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High Acuity Exam 2 > Renal > Flashcards

Renal Flashcards

1
Q

How many mL’s per kg should a patient have to measure urine output per hour?

A

0.5 mL per kg is how many mL’s of urine a patient should have

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2
Q

Metabolic acidosis

A

Metabolic acidosis (Hydrogen ions being reabsorbed) is the most common form in kidney issues

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3
Q

ADH

A

Used to reabsorb water in distal tubule

Diabetes Insipidus is a dysfunction of this. Nephrogenic DI is when kidney isn’t responding to ADH.

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4
Q

Renin

A

Released when theres low BP/Renal perfusion
RAAS constricts to perfuse kidneys, causes BP increases.
Aldosterone is excreted so water and sodium are reabsorbed. If kidney damage is present, third spacing occurs

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5
Q

AKI

A

***Characterized by rapid loss of renal function with progressive azotemia

Prerenal failure
Before the actual kidney structure
BUN/Cr ratio of >10:1

Intrarenal failure /Intrinsic failure
Within the kidney and organ structures
***Most common is Acute Tubular Necrosis (ATN). Contact dyes/Nephrotoxic drugs cause this
Prolonged ischemia, nephrotoxins, hemolysis, myoglobin, acute glomerulonephritis, lupus

Postrenal failure
Injury occurring after the kidney structure
*Mechanical obstruction, BPH, prostate CA, calculi, trauma and extra renal tumors

Alters bone metabolism because of Vitamin D

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6
Q

Pathophysiology of Prerenal AKI

A

Decreased blood supply to the kidney
Stimulation of renin-angiotensin-aldosterone system
Retention of sodium and water

Signs/Symptoms
***Decreased urinary output (<400 mL/day)
Elevated BP

Lab values

  • **Increased urine specific gravity (Concentrated because not enough water to dilute the solutes)
  • **Decreased urine sodium
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7
Q

Treatment and Nursing Care for AKI: Early Identification

A

Increase IV fluids
Usually fluid challenge of 250 cc NSS

***Look for increased urinary output and no crackles in the lungs (back up into lungs)

  • **Increased cardiac output
  • **Watch for changes in BNP (HEART FAILURE INDICATOR)

Treat any cardiac rhythm disturbances

Monitor use of ACE inhibitors (less perfusion to kidneys) and NSAIDs (can make worse, nephrotoxic)

*****Monitor (Increased) BUN, (normal) creatinine, GFR

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8
Q

AKI Labs

A

Increased urine osmolality & specific gravity (>1.025)

Decreased urine Na+

Increased BUN & creatinine (increased BUN to serum creatinine ratio 10:1)

Serum creatinine may be normal to high normal

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9
Q

AKI Nursing Interventions

A

Goal to increase renal perfusion

Most commonly fluid challenges/bolus

If no increase in urine output - bolus should be repeated

Monitor closely for S/S of fluid overload

Respiratory distress, elevated blood pressure

Monitor urine output
***Monitor blood pressure & SaO2 (May drop)

Monitor body weight daily
Monitor for acid-base changes

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10
Q

Pathophysiology of Intrarenal AKI

A

Direct damage to kidney tissue (nephrons, cortex) from acute tubular necrosis (ATN) or ischemia (decreased blood supply)

Results in tubular swelling and eventually necrosis

Kidney cells block kidney blood and filtrate flow

Ischemia causes the renal tubular cells to swell & become necrotic

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11
Q

Treatment for Intrarenal AKI

A

High index of suspicion
**High, uncontrolled glucose levels
Decreased urinary output
**High BUN and creatinine

Forcing IV fluids as tolerated

***Administration of acetylcysteine (Mucomyst)

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12
Q

Acute Kidney Injury Intrarenal Findings

A 
Client findings
Oliguria
***Increased blood urea nitrogen (BUN)
***Elevated serum creatinine levels
Urine: high sodium; ***presence of casts; fixed SG (1.010) 
Difficult to differentiate from prerenal
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13
Q

Acute Kidney Injury Intrarenal Interventions

A

Administer fluid challenges
***Administer loop diuretics

Administer Ca+ channel blocker &/or Dopamine to restore vascular tone & promote renal perfusion

Low dose Dopamine is “renal-protective” & dilates the renal artery, high dose Dopamine constricts the peripheral arteries

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14
Q

Teaching to Prevent the Acceleration of AKI

A

Maintain a normal BP and glucose control
Drink fluids and avoid becoming dehydrated
Monitor weight frequently
Avoid medications that can accelerate renal failure (dyes, aminoglycoside antibiotics)
Exercise
Take ACE inhibitors or ARBs as directed
Moderate protein ingestion with low-cholesterol diet

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15
Q

Acute Kidney Injury (AKI) Postrenal

A

Often called “Obstructive or Disrupted” Acute Renal Failure

Results from disruption or obstruction of the flow of urine from the kidneys
Problem/obstruction may occur anywhere after the filtered urine is collected in the renal calyces.

