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Health Assessment Spring 2019 > Renal > Flashcards

Renal Flashcards

1
Q

What are some History-basic renal questions?

A
  • Have you ever had any kidney problem?
  • Have you ever had kidney stones?
  • Have you had changes in bowel or bladder function in the last year?
  • Has your appetite for food changed in the last year? (Voluntary avoidance of foods having a high protein content is a subtle sign of renal disease.)
  • Have you ever had kidney failure, dialysis, or more than two kidney infections?
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2
Q

What are some type and degree of Renal Dysfunction?

What are some Co-morbidities?

A
  • Type and degree of impairment

–Chronic Kidney Disease (CKD) =GFR less 60ml/min/1.73m2 for 3 months

–Chronic Renal Failure (CRF) =15ml/min/1.73m2

–ESRD=loss of renal function for 3 months or more (Diabetes accounts for half of cases & HTN for one fourth. Polycystic 10%-genetic autosomal dominant)

–Acute Kidney Injury-Sudden dec. function/UO

  • Co-morbidities: CV disease, HTN, & electrolyte issues
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3
Q

What are somethings to note about Pre-Operative Evaluation of the patient with Renal Failure?

A
  • Acute renal failure pts. requiring surgery are VERY ill (post –operative complication or trauma)
  • Chronic renal failure often present for AV fistula creation or revision
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4
Q

What do you want to assess when you do a review of systems in a pt with renal failure?

A

Assess for issues related to:

  1. Uremia
  2. Dialysis
  • Intermittent hemodialysis (AV fistula)
  • Continuous peritoneal dialysis (implanted catheter)
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5
Q

In what situation is Dialysis required?

A
  • Oliguria
  • Fluid overload
  • Hyperkalemia
  • Severe acidosis
  • Metabolic encephalopathy
  • Pericarditis
  • Coagulopathy
  • Refractory GI symptoms
  • Drug toxicity
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6
Q

What is Hemodialysis and what do you need?

A
  • Diffusion of solutes between the blood and the dialysis solution remove metabolic wastes and restore buffers to the blood
  • Need vascular access

–AV fistula = cephalic vein anastomosed to radial artery

–Jugular or femoral vein for emergency access

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7
Q

What are 6 important things about pre-operative dialysis?

A
  1. Optimization, optimization, optimization!
  2. Dialysis should occur day of surgery or day before surgery
  3. Review dialysis flowsheet if available
  4. Amount of fluid “taken off”
  5. Pre and post dialysis weights compare with day of surgery weight
  6. Note POST dialysis chemistry! Serum K < 5.5 mEq/L
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8
Q

What is the general rule about medication and dialysis?

A
  • General rule: scheduled doses of drugs are administered after dialysis
  • Low-molecular weight, water soluble, non protein bound drugs are readily cleared by dialysis
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9
Q

What should the Neuro Assessment consist of with Renal Failure?

A
  • Uremic Encephalopathy
    1. Asterixis
    2. Myoclonus
    3. Lethargy
    4. Confusion
    5. Seizures
    6. Coma
  • Autonomic Neuropathy
  • Peripheral Neuropathy
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10
Q

What are some components of a Neuro Assessment S/P Dialysis?

A
  • Disequilibrium syndrome (dialysis related) transient CNS disturbance after rapid decrease in ECF osmolality compared with ICF osmolality
  • Dementia
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11
Q

What can be seen with a Hematological Assessment in Renal Failure?

A
  • Anemia typical Hgb = 6-8 g/dL
    1. Decreased erythropoietin production
    2. Decreased RBC production & cell life span
    3. GI blood loss, hemodilution, bone marrow suppression
    4. Excess PTH replaces bone marrow with fibrous tissue
  • Most patients tolerate the anemia well (exception CAD)
    1. Increased 2,3- DPG (diphosphoglycerate)
    2. Metabolic acidosis also favors rightward shift
  • Impaired platelets (qualitative) – prolonged bleeding time
    1. Decreased plt factor III activity
    2. Decreased adhesiveness & aggregation
  • Impaired WBC function – infections
  • Release of defective von Willebrand factor
  • Dialysis = Residual anticoagulation VS promotion of hypercoagulable state
  • Hypocomplementemia with dialysis
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12
Q

Why is asceptic technique important?

