Renal Flashcards
Kidney function
Maintain acid base balance
Excrete end products of body metabolism
Control fluid and electrolyte balance ( Sodium and potassium)
Excrete bacterial toxins, water soluble medications and medication metabolites
Secrete renin to regulate the BP and erythropoietin to stimulate the bone marrow to produce red blood cells
Synthesize vitamin D for Calcium absorption and regulation of the PTH
Serum creatinine (50 - 120 mmol)
Measures the amount of creatinine in the serum. Creatinine is an end product of protein and muscle metabolism.
It reflect glomerular filtration rate. Kidney disease is the only pathological condition that increases serum creatinine. It increases only when 50% of function is lost.
Blood Urea Nitrogen (BUN) (3.6 - 7.1 mmol)
Measures the amount of nitrogenous urea, a by product of protein metabolism in the liver.
It indicates the level of renal clearance of the urea nitrogen waste products. An elevation does not always mean that renal disease is present.
Some factors that can elevate the BUN level include, dehydration, poor renal perfusion, intake of a high protein diet, stress, infection, GI bleeding, corticosteroid use and factors that can cause muscle breakdown.
BUN/Creatinine ratio
BUN is divided by the creatinine level to obtain the ratio
Elevated levels suggest renal dysfunction
Increased occurs with FVE
Decreased indicated FVD, obstructive uropathy, catabolic state and a high protein diet
Acute Kidney Injury/Failure: Causes
The rapid loss of kidney function due to renal cell damage. Occurs abruptly and can be reversible. AKI leads to cell hypo perfusion, cell death and the decompensation of renal function.
Causes:
Prerenal: Outside the kidney; caused by intravascular volume depletion such as with blood loss associated with trauma or surgery, dehydration, decreased cardiac output, decreased peripheral vascular difference, decreased perfusion/blood flow and prerenal infection or obstruction
Hypotension, irregular/decreased HR, any form of SHOCK (shock kills the kidneys)
Intra renal: Caused by tubular necrosis , prolonged prerenal ischemia, intrarenal infection or obstruction and nephrotoxicity
Glomerulonephritis, Nephrotic Syndromes, Dyes for heart cath and CT scan, Mycin drugs, malignant HTN and DM
Post renal: Between the kidney and urethral meatus such as bladder cancer, calculi and infection
Enlarged prostate, Kidney stone, Edematous stoma (ileal conduit)
Acute Kidney Injury: Oliguric Phase and Interventions
For some, Oliguria (less than 400 ml/day) does not occur and urine output is normal. Otherwise, it lasts for 8 to 15 days; the longer = less chance of recovery.
Symptoms: FVE ( HTN, HF), Uremia (anorexia, N/V, pruritus, uremic frost), metabolic acidosis, Neurological changes, Pericarditis. Anemia (Not enough erythropoietin)
Elevated BUN and Creatinine, decreased GFR, Hyperkalemia, Decreased Sodium, Hypervolemia, Hypocalcemia. Osteoporosis.
Client will be treated with fluid challenges (IV boluses of 500 to 1000 an hour), Fluids will be restricted, Diuretics given to increase renal blood flow and diuresis of retained fluid and electrolytes.
The signs and symptoms of AKI are primarily caused by the retention of nitrogenous wastes, the retention of fluid and the inability of the kidneys to regulate electrolytes.
AKI can progress to chronic kidney disease.
Acute Kidney Injury: Diuretic Phase and Interventions
Urine output rises slowly followed by diuresis. Excessive urine output indicates that damaged nephrons have recovered ability to excrete wastes.
Dehydration, hypovolemia, hypotension and tachycardia can occur. LOC improves. Hypokalemia, Hyponatremia and Hypovolemia (Be cautious of shock).
Administer IV fluids as prescribed, which may contain electrolytes to replace losses
Chronic Kidney Disease: Description and Causes
A slow and progressive and irreversible loss in kidney function, with a GFR less than or equal to 60 ml/minute for 3 months or longer. It occurs in stages and eventually leads to end stage kidney disease.
CKD affects all major body systems and may require dialysis or kidney transplantation to maintain life.
