👩🏾🎓- Renal & Crisis Test Flashcards
Two functions of the kidney
Regulatory- controls fluid/electrolyte & acid/base balance
Hormonal- RBC formation, BP regulation, vitamin D activation
What is the functional unit of the kidney
Nephrons
Normal renal function values
BUN, creatinine, Uric acid, GFR, urine output
BUN- 8 to 25 mg/dL
Creatinine- 0.6 to 1.3 mg/dL
Uric Acid- 2.5 to 8.0 mg/dL
GFR- 125 ml/min
Urine output- 1 to 3 L/day
Hormones in kidney function
ADH- antidiuretic hormone regulates osmolarity
RAAS- renin angiotensin aldosterone System regulates BP and volume
ANF- atrial natriuretic factor regulates BP and volume
Decreased GFR will cause which hormone to be secreted
Renin
3 most common causes of kidney disease
Diabetes
Hypertension
Glomerulonephritis
Types of drugs that are nephrotoxic
Example of each
NSAIDS - ibuprofen, naproxen, ketorolac
Chemo- cisplatin, methotrexate, cyclophosphamide
Antibiotics- vancomycin, gentamicin, amphotericin B, methicillin
Acute kidney injury vs chronic kidney disease
AKI- sudden onset, about 50% kidney function, usually last a few weeks but no more than 3 months, with treatment function resolved to original state
CKD- gradual onset, permanent, less than 10% function is present, fatal with renal replacement therapy
Three causes/subcategories of AKI
Prerenal- outside the kidney, caused by decreased intravascular volume, sepsis, dehydration and obstruction
Intrarenal- actual damage to renal parenchyma, causes by tubular necrosis, prolonged prerenal ischemia, infection and nephrotoxicity
Postrenal- obstruction of urinary outflow from the collecting ducts in the kidney to the external urethral orifice, causes renal stones, bladder tumors, prostate cancer, blood clots
4 phases of acute kidney injury
Onset phase- begins with precipitating event
Oliguric phase- urine output below 400mL/day. HIGH electrolyte levels. Requires supportive measures (no nephrotoxic drugs, decrease BP and possible dialysis). ⬇️ gfr, hyperkalemia, hypocalcemia
Diuretic phase- occurs when cause of AKI has been corrected. Urine output from 3-5L/day. LOW electrolyte levels.
Recovery phase- NORMAL electrolyte levels. ⬆️ gfr, complete recovery may take 1-2yrs. Memory improves
How is AKI diagnosed
X-ray (kub)
Renal ultrasound
Serum labs (CBC, bun/creatinine, electrolytes)
Urine labs (24hr collection, u/a, specific gravity)
CT scans/MRI
Nuclear imaging
Cystoscopy
Renal biopsy
Clinical manifestations of hypovolemia or reduced CO
Prerenal azotemia
Hypotension
Tachycardia
Decreased Central Venous Pressure
Decreased urine output
Weakness/fatigue
S&S of volume overload
Intrarenal or postrenal azotemia
Hypertension
Tachycardia
Increased central venous pressure
Increased jugular vein distention
SOB, crackles, pulmonary edema
Weight gain/ edema
Azotemia
S&S
Inability to secrete waste, elevated BUN
S&S- n/v, anorexia, headache, confusion, weakness/fatigue
Lab changes during an AKI
⬆️ BUN
⬆️ creatinine
⬆️ K, Ph, Mg, PaCO2
⬇️ Ca, HCO3
↕️ Na is variable
↕️ H&H are usually stable unless patient is hemorrhaging
Normal lab values
Bun, creatinine, k, ph, Mg, Ca, Na, hemoglobin, hematocrit, HCO3, PaCO2
Bun: 10-20 mg/dL
Creatinine: 0.5-1.1 mg/dL
K: 3.5-5 mEq/L
Phosphorus: 3-4.5 mg/dL
Mg: 1.3-2.1 mEq/L
Ca: 9-10.5 mg/dL
Na: 135-145 mEq/L
Hemoglobin: 12-17 mmol/L
Hematocrit: 38-50%
HCO3: 22-26 mEq/L
PaCO2: 35-45 mmHg
What is the most serious electrolyte disorder in kidney injury
Hyperkalemia
How is hyperkalemia treated
IV insulin
IV glucose (push k back in cell. Glucose to prevent hypoglycemia)
IV Ca gluconate (⬇️ threshold ❤️ arrhythmia)
Sodium polystyrene sulfonate (kayexelate)
Lasix, sodium bicarb, albuterol nebs
Emergent hemodialysis
Under what conditions should kayexelate NOT be given
Hypoactive bowels
Common causes of chronic kidney disease
Diabetes
Hypertension
Glomerulonephritis (lupus, wegeners, hiv, amyloidosis)
Interstitial nephritis (allergic or pvelo)
Microangiopathic vascular disease (scleroderma)
Cogenital
Genetic disease (pkd)
Neoplasm or tumor
Transplant rejection
Hepatorenal syndrome
Hepatorenal syndrome
Life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or liver failure
List the 5 phases of chronic kidney disease
Stage I- gfr > 90ml/min. (Screen)
Stage II- gfr 60-89ml/min (Reduce risk factors)
Stage III- gfr 30-59ml/min (Slow progression)
Stage IV- gfr 15-29ml/min (Manage/rrt)
Stage V- gfr < 15ml/min (Rrt/transplant)
Ca has an adverse relationship with which other electrolyte
⬇️ Ca = ⬆️ phosphate
Lab changes in CKD
Bun & creatinine gradual increase to very high levels
Na initial decrease, later maybe increased or “normal”
K & Ph rise quickly
Ca decreased
Metabolic acidosis due hydrogen ions not being excreted and unable to bind to HCO3
⬇️ iron, folic acid. ⬆️ cholesterol
People with CKD are more prone to which 3 conditions
Metabolic acidosis , ❤️ problems and bleeding
Cardiovascular changes in CKD
At risk for ?