A
  • Infection common cause of death
  • Care with ETT- prone to pulmonary infection
  • IVs, Line insertion
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13
Q

What can you see with a cardiovascular assessment in renal failure?

A
  • ↑ Cardiac output–compensation for ↓ O2 carrying capacity
  • HTN – Na retention, renin-angiotensin activation
  • Left ventricular hypertrophy common
  • CHF with pulmonary edema after limits of compensation reached
  • Deposition of calcium - in the conduction system & on the heart valves
  • Arrhythmias – electrolyte imbalances
  • Uremic pericarditis – can be asymptomatic, chest pain, tamponade, usually secondary to inadequate dialysis
  • Accelerated CAD, PVD
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14
Q

What needs to be assessed regarding fluid balance in renal failure?

A
  • Fluid overload VS intravascular depletion status post dialysis/ aggressive diuretic therapy
  • Body weight
  • VS (orthostatic hypotension & tachycardia)
  • Atrial filling pressures
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15
Q

What is typically seen with a pulmonary assessment in Renal Failure

A
  • Minute ventilation increased to compensate for metabolic acidosis
  • Increased pulmonary extravascular water= interstitial edema = widened alveolar/arterial O2 gradient
  • “Butterfly wings” on CXR secondary to increased permeability of alveolar capillary membrane (edema even with nml pulmonary capillary pressures)
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16
Q

What is typically seen in an Endocrine Assessment in Renal Failure?

A
  • Peripheral resistance to insulin = poor glucose tolerance
  • Hyperparathyroidism = prone to fractures
  • Abnormal lipid metabolism = accelerated atherosclerosis
  • Kidneys do not degrade hormones and proteins normally = increased circulating PTH, insulin, glucagon, GH, LH, PL
17
Q

What is typically seen in a GI/Liver assessment in a patient with renal disease?

A
  • 10-30% of patients will develop GI Hemorrhage
  • Anorexia
  • Nausea and Vomiting
  • Hypersecretion of gastric acid + delayed gastric emptying (autonomic neuropathy)
  • High incidence of Hep B and C in these pts (multiple transfusions, etc.)
  • Ascites with dialysis
18
Q

What is the impact of renal failure on drugs?

What are some considerations of Patient’s medication?

A
  • Effects altered due to:

–Anemia

–Decreased serum protein

–Electrolyte abnormalities

–Fluid retention

–Abnormal cell membrane activity

  • Drugs ELIMINATED BY KIDNEYS UNCHANGED are CONTRAINDICATED

–Gallamine, phenobarbital, LMWH

Patient’s Medications

  • Many drugs cleared by kidneys.
  • LMWH cleared by kidneys and Not removed during dialysis= prolonged duration
19
Q

What do you look for in a physical assessment with a renal patient?

A
  • General impression related to fluid and electrolytes……
  • How do you assess fluid status?

–VS, mucus membranes, orthostatics etc. , auscultate the lungs

20
Q

What Blood test do you want to send to the lab?

What is necessary?

A

Note: Current laboratory tests of renal function are often nonspecific, insensitive (>50% of the nephrons must be destroyed before test results change) or impractical.

  • Chem Panel
  • Renal Function Test
  • BUN
  • Cr
  • Cr clearance
  • CBC
  • Pulm: CSR, ABG
  • Cardiac: EKG, ECHO
21
Q

Whats part of a normal chem panel?

A
  • Sodium (135-145 mEq/L)
  • Potassium (3.5-5.0 mEq/L)
  • Chloride (95-105 mEq/L)
  • Sodium Bicarbonate (venous – 19-25 mEqL; arterial 22-26 mEq/L)
  • Calcium (4.5-5.5 mEq/L)
  • Phosphate (2.4-4.7 mg/dL)
  • Magnesium (1.5-2.5 mEq/L)
  • Serum Osmolality (280-300 mOsm)
22
Q

Whats part of a normal Renal Function Test?