Hypervolemia can occur because of the kidneys inability to secrete sodium and water; Hypovolemia can occur because of the kidneys inability to conserve sodium and water
Causes: May follow AKI DM and other metabolic disorders HTN Chronic urinary obstruction Recurrent infections Renal artery occlusions Autoimmune Disorders
Chronic Kidney Disease: Assessment
Neurological: Asterixis, Ataxia, Inability to concentrate or decreased attention span, Lethargy and daytime drowsiness, Myoclonus, Paresthesias, Seizures, Slurred speech, Tremors, twitching or jerky movements, Coma
Cardiovascular: HTN, HF, Peripheral Edema, Cardiomyopathy, Pericardial Effusion/friction rub, Uremic Pericarditis and Cardiac Tamponade
Respiratory: Crackles, Depressed Cough Reflex, SOB, Tachypnea, Kussmauls, Pleural Effusions, Pulmonary Edema, Uremic Halitosis/pneumonia
Hematological: Abnormal bruising and Bleeding
GI: Anorexia, N/V, Constipation, Diarrhea, Metallic taste in the mouth, Stomatitis, Uremic fetor/gastritis
Urinary: Polyuria, Nocturia, Proteinuria, Diluted Straw colored appearance, Hematuria, Oliguria (later)
Integumentary: Decreased skin turgor, Dry skin, Yellow -gray pallor, Ecchymosis, Pruritus, Purpura, soft tissue calcifications, Uremic frost (late, pre-morbid)
Musculoskeletal: Bone Pain, Muscle Weakness and cramping, pathological fractures, Renal Osteodystrophy
Reproductive: Decreased fertility, libido, Impotence, infrequent or absent menses
Chronic Kidney Disease: Interventions
Same as the interventions for AKI.
PUT ON CARDIAC MONITOR
Administer a prescribed diet (moderate protein), high carbohydrate, low potassium and low phosphorus
Provide Oral care to prevent stomatitis and reduce discomfort from mouth sores
Provide oral care to prevent pruritus
Teach the client about fluid and dietary restrictions and the importance of daily weights
Provide support and prepare client for dialysis and transplantation; encourage healthy life style and discuss choices.
Special problems in kidney disease: Activity intolerance and insomnia (fatigue results from anemia and the buildup of waste from the diseased kidneys) - provide adequate rest periods Anemia/GI Bleeding Hyperkalemia/Hypermagnesemia/Hypocalcemia Hyper/Hypovolemia HTN Infection Metabolic Acidosis Muscle cramps Neurological changes Ocular irritation Pruritus Psychosocial Problems
Anemia from Kidney Disease
Results from the decreased secretion of erythropoietin by damaged nephrons, resulting in decreased production of red blood cells
Monitor hcb/hct
Administer hematopoietics such as epoetin alfa pr darbepoetin alfa, as prescribed to promote maturity in RBC’s
Administer folic acid and iron (not at the same time as phosphate binders)
Blood transfusions ( can make organ transplantation diffucult)
Gastrointestinal Bleeding from Kidney disease
Urea is broken down by the intestinal bacteria to ammonia; ammonia irritates the GI mucosa, causing ulceration and bleeding.
Avoid ASA because it is excreted by the kidneys - aspirin toxicity can occur and prolong bleeding time
Infection from Kidney Disease
The client is at risk for infection caused by suppressed immune system, dialysis access site and possible malnutrition
Metabolic Acidosis from Kidney Disease
The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis
Administer sodium bicarb as soon as possible
Ocular Irritation from Kidney disease
Calcium deposits in the conjunctivae cause burning and watering in the eyes
Potential for Injury
The client is at risk for fractures caused by alterations in the absorption of calcium, excretion of phosphate and vitamin D metabolism.
Avoid skin breakdown as it causes increased potassium levels
Uremic Syndrome
Systemic clinical and laboratory manifestations of severe or end stage stage kidney disease due to accumulation of nitrogenous waste products in the blood caused by the kidneys inability to filter out these waste products
Hemodialysis
The machine acts as the glomerulus. Is done 3 to 4 times a week, so the client has to watch what they eat and drink in between treatments. To prevent clots, they are given anticoagulants during treatment.
Electrolytes and BP are constantly watched. Those with unstable cardiovascular system cannot tolerate it –> hemodynamic shock.
Glomeruloephirits
Inflammation of the filter. Acute can lead to chronic.
Antibodies lode in the glomerulus; causes scarring and effects filter after a systemic infection such as streptococcal infection. This infection will also attack the heart valves if antibiotic therapy is not completed.
