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Health Assessment Oral > Renal > Flashcards

Renal Flashcards

1
Q

In a patient with renal disease, what would you want to ask them regarding dialysis?

A
  • When they had dialysis? Yesterday or today?
    • Preferred is day before
    • If Dialysis is day of surgery→ may be hypokalemic, dry and might need bolus
  • Review dialysis flowsheet.
    • How much fluid taken off
    • Pre and post dialysis weights compare with day of sx weight
  • Neuro assessment
    • Assess for disequilibrium syndrome
      • Transient CNS disturbance after rapid decrease in ECF osmolality compared with ICF
    • Dementia- long term
  • What type of dialysis do they have done?
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2
Q

What tests would you want to obtain in the renal patient who has just had dialysis?

A
  • Note post dialysis chemistry
    • Serum K <5.5meQ/L
  • BMP
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3
Q

What are some diagnostic tests you can use to assess for pulmonary changes in a patient with renal disease?

A
  • Increased pulmonary extravascular water→ interstitial edema= widened alveolar/arterial o2 gradient (when uremic/further away from dialysis)
  • CXR” butterfly wings”
    • Secondary to increased permeability of alveolar capillary membrane
    • Edema with normal pulmonary capillary pressures
  • Renal pt with have increased mV to compensate for metabolic acidosis
  • From lab Tests at back of ppt:
    • CXR
      • Fluid status
      • Presence of HTN related CV disease
      • Pericardial effusion
      • Uremic pneumonitis
    • ABG
      • Hypoxia
      • acid /base status; especially if dypnea noted on exam
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4
Q

What are some CV changes noted on assessment of renal failure patient?

A
  • Increased CO
    • Compensation for decreased o2 carrying capacity
  • HTN
    • Na retention, RAAS activation→ SNS activity released around hemodialysis
      • Keep BP 20% of norm
  • LVH common
  • CHF with pulmonary edema after limits of compensation reached
  • Deposition of calcium
    • In conduction system
    • Heart valves
      • Make stenotic, less compliant
      • Makes retrograde flow→ ECHO
  • Arrhythmias- electrolyte imbalances
  • Uremic pericarditis
    • Can be asymptomatic; secondary to inadequate dialysis
      • CP- not always MI
      • tamponade→ inflammation worse
        • Inquire about CP, recent exercise intolerance change
  • Accelerated CAD, PVD,- stroke and MI risk
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5
Q

What are some cardiac tests you might want on a renal patient?

A
  • EKG
    • hyper/hypokalemia
    • Hypocalcemia
    • Ischemia
    • Conduction blocks
    • LVH
  • ECHO
    • Ventricular EF
    • HYpertrophy
    • Wall motion abnormalities
    • Pericardial fluid
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6
Q

What are some lab abnormalities you can expect in a renal patient?

A
  • Assess adequacy of dialysis
  • Metabolic acidosis with high anion gap
  • Hyponatremia- dilutional issue
  • Hypocalcemia
    • Check ionized Ca-> can impact BP
  • Hypoalbuminemia→ impact with warfarin, highly protein bound drugs
  • Hyperkalemia
    • Hypokalemia with dialysis
  • Hypermagnesemia
    • Not problem unless you give exogenous Mg→ impairs NM weakness
  • Hyperglycemia
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7
Q

What are some examples of renal functions tests?

A
  • GFR- parallels nephron function
    • BUN (10-20 mg/dL)
    • Plasma creatinine (0.7-1.5 mg/dL)
      • GFR can decrease 50% without rise in Cr
      • Not accurate indicator of fxn esp in elderly- low muscle mass and low clearance
    • Creatinine clearance (110-150mL/min)
      • Gold standard to estimate GFR
        • Normal 100-120 mL/min
        • Decreased renal reseve 60-100 mL/min
        • Mild renal impairment= 40-60 mL/min
        • Moderate insufficiency= 25-40 mL/min← start to see symptoms
        • Renal failure <25 mLmin
        • ESRD < 10 mL/min- need dialysis
  • Renal tubular function- how well kidneys are concentrating urin
    • Urine specific graviety (1.003-1.030)
    • Urine oxmolarity (38-140 mOsm/L)
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8
Q

What are some hyperkalemia treatments if renal patient is symptomatic or >6.5 mEq/L?

