Renal Flashcards
Glomerular filtration definition
Passive, non-selective process- hydrostatic pressure forces fluid and dilutes through membrane.
GFR definition
Amount of fluid filtered from blood into capsule per minute
Urine formation
- By Kidneys: processes 180 L of blood-derived fluid a day. 1% is excreted as urine, rest is returned to circulation.
- By nephrons via 3 processes.
- glomerular filtration
- tubular reabsorption
- tubular secretion
Serum creatinine
- 6-1.2 mg/dL (male)
0. 5-1.1 mg/dL (female)
Creatinine clearance
90-139 mL/min/m2 (male)
80-125 mL/min/m2 (female)
Serum albumin
3.2-5 g/dL
K+
3.5-5 mEq/L
Sodium
135-145 mEq/L
Calcium
4.5-5.5 mEq/L
Phosphorus
3-4.5 mg/dL
RBCs
4.0-6.2 million/mm3
GFR
125 mL/min
Polyuria
Urine volume >2L/day
Oliguria
Urine output
Hematuria
Most characteristic of glomerulonephritis. May also be due to trauma or tumor
Osmolality
1200 normal
RIFLE
Acute kidney injury progression CKD
R- risk I- injury F- failure L- loss E- end stage kidney disease
Types of AKI: pre renal azotemia
S/S
AKI: pre renal azotemia
- hypotension
- tachycardia
- decrease UO
- decreased CVP
- decreased cardiac output
- lethargy
Types of AKI: intrarenal; post renal key features
Renal:
- oliguria, anuria
- ^urine specific gravity
Cardiac:
- HTN
- tachycardia
- JVD
- increased CVP
- ECG changes; tall T waves
Respiratory:
- SOB
- Orthopnea
- crackles
- pulmonary edema
- friction rub
GI:
-anorexia, N/V, flank pain
Neuro:
Lethargy, HA, tremors, confusion
General:
-generalized edema, weight gain
BUN
10-20 mg/dL
Bicarbonate level
21-28 mEq/L
Decreases in kidney disease
Causes of Prerenal AKI
Any condition decreasing blood flow to the kidneys leading to ischemia in nephrons;
- shock (hypovolemia, hemorrhage)
- heart failure
- pulmonary embolism
- anaphylaxis
- sepsis
- pericardial tamponade
Causes of intrarenal AKI
Actual physical, chemical, hypoxic, or immunologic damage directly to kidney tissue;
- acute interstitial nephritis
- exposure to nephrotoxins
- acute glomerular nephritis
- vasculitis
- acute tubular necrosis
- renal artery/vein stenosis
- renal artery/vein thrombosis
- formation of crystals/precipitates in nephron tubes
Causes postrenal AKI
Obstruction of urine collecting system anywhere from calyces to the urethral meatus;
- ureter, bladder, urethral cancer
- kidney, ureter, bladder stones
- bladder atony
- prostatic hyperplasia, or cancer
- cervical cancer
Amount of fluid permitted
Equal to urine volume plus 500 mL
Indications for dialysis
Presence of uremia Persistent high K+ Metabolic acidosis Continues fluid overload Uremic pericarditis Encephalopathy
Peritoneal dialysis
Uses peritoneum as dialysing membrane.
Abdominal cath care needed.
Can be done at home
Fill, dwell, drain
Fluid should be clear, yellow
Hemodialysis
- HDC Have 2 or 3 lumens: inflow/outflow & blood draw.
- IJ or subclavian vein
- AV fistula or AV graft
- have to have dialysate
- complex, more efficient clearance
Chronic kidney disease
Progressive, irreversible disorder; kidney function does not recover.
Uremia S/S
- metallic taste in mouth
- anorexia
- N/V
- muscle cramps
- uremic “frost” on skin
- itching
- fatigue & lethargy
- hiccups
- edema
- dyspnea
- muscle cramps
- parasthesias
End-stage kidney disease
ESKD
When kidney function is too poor to sustain life
4 different types of CRRT
- SCUF
- slow continuous ultrafiltration - CVVH
- continuous vevo venous hemofiltration - CVVHD
- continuous vevo venous hemodiafiltration - CVVHDF
- continuous vevo venous haemodiafiltration
Never give hemodialysis pts these type of drinks
Citrus drinks.
Orange, grapefruit, prune, or tomato.
Cranberry is okay
Foods high in potassium avoided in hemodialysis pts
Oranges, bananas, prunes, extra milk. Not to be given.
Mandarin oranges are fine.
Check patency of fistula daily by:
Feeling for thrill over anastomosis along fistula.
And by listening for bruit with a stethoscope.
Hemodialysis
Used with patients in L & E levels of AKI.
Indications for dialysis include:
-presence of uremia, persistent high K+,
metabolic acidosis, cont. fluid overload, uremic pericarditis, & encephalopathy.
Hemodialysis catheter (HDC)
Usually in internal jugular or subclavian vein.
Femoral site may be used but only for a couple of days (high risk infection)
Subclavian HDC Inserted at bedside by physician or NP.
Monitor for manifestations of complications:
Pneumothorax (reduced breath sounds, tracheal deviation, poor movement one side of chest), subcutaneous emphysema.
Cath is checked by xray before use.
