renal and acid base emergencies Flashcards
1
Q
introduction
A
- both medical and traumatic problems heavily depend on renal function to maintain homeostasis
- role of kidneys:
- fluid and electrolyte balance
- blood pressure regulation
- red blood cell synthesis
- metabolic waste removal
- medication metabolism
- acid base balance
2
Q
kidney blockage
A
- affects the whole body
- backup of fluids will affect pulmonary and cardiac systems
- fluid buildup -> edema
- fluid in lungs
3
Q
renal anatomy
A
- in retroperitoneal space at level of costovertebral angle (T12-L3)
- perfusion:
- renal arteries
- receives about 25% of cardiac output
- 1,200 ml of blood/min
4
Q
anatomic structures
A
5
Q
nephron
A
- functional unit of kidney
- responsible for filtrating reabsorbing, and secreting fluids, electrolytes, and waste products by forming urine
- lack of filtration -> sepsis (ex. uti)
- each contains:
- bowman’s capsule
- glomerulus
- proximal tube
- loop of Henle
- distal tubule
- collecting duct
6
Q
secretion
A
- filtrate not reabsorbed by nephron travels to disetal collecting tubule
- secreted as urine
- normal urine: 95% water and 5% solute
- kidney can concentrate urine based on physiologic requirements
- normal urine output >500 ml/day
- <500 ml/day -> oliguria
7
Q
renal failure
A
- inability of kidneys to cleanse blood
- resultant buildup of waste products
- classifications of acute renal failure: (dont know symptoms of each)
- prerenal
- intrarenal
- postrenal
8
Q
prerenal renal failure
A
- decreased renal perfusion results in decreased glomerular filtration rate (GFR) and decreased urine output
- secondary to:
- hypovolemia
- cardiac failure
- decreased CO
- accumulation of metabolic waste products in blood
- increased blood urea nitrate (BUN), creatinine **
9
Q
prerenal renal failure: treatment
A
- correction of underlying cause of hypoperfusion
- hypovolemia
- control active hemorrhage
- IV crystalloids, blood and blood products
- cardiac failure
- diuretics
- nitrates
- inotropic agents
- vasopressors
10
Q
intrarenal renal failure
A
- results from direct damage to kidney parenchyma
- secondary to trauma, infection, or disease
11
Q
postrenal renal failure
A
- renal failure secondary to obstruction of urine flow
- urine backs up into kidney filtration cannot occur
- causes of obstruction:
- prostatic hypertrophy
- renal calculi (kidney stones)- calcium build up
- neoplasms
12
Q
renal calculi
A
- kidney stones
- severe back pain
- build up of calcium
13
Q
postrenal renal failure: treatment
A
- correction of obstruction
- urine clearance
- foley catheter- tube inserted directly into bladder to allow passage of urine
- suprapubic urinary catheter
14
Q
dialysis
A
- filter blood
- for people with non functioning kidneys
- method of removing toxins from blood when kidneys cannot
- blood circulated through filters
- used in patients with:
- kidney failure
- acute poisoning
- patients have a fistula implanted under the skin forearm into the bicep -> dialysis into renal system
- do not do blood pressure on the fistula arm!
15
Q
acute emergencies in chronic renal failure (CRF)
A
-regular dialysis needed for CRF patients
16
Q
complications of dialysis
A
- hypotension- when you take the blood out you arnt getting the same amount of blood flow
- muscle cramps
- nausea and vomiting
- headache
- chest and back pain- electrolyte abnormalities
- febrile reactions
- first use syndromes
- pruritis
- uncommon but serious complications:
- disequilibrium syndrome
- dialyzer reactions
- arrhythmias
- cardiac tamponade
- intracranial bleeding
- seizures
- hemolysis
- air embolism
- dialysis associated neutropenia and complement activation
- hypoxemia
17
Q
BUN
A
- diagnostic tool
- urea formed by liver, excreted by kidneys
- urea accumulates in blood if renal dysfunction occurs
- urea builds up in renal failure patients
- waste build up but everyone has it -> normal range is 5-20 mg/dl
- increases with renal failure
- can be affected by hydration status `
18
Q
creatinine
A
- waste product of creatine phosphate, a high energy molecule found in skeletal muscle tissue, released into blood
- normal value: .5-1.2 mg/dl
- best indicator of renal function
- increases with renal failure
- creatinine of 3-4 mg/dl indicates decreased of GFR by 50%
19
Q
other lab values used to evaluate renal failure
A
- urinalysis
- proteinuria indicates intrarenal or postrenal renal failure
- ketonuria, glycosuria, elevated specific gravity (hydration status) indicates prerenal origin of renal failure
- serum protein
- serum albumin
- complete blood count
20
Q
chronic renal failure
A
- permanent loss of renal function
- 80% of nephrons in the kidneys destroyed
- S/S include changes in urinary habits, nausea, vomiting, dyspnea, or acute coronary syndrome
- treatment:
- fluid administration
- administration of diuretics (long-term solution)
- pain medication
- dialysis - 2-3 times a week
- kidney transplant
21
Q
if you miss dialysis (chronic renal failure symptoms)
A
- difficulty breathing
- pitting edema- push in on skin and indentation stays*
- dry flakey skin
- fluid build up
- weakness/fatigue
- increased BP- due to high build up fluid (u cant urinate)
- cardiovascular and pulmonary signs *
- make sure fistula isnt infected
- diabetes is the biggest cause
- high BP can cause CRF
22
Q
renal failure: hyperkalemia
A
- high potassium
- cardiac abnormalities- tented T waves, abnormal EKGs**
- 3.5-5 is normal
- serum potassium greater than 5.5 mEg/L