Signs:
Sore throat, Malaise and Headache (retaining toxins), BUN and Creatinine UP, Sediment/protein/blood in urine (proteinuria is vee bad), Rusty Coke Urine, Flank Pain, BP up, Facial Edema, UO down, Specific gravity up (concentrated pee), Client is going into FVE
Treatment:
Get rid of strep or source of infection
Balance activity with rest/ Conserve energy
I&O and daily weights
Monitor Blood Pressure
How is fluid replacement determined = 24 hour fluid loss plus 500 ml
Dietary needs: Protein decreased, Sodium decreased, Carbohydrates Increased
Dialysis
Blood and protein may be in Urine for MONTHS
Teach S/s of Renal failure: Malaise, Headache, anorexia, N/V, decreased output and weight gain
Nephrotic syndrome
Inflammatory response in the glomerulus, big hole begin to form so protein starts to leak out in the urine. Client is hypoalbuminemic and cannot hold fluid in the vascular space so it goes into the third space and circulating blood volume decreases. Kidneys attempt to compensate by secreting aldosterone to retain sodium and water, but it just goes into the third space even more.
Protein loss can cause Blood clots - protein usually prevent blood from clotting and high cholesterol and triglycerides. ]
Causes: Bacteria or viral infections NSAIDS Cancer and genetic disposition Systemic disease such as diabetes or lupus Strep
S/s
Proteinuria, Hypoalbuminemia, Edema and Hyperlipidemia
Treatment: Diuretics ACE inhibitors to block aldosterone secretion Prednisone to decrease inflammation/ Shrinks holes so that protein can't get out, immunosuppressed Lipid lowering for hyperlipidemia Decrease sodium Increase Protein Intake Anticoagulant for 6 months Dialysis
limit protein with kidney problems except with Nephrotic Syndrome
Vascular Access for Hemodialysis
With hemodialysis, blood is being removed, cleansed and then returned at a rate of 300 - 800 ml/min
Vascular access is a site they have access to a large blood vessel because very rapid blood flow is essential for hemodialysis.
AVF - Arteriovenous fistula in forearm with an anastomosis between an artery and a vein
AVG = Arteriovenous graft - a synthetic graft to join the vessels
Both require surgery. The access site takes weeks to mature and be ready for repeated venipunctures.
During Dialysis, two needles are inserted into the vascular access. One needle will allow blood to be pulled and one will be used to return blood.
Atrial Access will remove blood and Venous access will return blood.
For temporary access, the internal jugular or femoral veni is often used for cath palcement.
Vascular Access for Hemodialysis
With hemodialysis, blood is being removed, cleansed and then returned at a rate of 300 - 800 ml/min
Vascular access is a site they have access to a large blood vessel because very rapid blood flow is essential for hemodialysis.
AVF - Arteriovenous fistula in forearm with an anastomosis between an artery and a vein
AVG = Arteriovenous graft - a synthetic graft to join the vessels
Both require surgery. The access site takes weeks to mature and be ready for repeated venipunctures.
During Dialysis, two needles are inserted into the vascular access. One needle will allow blood to be pulled and one will be used to return blood.
Atrial Access will remove blood and Venous access will return blood.
For temporary access, the internal jugular or femoral veni is often used for cath placement.
Do not use for IV access. When client has access, No blood return, No needle sticks and no constrictions.
Ensure Patency by feeling for thrill and hearing the Bruit.
Peritoneal Dialysis Types and complications
Use peritoneal membranes as a filter.
Consists of dwell time and then exchange.
Warm fluid = vasodilation.
Usually for clients that cannot tolerate hemodialysis. If the fluid does not come out, shake pt from side to side.
CAPD
Client is energetic and active in their treatment and that also has the ability to learn and follow instructions. 4x a day, 7 days a week. Cannot have client with arthritis or disc disease do this because fluid causes pressure on the back. NO COLOSTOMY.
CCPD
DONE AT NIGHT
Complications: Infection ( Peritonitis) Constant sweet taste from glucose in hypertonic solutions May get a hernia Altered body image Anorexia Low back pain
Dietary needs
Increase FIBER to increase peristalsis
INCREASE Protein because there are big holes in the peritoneum and lose protein with each exchange
Continuous Renal Replacement Therapy
Typically done in the ICU setting ad is continous so that the client doesn’t have drastic fluid shifts. Never more than 80 ml of blood out of the body at one time.