When urine flow is obstructed, pressure increases in the nephron and the glomerular filtration rate (GFR) begins to slow. As back pressure increases or is prolonged, nephron damage can occur

Serum creatinine and BUN begin to rise

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16
Q

Treatment and Nursing Care for Postrenal AKI

A

High index of suspicion

Relieve the obstruction by mechanical or surgical methods

***Watch for post-obstructive diuresis and resultant fluid volume deficit

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17
Q

CKD Stage 1

A

Normal glomerular function >90 to 125mL/min/1.73m2

Stage One
Normal GFR or >90mL/min/1.73m2

At risk, or has had kidney disease or comorbid conditions that indicated kidney damage of three consecutive months

Should be diagnosed quickly as “high-risk” & disease preventative strategies should be implemented.

Controlling HTN
Controlling blood sugar
Monitoring for protein (microprotein) in urine
Controlling hypotensive or decreased cardiac output states

18
Q

Stage 2 CKD

A

Stage Two
GFR 60 to 89mL/min/1.73m2
Clients should be followed closely
Clients need education about renal protection
Clinicians should attempt to slow, or hopefully prevent further renal & cardiovascular damage

19
Q

Stage 3 CKD

A

Stage Three
GFR 30 to 59mL/min/1.73m2
Complications of reduced function begin at this stage
Treatment of anemia, bone disease and other metabolic disorders may be warranted at this point.

20
Q

Stage 4 CKD

A

GFR 15 to 29mL/min/1.73m2
Clients should be prepared for RRT
Clients begin to C/O of generalized fatigue and social isolation
Loneliness & depression frequently ensue

21
Q

Stage 5 CKD

A

GFR <15 mL/min/1.73m2
RRT (HD, PD, or scheduled transplantation should be initiated upon evidence of uremia)
Treatment will endure for a life-time
Management of metabolic complications will provide better client outcomes when the client starts on RRT
Ideally the client should start the RRT in a non-acute, community care setting
Clients are classified as ESRD, once they begin RRT

22
Q

End Stage Renal Disease

A

Irreversible GFR of <15ml/min

CKD stage 5 is considered ESRD

Leading cause of death for clients with ESRD is cardiovascular disease

Cardiovascular disease is the second-leading cause of long-term hospitalization

Because of multi-system organ involvement most clients will require ICU admission for stabilization & treatment of systemic infections & multiple organ dysfunction (MOD)

23
Q

Diuretic Phase of ATN

A

Usually 1-2 weeks

Urinary output gradually increases
Hypovolemia can result

Nonoliguric ATN does not do this

Complications
Hypovolemia
Hypokalemia

24
Q

ESRD postop

A

Treatment of choice: Renal transplantation

Management of hemodynamic status, acid-base balance, fluid and electrolytes, blood glucose, respiratory management, immunosuppression monitoring and patient education

Ambulation

Frequents assessment for complications
***Hypotension, hypokalemia, hyperglycemia (steroids)
Graft rupture - hemorrhage
Acute rejection
Acute tubular necrosis
Urologic infections or complications- monitor Foley patency
Renal tubular acidosis – frequent administration of NaHCO3 until kidney begins to function well

Assessment of circulatory function

Bowel elimination

Daily weights & assessment of fluid volume balance
Hourly I&O
Replace mL for mL if diuresing

25
Q

ESRD Discharge teaching

A

Activities of daily living
Regular exercise
When to return to work or school

Abstinence or minimal alcohol consumption

Dietary consultation
Food-medication interactions
Increased fluid intake
Components of well-balanced diet
Special diets to control comorbid conditions (diabetes, hypertension, CHF)

Dental care & dental prophylaxis

Financial counseling
Expenses associated with medications
Vocational rehabilitation as needed

Healthcare follow-up & laboratory testing schedules
S/S of infection
Annual vaccinations & preventative health activities
Medications

26
Q

Renal Replacement Therapy (RRT): Hemodialysis

A

Process by which solute & fluid removal occur as blood crosses an artificial semipermeable membrane (hemodialyzer or dialyzer)

Require direct access to vascular compartment

Clients with rapid onset renal failure will need a temporary venous access generally through a femoral or internal jugular central venous catheter (CVC)
***Femoral: highest risk of infection; kinking problems

For permanent RRT clients, need a surgically created fistula (artery & vein anastamosed together) or a surgically placed “A-V graft” made of artificial membrane

Natural fistulas are preferred because of optimal use and length of “usability” for permanent (repeated access).

27
Q

Hemodialysis Access

A

Arteriovenous - (AV Graft)
Surgical procedure to insert a synthetic or semibiologic material to create the AV fistula
Accessible about 2 weeks after insertion

External AV Shunt- rare since 1960’s
2 Teflon tips brought out through the skin for AV access

Native Fistulas
Preferred access- take 3 months to mature

Avoid phlebotomies, & blood pressure measurements in this entire arm to avoid damage (clotting)

Accessed using 14-16 gauge needles for connection to HD

Central Venous Catheter (CVC)