Hypertension
Fluid overload
Heart failure (results from htn, hypervolemia, anemia and ultimately causes LV enlargement)
Risk for- CAD, pericarditis, pericardial effusion
Pulmonary changes in CKD
Dyspnea/tachypnea (watch for kussmauls)
Crackles
Pulmonary effusions
Pulmonary edema
Pneumonitis
Kussmauls breathing indicates what
Severe acidosis
Associated with CKD
Neurological changes in CKD
Untreated?
Lethargy
Decreased alertness/cloudy mentation
Poor concentration
Neuropathy
If untreated can cause seizures, coma
Integument changes in CKD
Yellow or darkening of skin
Pruritus
Uremic frost (uremia seeping from pores)
Urinary changes in CKD
Initially May appear “normal”
Oliguric
Anuric (may occur once crrt is initiated)
Psychosocial concerns in CKD
Anxiety
Depression
Fear of death
Economic status changes
Loss of independence
Loss of control
Role change at home and/or work
S&S of uremic syndrome
Anorexia, n/v
Weakness, fatigue
Itching
Uremic frost
Muscle cramps
Hiccups
Stomatitis
Ulcers
Bowel changes (diarrhea or constipation)
Prescribed diet for some in CKD would consist of
Moderate protein (to decrease the workload on the kidneys)
High carb
Low potassium , low phosphorus
Dietary changes for CKD
Fluid, protein, k, na, ph
Fluid- restricted to 1-1.5 L/day
Protein- restricted in early stages because it slows CKD
K- restricted to 70 mEq/day
Na- typical restriction is 2g/day
Ph- restricted to 700 mg/day
Hemodialysis vs CRRT vs Peritoneal dialysis
Hemodialysis- fluid & waste removal with dialysate and ultrafiltration via machine, generally required 12 hours/week in divided treatments, may be used emergently
CRRT- fluid & waste removal by hemofiltration (and sometimes dialysate) via machine, continuous treatment, typically reserved for icu
Peritoneal dialysis- fluid & waste removal with dialysate and ultrafiltration in peritoneal cavity
List the 5 types of crrt
Continuous veno-venous hemofiltration CVVH: filter only, no dialysate
Continuous veno-venous hemodiafiltration CVVHD: filter & dialysate
Continuous arterio-venous hemofiltration CAVH: filter only, no dialysate
Continuous arterio-venous hemodiafiltration CAVHD: filter & dialysate
SCUF: slow continuous ultrafiltration
What 3 things must be prescribed by a doctor in hemodialysis treatment
Dialysate, Time (schedule) and ultrafiltration
How does dialysate function
Regulates blood acidity and electrolytes
Two primary types of hemodialysis access
Venous catheter (external access)
Fistula or graft (internal access)
Venous catheters and hemodialysis access
Vascath, permcath
Inserted in jugular, subclavian or femoral vein
Vascath (non tunneled)- temporary
Permcath (tunneled)- lasts longer than vascath, but not intended to be permanent
Internal access and hemodialysis access
Fistula, graft
AV fistula- surgical anastomosis of vein and artery
AV graft- surgical implantation of artificial graft to connect vein & artery (listen for bruit and thrill)
Hemodialysis access: risks
Venous catheters vs internal access
Venous catheters- infection, embolism (air or thrombus), pneumothorax after insertion
AV fistula or graft- infection, clotting, loss of blood flow secondary to hypotension, steal syndrome, aneurysm in access
Steal syndrome
Ischemia resulting from a vascular access device
Risk associated with fistula or graft hemodialysis access
Disequilibrium syndrome
S&S, treatment
Occurrence of neurological s&s attributed to cerebral edema during or following shortly after hemodialysis
S&S- vomiting, confusion, headache, twitching, seizures
Treatment- slow or stop dialysis and give hypertonic saline and mannitol to pull off fluid from brain
List 4 things to report immediately associated with issues in a fistula or graft
Loss of thrill
S&S of infection
Bulging
Pain
Hemodialysis: special considerations
- daily weights before and after treatment
- know your patients dry weight
- medication management around dialysis
- protect and assess access continually
- assesses the CKD patient appropriately (watch hemodynamics and monitor for complications)
Dietary considerations for the HD patient
Fluid restriction
Less Na
Less proteins 8-10 oz/daily
Grains/cereal/bread 6-11 servings
Milk, cheese, yogurt 1 oz/day (⬆️ phosphorus)
Veggies & fruit 2-3 servings each (watch for K)
When was peritoneal dialysis and hemodialysis first performed
Peritoneal dialysis- 1923
Hemodialysis- 1937 at the university of Lund, Sweden
Continuous ambulatory peritoneal dialysis CAPD
Dialysate is constantly in peritoneal cavity
4-5 manual exchanges during day
Low concentration dialysate swells over night
Continuous-cycle peritoneal dialysis (CCPD, cycler)
Dialysis dwells primarily overnight
4-5 machine/cycler exchanges overnight
Low concentration dialysate dwells during day
What 3 things are prescribed by a doctor in peritoneal dialysis
Dialysate, dwell time and additives
List the 3 dialysate options
Higher concentration ?