A
  • Calcium gluconate 10%; 10-20 mL IV
    • MOA- antagonizes K effect on cardiac muscle
    • Onset- immediate
    • Duration- brief
    • s/e- avoid with dig therapy
  • Sodium bicarb 50-100 mEq IV
    • MOA- shift K into cell
    • Onset prompt
    • Duration short
    • S/E Na overload
  • Glucose 50 mL of 50% soluntion + 10 units regular insulin
    • MOA- shift K into cells
    • Onset prompt
    • Duration short
    • S/E Hyperglycemia and hypoclycemia
  • Dialysis
    • MOA- remove K from body
    • Onset- immediate
    • S/E- need vascular access
  • Ion exchange resin (Kayexalate)
    • MOA- remove K from body
    • Onset 1-2 hours
    • S/E - Na overload
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9
Q

What are some hemetologic considerations for a patient with renal failure?

A
  • Anemia typical 6-8 g/dL
    • decreased erythropoietin produciton
    • decreased RBC rpoduction and cell life span
    • GI blood loss, hemodilution, bone marrow suppression
    • EXCESS PTH- replaces bone marrow with fibrous tissue
      • difficulty producing RBC
    • Most patients tolerate the anemia well (Except for CAD pt)
      • increased 2,3 DPG
        • shift oxygen disassociation curve to right
      • metabolic acidosis also favors rightward shift
        • avoid giving blood tx bc they tolerate it well
  • Impaired paltelets - prolonged bleeding time–> normal PLT count but not fx well
    • decreased plt factor III activity (inhibited)
      • decreased/defected von willebrane factor
    • Decreased adhesiveness and aggregation
      • order type and cross- see in fridge if bleeding sx
  • Impaired WBC function- infection
    • 25% die each year and 1/2 from infection
  • Release of defective von willebrand factor
  • dialysis=- residual anticoagulation vs promotion of hypercoaguable state
    • heparin admin
  • hypocomplementemia with dialysis- lower levels of compliment
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10
Q

What impact does renal failure have on drug pharmacokinetics and dynamics?

A
  • Effects altered due to
    • Anemia
    • Decreased serum protein
    • Electrolyte abnormalities
      • Lithium ARB, ACE, digoxin (high K)
    • Fluid retention
      • Vd change→ more space for water soluble drugs to distribute (change dosing)
    • Abnormal cell membrane activity
  • Drugs eliminated by kidneys unchanged are contraindicated
    • Morphine- can’t clear active metabolites→ respiratory depression
    • Contraindicated: gallamine, phenobarbital, LMWH
      • Call pharmacist to assess for antibiotic needed if on dialysis (GFR b/w 10-25)
    • LMWH- not removed well by dialysis- risk of bleeding increased further
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11
Q

What should you assess for in the review of systems in the patient with renal failure?

A
  • Uremia
    • Metabolize proteins→ breakdown→ ammonia→ liver converts ammonia to urea→ rely on kidneys to remove urea
  • Dialysis- Required in the following situations (CAPE OF HD (G))
    • Coagulopathy
    • Severe acidosis
    • Pericarditis
    • Metabolic encephalopathy
    • Oliguria
    • Fluid overload
    • Hyperkalemia
    • Drug toxicity
    • Refractory GI symptoms
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12
Q

In what situations might dialysis be indicated prior to surgery?

A

Required in the following situations

  • Oliguria
  • Fluid overload
  • Hyperkalemia
  • Severe acidosis
  • Metabolic encephalopathy
  • Pericarditis
  • Coagulopathy
  • Refractory GI symptoms
  • Drug toxicity
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13
Q

What are some types and degrees of renal impairment?

A
  • Chronic kidney disease
    • GFR <60 mL/min/ 1.73 m2 for 3 months
    • <25 mL/min–> see s/s Of uremia
  • Chronic renal failure= 15 mL/min/1.73m2
  • ESRD= loss of renal fucntion for 3 or more months
    • DM accounts for half cases
    • HTN counts 1/4
  • Acute kidney injury
    • sudden decrease in function/UOP
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14
Q

What is an important consideration for patient that may be eventually needing dialysis d/t renal failure?