28
Q

Bleeding at fistula sight if patient has been heparinized

A

PUT PRESSURE TO STOP BLEEDING

29
Q

Continuous Renal Replacement Therapy

A

***Hemodynamically unstable patients are candidates for this

Primary goal to remove excess fluid volume, solutes, & balance electrolytes

It is continuous rather than intermittent

CRRT lasts 8 or more hours in an ICU setting – typically 24/7

Appropriate clients
Hemodynamically unstable
Cardiovascular instability

Treatment is generally initiated by HD nurses but is monitored/continued under the RN’s supervision

30
Q

Continuous Renal Replacement Therapy

A

***Hemodynamically unstable patients are candidates for this

Primary goal to remove excess fluid volume, solutes, & balance electrolytes

It is continuous rather than intermittent

CRRT lasts 8 or more hours in an ICU setting – typically 24/7

***Appropriate clients
Hemodynamically unstable
Cardiovascular instability

Treatment is generally initiated by HD nurses but is monitored/continued under the RN’s supervision

31
Q

Types of CRRT

A

Continuous venovenous hemofiltration (CVVH)
Fluid & solute removal – uses replacement solution. More uremic patient/more waste product removal

Continuous venovenous hemodialysis (CVVHD)
Fluid & solute removal under pressure (convection and diffusion) – no replacement solution needed

***Slowing down a rate causes more clots, not many patients can tolerate a high flow, which is better for reducing clots

32
Q

Nursing Interventions - CRRT

A

Some provide hemofiltration only
Removal of excess fluid with minimal removal of solutes (SCUF)

Some provide removal of fluids & solutes (metabolic wastes)
CVVH modalities remove fluid & wastes
Some of the removed fluids are replace by IV fluids each hour

HD is the addition of dialysate fluid to the therapy
The dialysis hemofilter increases diffusion
Increases the amount of solutes removed

A pump is added to the therapy to provide pressure to push the blood through the hemofilter, facilitate exchange & reduce duration of treatment

33
Q

Nursing Assessment

for CRRT

A

Close (1:1 or 1:2) monitoring at all times
Cardiac & pulmonary status evaluation
ECG & pulmonary assessment pre-treatment
Peripheral vascular flow & pulses
Neurological evaluation
Gastrointestinal status
Skin assessment
Monitor for fluid volume changes
I & O, hourly fluid balance
V/S with O2 saturations
Skin turgor & mucus membranes

34
Q

Complications of HD

A 
Hypotension/Hypovolemia
Loss of blood
Sepsis
Muscle cramps
Disequilibrium Syndrome
Dysrhythmias &amp; Angina
35
Q

Peritoneal Dialysis

A

Peritoneal membrane is used as semipermeable membrane for dialysis

Dialysate is introduced through a peritoneal dialysis catheter (PD catheter) in the periumbilical area & allowed to “dwell” in the abdomen a specific number of hours

Through the process of osmosis, diffusion & ultrafiltration, the metabolic wastes & excess fluid is extracted into the dialysate & then the fluid is allowed to flow out into a collection system for disposal

Entry, dwell & drain – a three part process over several hours is known as one exchange

Dialysate is a dextrose-based solution that acts as an osmotic gradient

36
Q

Peritoneal Dialysis – 2 types

A

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Done by client/family at home in clean environment under sterile conditions
4 times per day
Exchange of 1.5 - 3L

Automated Peritoneal Dialysis (APD)

Client is connected to a machine “cycler” which performs the exchanges throughout the night or during a specified period of time.

4 or more exchanges per night last 1 to 2 hrs each

Usually provided in an acute care setting

Requires special education & training for nursing staff to monitor/operate the “cycler”

37
Q

Peritoneal Dialysis contraindications/indications

A

Peritoneal Dialysis contraindications
***Obese clients w/ large abdominal wall and fat deposits

Clients with abdominal wall adhesions or adhesion from intraabdominal surgeries

Peritoneal Dialysis indications

Clients with hemodynamic instability
More gentle form of dialysis
Clients with limited vascular access
Pediatric & geriatric clients

Require extensive education/training of client & significant other as secondary provider of care
Require sterile technique

38
Q

Peritoneal Dialysis assessments

A

PD avoids rapid fluid shifts & electrolyte changes as does hemodialysis

Hemodynamic & pulmonary status monitoring

Condition of PD Catheter & insertion site

Skin integrity
Maintenance of sterile catheter &amp; connections
Monitoring glucose (finger-stick) levels

***Dialysate is commonly glucose based & can lead to hyperglycemia

39
Q

Peritoneal Dialysis nursing interventions

A

Treatment of hyperglycemia
Sliding scale insulin coverage
Adding insulin to the dialysate

Monitoring weight gain/loss
Due to excessive fluid loss or retention

Treatment of peritonitis
Culture dialysis return
Failure to maintain aseptic techniques
Treat immediately
Oral antibiotics
Parenteral antibiotics
Antibiotics in dialysate

Possible removal of catheter
Warming of dialysate
Commercial device only
No microwave, stove-top, etc.

40
Q

Peritoneal Dialysis family/client teaching

A

Aseptic technique for PD

S/S of infection

Site inspection

PD catheter care & sterile dressing

Personal hygiene with PD catheters

Diet & fluid restriction

Prompt reporting of problems to healthcare provider

Set-up, storage, supplies & machinery

High Acuity Exam 2 (4 decks)

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