- 5% glucose
- 5% glucose
- 25% glucose
* higher concentration of glucose, removes more fluid & solutes*
What are the 3 steps to perform peritoneal dialysis treatment (exchange)
- Fill peritoneum with 1-2 L dialysate (takes about 20 mins)
- Dwell dialysate (3-5 hrs)
- Drain effluent (takes about 20mins)
What’s in hemodialysis dialysate
Sodium Bicarbonate Acetate Chloride Calcium Potassium Magnesium (Treated) tap water
What’s in peritoneal dialysis dialysate
Glucose Lactate Sodium Potassium Chloride Calcium Magnesium Hydrochloric acid (prevents caramelization)
Complications of peritoneal dialysis
- peritonitis
- leakage
- bleeding
Long term: hypertriglyceridemia, abdominal hernia or exacerbation of hemorrhoids and hiatal hernia
S&S of peritonitis
associated with complications of PD
Cloudy drainage
Abdominal pain
Rebound tenderness
Hypotension
Peritoneal dialysis dietary restrictions
Protein requirements increase (protein is pulled across the peritoneal membrane
Fruits and vegetables aren’t restricted b/c PD patients don’t have issues with K regulation
No fluid or sodium restriction
Restricted phosphorus and carbs
List the 3 types of crisis
-maturational crisis
Predictable, transitional points
Ex: getting married in a few weeks
-situational crisis
Unexpected, unpredictable, common
Ex: going through a divorce
-adventitious crisis
Unexpected, unpredictable, uncommon
Ex: big and devastating
Crisis vs disaster
Crisis- upset in a previously steady state = poor problem solving
Disaster- overwhelming event that leads to temporary disruption of function
Mass casualty vs multi casualty
Mass casualty- 100 or more affected
Multi casualty- 2 but less than 100
List the 8 types of disaster
Internal External Predictable Unpredictable Natural Frequent Rare Manmade
Acts of terrorism
Examples
Violence against persons or property in violation of the crimson laws of the U.S
Ex- assassinations, kidnapping, hijacking, bombings, imputed based attacks, chemical/biological/nuclear/radiological weapons
Phases of a disaster
Mitigation- lessen the impact of a disaster before it strikes
Preparedness- activities undertaken to handle a disaster when it strikes
Response- search and rescues, clearing debris and feeding and sheltering victims
Recovery- getting a community back to its pre-disaster status
Classic 5 response phases
Heroic- need to help
Honeymoon- survivors reminisce
Disillusionment- delay in receiving help
Reconstruction- sense of normalcy
PTSD- 1 to 3 months later
Who declares a state of emergency
Governor has to declare a state of emergency
S&S of transplant rejection
Oliguria Edema Fever Increasing BP Weight gain Swelling or tenderness over transplant site
S&S of kidney trauma
Flank pain Renal colic Hematuria Flank mass/swelling Ecchymosis Abdominal wounds
Emergency severity index
Five level triage algorithm
1 (most urgent) to 5 (least urgent)
Parkland formula
Calculates fluid requirements for burn patients in a 24hr period
4ml/kg x %TBSA
Heat exhaustion vs heat stroke
Symptoms, treatment
- Exhaustion
symptoms: faint or dizzy, excessive sweating, cool, pale, clammy skin, n/v, rapid weak pulse, muscle cramps
Treatment: move to cooler location, drink water, take a cool shower or use cold compress
-stroke
Symptoms: throbbing headache, no sweating, body temp above 103, red, hot, dry skin, n/v, rapid strong pulse, may lose consciousness
Treatment: get emergency help, keep cool until treated
Trauma triad of death
Coagulopathy, metabolic acidosis, hypothermia
What is the antidote for benzodiazepines overdose
Flumazenil
Convection, conduction, evaporation
Convection- heat is loss by being exposed to cool air or water
Conduction- loss of heat to cold object
Evaporation- loss of heat through sweating
Clinical manifestations of hypothermia
Myocardial irritability (arrhythmias), bradycardia and altered mental status