For the client with a fragile cardiovasuclar status and acute renal failure
Kidney Stones
Causes: Diet high in calcium, vit. D., Protein, Oxalate, purines or alkali Obstruction and urinary stasis Dehydration Use of diuretics UTI's and prolonged cath Immobilization Hypercalcemia and Hyper PTH Elevated uric acid levels
Signs:
Pain, N/V, WBC’s in urine, Hematuria ( Secondary hemorrhage), Urinary frequency with alternating retention. UTI signs. Fever. Renal Colic and ureteral colic.
Get urine specimen and have it checked for blood.
Treatment: Monitor Vitals/infection Zofran, NSAIDS and Narcotics Intake and Output Encourage fluid intake 3000 ml day IV fluids Ambulation
Cystitis
Inflammation of the bladder/urinary tract, Usually caused by E.Coli, Enterobacter, Pseudamonas and Serratia
Altered mentation is a sign of UTI in older adults
Encourage 3000ml/day fluids especially if the client is taking sulfonamides as it can form crystals n the concentrated urine.
Maintain an acidic urine PH (5.5) and alter diet to do so
If the clent is prescribed an aminoglycoside, sulfanomide or nitrofuritoin, the actions of these medications are decreased by acidic urine.
Discourage caffeine products.
Client instructions following kidney transplantation
Avoid prolonged sitting
Monitor intake and output
Recognize the signs and symptoms of injection and rejection
Use medications as prescribed, and maintain immunosuppressive therapy for life
Avoid contact sports
Avoid exposure to persons with infections
Know the signs and symptoms of medical emergancy
Ensure follow up care
Urosepsis
Gram negative Bacteremia originating from urinary tract
Can lead to septic shock
FEVER
Pyelonephritis
Acute can occur after bacterial contamination of the urethra or following an invasive procedure of the urinary tract
Chronic follows chronic urinary flow obstruction with reflux. Can lead to AKI or AKD.
Acute
Fever Chills, tachycardia, Tachypnea, Nausea, CVA tenderness, Headache, Dysuria, Frequency and Urgency, Cloudy/Bloody/Foul smelling urine
Chronic
Inability to conserve sodium, poor urine concentrating ability, Pyuria (pus in urine), Azotemia (lots of nitrogen products in the blood) and Proteinuria
Treatment INCREASE INTAKE AND OUTPUT MOnitor weight Monitor V/s High Calorie, Low protein diet Monitor for AKI and AKD
Polycystic Kidney Disease
Cyst formation and hypertrophy of the kidneys which leads to rupture, infection, formation of scar tissue and damaged nephrons
Ultimate result is AKD
Infantile - kills infant in a few months after birth
Adult: autosomal dominant trait that manifests between 30 and 40 years old
Recurrent UTI’s, Hematuria, proteinuria, pyuria, Calculi, HTN, increased abd girth, palpable abd masses
Monitor for gross hematuria indicateds cyst rupture
Increase sodium and water intake because sodium loss rather than retention occurs
Prevent constipation because of pressure on cysts
DIALYSIS or transplantation
Prostatitis
Prostatitis is swelling and inflammation of the prostate gland, a walnut-sized gland situated directly below the bladder in men. The prostate gland produces fluid (semen) that nourishes and transports sperm. Prostatitis often causes painful or difficult urination
Prostatitis signs and symptoms depend on the cause. They can include:
Pain or burning sensation when urinating (dysuria)
Difficulty urinating, such as dribbling or hesitant urination
Frequent urination, particularly at night (nocturia)
Urgent need to urinate
Cloudy urine
Blood in the urine
Pain in the abdomen, groin or lower back
Pain in the area between the scrotum and rectum (perineum)
Pain or discomfort of the penis or testicles
Painful ejaculation
Flu-like signs and symptoms (with bacterial prostatitis)
Complications of prostatitis can include:
Bacterial infection of the blood (bacteremia)
Inflammation of the coiled tube attached to the back of the testicle (epididymitis)
Pus-filled cavity in the prostate (prostatic abscess)
Semen abnormalities and infertility, which can occur with chronic prostatitis
Isotretinoin
is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception
Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication
