&S: 1. Abdominal pain 2. cloudy effluent
Dietary needs of peritoneal dialysis
*↑ fiber - have ↓ peristalsis due to abdominal fluid
*↑ protein - big holesin peritoneum and lose protein with each exchange
What are kidney stones
Nephrolithiasis - kidney stone Disease; urolithiasis or uterolithiasis → stone in ureter
S&S of kidney stones
• Pain, N/V
•WBC’s in urine
* hematuria (blood in urine)
* anytime you suspect a kidney-stone get a urine specimen ASAP
* if stone is present, client gets pain meds ASAP
Kidney stone treatment
• Ondansetron (Zofran)
•NSAIDS or opioid narcotics
* alpha adrenergic blockers (relax smooth muscles of uterer)
**↑ fluids
** STRAIN URINE- send stone for analysis
** extracorporeal shock wave lithotripsy (ESWL) to CRUSH STONE
• possible surgery to remove stone
What is the best indicator of effective shock ware lithotripsy (ESWL)
- Sand like sediment settled in thebottom of the indwelling catheter bag