A
  • GFR

–Blood Urea Nitrogen (10-20 mg/dl)

–Plasma Creatinine (0.7-1.5 mg/dl) GFR can decrease 50% w/o rise Not accurate indicator esp in elderly

–Creatinine Clearance (110-150 ml/min)

  • Renal Tubular Function

–Urine Specific Gravity (1.003-1.030)

–Urine Osmolarity (38-140 mOsm/L)

23
Q

Describe BUN

A
  • BUN normal = 10-20 mg/dL
  • Varies inversely w/GFR & directly w/protein catabolism
  • >50mg/dl is indicative of a ↓ GFR (in patients with nml diets)
  • BUN is not a sensitive index b/c urea clearance also depends on the production of urea
  • BUN can be abnormal despite a normal GFR due to:

–High protein diet

–GI bleed

–Febrile illness

  • The most common cause of ­BUN is CHF secondary to the reabsorption of BUN
24
Q

Describe Plasma Cr

A
  • Plasma Cr is a specific indicator of GFR
  • 8 -17 hr lag time after a change in GFR before the ↑ Cr levels are seen.
  • Suggestive [but not indicative] of Acute Renal Failure.
  • Usually a 50% ↑ in plasma Cr reflects a corresponding ↓ in GFR.
  • Skeletal muscle = source of Cr
  • Elderly patient- Cr levels stay nml constant due to:

–↓ muscle mass and GFR

–If CR ↑ in the elderly, this may be indicative of renal failure.

25
Q

Describe Creatinine clearance

A
  • 24 hour collection most accurate although 2 hour tests also helpful
  • Creatinine Clearance approximates GFR
  1. Normal 100-120ml/min
  2. ↓ Renal Reserve 60-100 ml/min
  3. Mild Renal Impairment 40-60 ml/min
  4. Moderate Insufficiency 25-40 ml/min
  5. Renal Failure <25 ml/min
  6. ESRD <10 ml/min
26
Q

What are some common lab test abnormalities with renal failure?

A
  • Assess the adequacy of dialysis
  • Hyponatremia (hypernatremia rare)
  • Hyperkalemia (hypokalemia with dialysis)
  • Metabolic acidois with high anion gap
  • Hypermagnesemia
  • Hypocalcemia (unclear etiology)
  • Hypoalbuminemia (esp. with dialysis)
  • Hyperglycemia (if insulin resistant)
27
Q

What is the treatment for hyperkalemia if symptomatic or 6.5 mEq/L?

A
28
Q

What are the components of a normal CBC?

A

RBC 1.6-6.2 million/mm3 male

4.2-5.4 million/mm3 female

Hct 40-54% men; 38-47% female

Hgb 13.5-18 g/dL; 12-16 g/dL

RBC indices (MCV, MCH, MCHC)

WBC 5,000-10,000/mm3

Differential WBC

29
Q

What are some common CBC abnormalities in a RF patient?

A
  • Transfuse only when absolutely indicated <6-7g/dL or significant intra-operative blood loss
  • What does a normal plt count mean in a renal failure patient?
30
Q

What are some considerations with Coagulation Abnormalities in a RF patient?

A
  • If regional anesthesia is planned need coagulation panel!!!!
  • Increased bleeding despite normal PT, PTT,
  • Bleeding Time best screening test
  • Important cause of coagulation issues- release of defective von Willebrand factor
  • Rx- Desmopressin (0.3-0.4 mg/kg over 30 min), cryoprecipitate 10 units IV over 30 minutes
  • Blood warmer- set up and ready to go
31
Q

What are some examples of a pulm la?b test?

What complications might you see?

A
  • CXR
    1. Fluid status
    2. Determine presence of HTN related CV disease
    3. Pericardial effusion
    4. Uremic pneumonitis
  • ABG – hypoxia and acid/base status especially if dyspnea noted on exam
32
Q

What are some examples of Cardiac Test?

What might you see?

A
  • EKG
    1. Hyper or hypokalemia
    2. Hypocalcemia
    3. Ischemia
    4. Conduction blocks
    5. LVH
  • Echocardiography
    1. Ventricular EF
    2. Hypertrophy
    3. Wall motion abnormalities
    4. Pericardial fluid

Health Assessment Spring 2019 (8 decks)

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