Nursing care for pt returning from dialysis
Monitor for side effects:
- hypotension
- N/V
- headache
- malaise
- dizziness
- muscle cramps
- assess vascular access site
- observe for bleeding
- monitor LOC
Obtain VS & weight to compare.
All invasive procedures must be avoided for 4-6 hrs after dialysis.
Digoxin
Pts with kidney failure at high risk for toxicity. S/S: -N/V -anorexia -visual changes -restlessness -headache -fatigue -confusion -bradycardia & tachycardia
Therapeutic range: (0.8-2 ng/mL)
Hypophosphatemia
Complication of phosphate binding, especially in pts who are not eating adequately but are continuing to take phosphate-binding drugs.
Aluminum based phosphate binders
Aluminum hydroxide
If taken for prolonged periods, aluminum deposits may cause none disease or permanent neuro problems. Monitor: -muscle weakness -anorexia -malaise -tremors -bone pain
Calcium acetate & calcium carbonate, aluminum hydroxide
Used as phosphate binding agents and help prevent renal osteodystrophy.
Phases of oliguric AKI
- Onset
Begins with precipitating event & cont. until oliguria develops - Oliguric phase
Urine output of 100-400 mL/24hr
Does not respond to fluid challenges or diuretics - Diuretic phase
Sudden onset wishing 2-6 wk post oliguric phase. Urine flow increases rapidly & can result in UO of up to 10L/day - Recovery phase (convalescent)
Pt begins to return to normal levels of activity. Complete recovery may take up to 12 mths.
Bumetanide
Loop diuretic
May cause muscle cramps, dizziness, hypotension, HA, nausea
Obtain baseline VS before admin, assess for edema.
Teach pt to eat foods high in K+ such as; whole grains (cereals), legumes, meats, bananas, apricots, OJ, potatoes, raisins.
Triamterene
K+ sparing diuretic
Anti edema, anti hypertensive
Side effects: fatigue, nausea, diarrhea, abdominal pain, leg cramps, HA
Watch for hyperkalemia (muscle changes, tremors, cramps, AMS, cardiac arrhythmias)
Calcium carbonate
Calcium acetate
Administer with meals, thoroughly chew tabs
Give plenty of water.
Teach: do not take within 1-2h of oral medications, fiber containing food
Sodium polystyrene sulfate
Kayexalate
Antihyperkalemic
Do not mix with OJ if giving PO.
Side effects: anorexia, N/V, constipation.
Can cause fecal impaction in elderly.
Monitor K+ levels, assess EKG, mag, calcium levels, daily bowel pattern.
Epoetin Alfa
Epogen
Glycoprotein, erythropoietin
Used in tx of anemia to lessen need for RBC transfusion in chronically ill pts.
Side effects: fever, diarrhea, N/V, edema
Potassium chloride
Potassium replenisher
Side effects: N/V, diarrhea, flatulence, abdominal discomfort w/distention, phlebitis with IV admin (particularly when concentration >40m q/L)
Assess for hyperkalemia; skin pallor/coldness, paresthesia, feeling of “heaviness” in lower extremities.
Caring for a pt with PD catheter
-mask yourself/patient. Wash hands
-put on sterile gloves, remove old dressing, remove dirty gloves
-assess for s/s of infection; swelling, redness, or discharge around site
-use aseptic (sterile) technique
***To clean use cotton swabs soaked in iodine
Cover with sterile two 4x4, tape only edges of gauze.
Dry weight
Weight after all the extra fluid is taken off
Major complication of PD
Peritonitis
*cloudy dialysate outflow (effluent), fever, abdominal tenderness, pain, general malaise, N/V
- Warm dialysate bags to promote comfort
- constipation may occur which leads to poor dialysate flow. (Stool softeners & high fiber diet)
- bowel perforation can occur
- when first placed dialysate outflow may be bloody or blood-tinged last 2 wks
Diffusion
Spontaneous free movement of particles (solute) across a permeable membrane down a concentration gradient.
From higher concentration to lower
Osmosis
Movement of solvent across semipermeable membrane.
(Membrane that allows a solvent, but not the solute to pass through)
From lesser to greater concentration.
Ultrafiltration
Using a medium fine enough to retain colloidal particles, or large molecules
Uremic syndrome S/S
Neuro: fatigue, sleep disturbances, HA, seizures, COMA
Psych: depression, anxiety, denial, psychosis
Ocular: red eye syndrome, band keratopathy, hypertensive retinopathy
Cardio: HTN, CHF, ASHD, pericarditis, myocardiopathy, uremic lung
Skin: pallor, pigmentation, pruritis, ecchymosis, calcium deposits, uremic frost
Metabolic: carb intolerance, hyperlipemia, gout
Endocrine: hyperparathyroidism, thyroid abnormalities, amenorrhea, infertility, sexual dysfunction
Peripheral neuropathy: restless legs, parasthesia, motor weakness, paralysis
Anemia, bleeding
GI: anorexia, N/V, uremic factor on breath, gastroenteritis, peptic ulcer
Hemodialysis diet
Restricted: fluids, phosphorous, sodium, potassium
Protein to maintain nitrogen balance
- too high = waste products
- too low = decrease albumin, ⬆️ mortality
Enough calories to maintain or reach ideal weight
PD diet
Protein is lost during PD so usually 1.2-1.5g/kg per day recommended.
High-cal supplements (ensure, boost)
Sodium restrictions vary
K+ rarely restricted