A

Avoid IV on non dominant arm–> preserve for fistula

Jugular and femoral vein for emergency access

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15
Q

What are some neurological assessment considerations in patient with renal failure?

A
  1. Uremic encephalopathy
    1. Asterixis
    2. Myoclonus
    3. lethargy
    4. confusion
    5. seizures
    6. coma <– bolded need dialysis!
  2. Autonomic neuropathy- difficult to control BP
    1. more sensitive to VA, epdiural
    2. not as responsive to ephedrine
    3. need aline
  3. Peripheral neuropathy
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16
Q

Why are renal failure patients aenmic? How is this tolerated in renal patients?

A

Anemia is typical for renal patient, usually 6-8 g/dL

  1. Decreased erythropoiertin production
  2. decreased RBC produciton and cell life span
  3. GI blood loss, hemodiluation, bone marrow suppression
  4. Excess PTH
    • replaces bone marrow with fibrous tissue (decreasing RBC production)
      • difficulty producing RBC
  • Most patient tolerate this anemia fairly well
    • increased 2,3 DPG and metabolic acidosis allow right shift, releasing O2
17
Q

What is BUN and what does it indicate?

A
  • Normal 10-20 mg/dL
    • Varies inversely with GFR
    • Varies directly with protein cataboism
  • >50 mg/dL indicative of decreased GFR (in pt with normal diet)
  • BUN is NOT sensitive index b/c urea lcearance depends on production of urea
    • Conditions that can cause BUN to be abnormal despite normal GFR
      • high protein diet
      • GI bleed
      • Febriel illness
    • most common cause of increased BUN is CHF secondary to reabsorption of BUN
18
Q

What is creatinine and what does it indicate?

A
  • Plasma creatinine is specific indicator of GFR
    • produced by muscle in in metabolism in consistent way
    • very reliable, filtered and not reabsorbed and not impacted by physiologic changes
  • 8-17 hours lag time behind change in GFR
    • hypotension/hemoohrage– won’t see increase until later
  • Usually 50% increase Cr reflects correspondign decrease in GFR
  • Skeletal muscle= source of Cr
    • elderly patients- Cr levels stay normal due to
      • decrease in muscle mass and GFR
      • If Cr elevated in elderly, indicative of renal failure
19
Q

What is creatinine clearance? What do the values mean?

A
  • 24 hours collection of urine
    • most accurate way to measure GFR

Values:

  • Normal 100-120 mL/min
  • Decreased renal reserve 60-100 mL/min
  • Mild renal impairment 40-60 mL/min
  • Moderate insufficiency 25-40 mL/min <– start to see symptoms
  • Renal failure<25 mL/min
  • ESRD <10 mL/min<– HAVE TO HAVE DIALYSIS
20
Q

What are some hematologic issues that need to be addressed before the OR (in a renal failure pt)?

A
  • Transfuse only when absolutely indicated
    • 6-7 g/dL or significant intraop blood loss
  • Need coag panel!
    • Increased bleeding time despite normal PT,PTT
    • Bleeding time is best screening test (normal 3-10 minutes)
      • Renal patients have defective von willebrand factor
      • TX- DDAVP 0.3-0.4 mg/kg over 30 minutes can improve PLT fx
        • Cry 10 units IV over 30 minutes- also provide VWF
  • Have blood warmer set up and ready to go
21
Q

What are some GI/liver consequences for pt 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
22
Q

What are the rules of medication administration with dialysis?

A

• General rule: scheduled doses of drugs are administered after dialysis

  • Drugs coming out during dialysis:
    • Low-molecular weight
    • water soluble
    • non-protein bound drugs are readily cleared by dialysis

• Drugs ELIMINATED BY KIDNEYS UNCHANGED are CONTRAINDICATED

  • Gallamine
  • phenobarbital
  • LMWH
23
Q

What physiological findings in renal failure affect drug pK?

A

• Effects altered due to:

  • Anemia
  • Decreased serum protein
  • Electrolyte abnormalities
  • Fluid retention
  • Abnormal cell membrane activityw

Health Assessment Oral (12 decks)

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