- electrolyte disorder caused ingestion of potassium supplements, acute or chronic renal failure, blood transfusions, sepsis, addisons disease, acidosis, and crush syndrome
- S/S include weakness, muscle cramps, tetany, paralysis, palpitations, or arrhythmias
- diagnosed by ECG (peaked T waves) and lab values
23
Q
acid base physiology
A
- body can adjust for pH fluctuations
- buffering systems used for short term pH control
- ties up H+
- respiratory and renal systems used for long term acid base balance
- removes H+ from body
- manipulate pH with CO2, HCO3-, and H+ secretion/retention
- combination of buffer, respiratory, and renal systems maintain pH within normal 7.35-7.45 range
24
Q
what happens when patient has pH imbalance
A
- pH- <7.35 -> acidosis
- metabolic acidosis -> respiratory compensation -> increase respiratory rate to balance pH imbalance
- respiratory acidosis -> renal compensation
- metabolic alkalosis -> respiratory compensation
- respiratory alkalosis -> renal compensation
- LOOK AT CHART
25
Q
renal system
A
- slowest of three systems (buffers and respiratory)
- may take 25-48 hours to react to pH changes
26
Q
imbalances categorized according to origin: metabolic alkalosis
A
- metabolic alkalosis
- pH > 7.45
- result of:
- increased HCO3- intake
- increased H+ loss
- can occur secondary to:
- excessive bicarbonate ingestion
- blood transfusion
- vomiting nasogastric suctioning
- drug therapy/ abuse
27
Q
imbalances categorized according to origin: metabolic acidosis
A
- metabolic acidosis
- pH < 7.35
- result of :
- increased H+ reabsorption
- decreased HCO3- production
- decreased HCO3- intake
- impaired HCO3- reabsorption
- can occur secondary to :
- hypermetabolic state- hyperthyroidism
- anaerobic metabolism
- ketoacidosis
- acute or chronic renal, hepatic, and pancreatic failure
- diarrhea
- diabetes
28
Q
kidney stones
A
- renal lithiasis
- nephrolithiasis
- small mineral deposits that form inside kidneys (mineral and acid salts)
- form when urine becomes concentrated, and minerals crystalize and stick together
- calcium oxalate and uric acid
- may not cause pain until it moves around in kidney or passes into ureter
29
Q
risk factors for kidney stones
A
- family or personal history
- being obese: high BMI
- dehydration
- certain diets: high in protein, sodium and sugar
- digestive diseases and surgery; gastric bypass surgery, inflammatory bowel disease or chronic diarrhea
- other medical conditions: renal tubular acidosis, cystinuria, hyperparathyroidism, certain medications and some urinary tract infections
30
Q
symptoms of kidney stones
A
- severe pain in the side, back, below ribs
- pain that spread to the lower abdomen and groin
- pain that comes in waves and fluctuates in intensity
- pain on urination (dysuria)
- pink, red, or brown urine (hematuria)
- cloudy or foul smelling urine
- nausea and vomiting
- persistent need to urinate (usually small amounts)
- fever and chills if an infection is present
31
Q
tests/diagnosis of kidneys stones
A
- blood testing: too much calcium or uric acid in your blood
- urine testing: the 24-hour urine collection test may show that your excreting too many stone forming minerals or too few stone preventing substances
- imaging: imaging tests may show kidney stones in your urinary tract (x-rays or CT)
- analysis of passed stones: urinate through a strainer to catch stones and lab analysis will reveal the makeup of stones
32
Q
treatment for kidney stones
A
- small stones/minor symptoms:
- drinking water- 2-3 quarts/day
- pain relievers: ibuprofen, acetaminophen
- medical therapy: alpha blockers to relax muscles in ureter
- larger stones:
- lithotripsy- sound waves to break up stones
- surgery
- scope through urethra, bladder, ureters
- parathyroid gland removal
33
Q
urinary tract infection
A
- fever
- suprapubic pain
34
Q
pyelonephritis
A
- fever
- suprapubic pain that radiates through the back to the lower back
- back pain on percussion**
- can be life threatening if sepsis or complications develop
- may present with few symptoms to severe symptoms
- may or may not have associated dysuria
- may have no fever to a fever greater than 103
- costovertebral tenderness is common presentation over the affected kidney
35
Q
sepsis
A
- fever
- malaise
- may have pyelonephritis and sepsis as well
36
Q
vaginal/uterine infection, PID (pelvic inflammatory disease)
A
37
Q
STD
A
suprapubic pain and fever
38
Q
ongoing management of pyelonephritis
A
- IV access- NS bolus 250 ml
- cardiac monitoring
- antipyretics
- pain medications as needed
- antibiotics- readily respond to antibiotic therapy
- sepsis protocol if needed
39
Q
summary
A
- the renal system helps maintain a homeostatic state of balance
- disease process or toxic events, accidental or intentional, may put that balance at risk
- the provider has a responsibility to:
- maintain and optimize cardiopulmonary performance to maintain end organ perfusion
- treat symptoms of metabolic derangement until definitive treatment can be administered
40
Q
conclusions
A
- renal failure is a serious emergency
- what lab tests help to diagnose this emergency?
- what is the primary treatment for chronic renal failure and what are complications that can develop as a result
- how does hyperkalemia factor into renal failure
- how does acid base physiology factor into the renal buffer system and how does this buffer system counteract this physiology
- what are the various treatments for patients with kidney stones
