Renal day 2 Flashcards

Question

CKD: Sodium / Magnesium

Answer 1

HYPOnatremia (Dilutional) Confusion, seizures, coma Fluid restriction for self-correction HYPERmagnesemia Decreased reflexes, mental status, B/P, respiratory failure Avoid: Dark green veggies Grains, seeds, nuts Legumes Antacids with Mg+ Osmotic laxatives (Milk of Magnesia, Magnesium Citrate)

Answer 2

HYPOcalcemia Decreased intestinal Ca+ absorption Synthesis of 1,25 dihydroxyycholecalciferol HYPERphosphatemia furthers low Ca+ Increased parathyroid hormone excretion leads to bone resorption Osteomalacia Osteitis fibrosa Osteosclerosis HYPERphosphatemia Hypocalcemia Increased risk for fractures, CKD-MBD Avoid: Dairy products & foods containing dairy products Milk Ice cream Cheese Yogurt Pudding Protein sources contain Phosphate Phosphate binders

Answer 3

Parathyroid hormone levels increase Activated form of Vitamin D falls Old thinking: This was just decreased production of 1,25(OH)2D New understanding: Degradative pathways are up-regulated (some induced by FGF-23) Fall in 1,25(OH)2D is physiological with CKD Makes sense because you do not want a lot of 1,25(OH)2D around to cause more calcium & phosphorus absorption when you cannot excrete these ions

Answer 4

Systemic disorder of mineral & bone metabolism results in: Skeletal complications (Osteomalacia, osteitis fibrosa) Soft tissue complications (Vascular calcifications) Phosphate not restricted until patient requires RRT Then Phosphate restricted to < 1 g/day

Answer 5

HTN; Cause & consequence of CKD Aggravated by Na+ & H20 retention Increased renin production may contribute HTN, ECF volume overload, & anemia may develop into LV hypertrophy, which may lead to cardiomyopathy & HF HTN can cause retinopathy, encephalopathy, nephropathy B/P control; One of most important goals Dysrhythmias; Hyperkalemia & Decreased coronary artery perfusion Hyperinsulinemia stimulates hepatic production of triglycerides Altered lipid metabolism Decreased levels of enzyme lipase (Important in breakdown of lipoproteins) Increased VLDLs & LDLs Decreased HDLs

Answer 6

Death often r/t MI, ischemic heart disease, PAD, HF, cardiomyopathy, and/or stroke Traditional CV risk factors; HTN & Elevated lipids Nontraditional CV risk factors; Vascular calcification & arterial stiffness Calcium deposits associated with stiff blood vessels Vascular smooth muscle cells change High Ca+ & phosphate Impaired renal excretion Drug therapies to treat bone disease

Answer 7

Caused by impaired glucose metabolism (Cellular insensitivity to normal action of insulin) Mild-moderate hyperglycemia Hyperinsulinemia Uremic patients with DM may require less insulin than before onset of CKD Excretion of insulin dependent on kidneys Insulin dosing must be individualized May improve after starting dialysis

Answer 8

Decreased production of erythropoietin Other factors: Nutritional deficiencies Decreased RBC life span, HD & Increased hemolysis Blood sampling GI bleeding Increased Parathyroid hormone Decreased iron stores Folic acid lost in dialysis Bleeding tendencies Defect in platelet function Infection Change in WBC function Altered immune response & function Hyperglycemia External trauma

Answer 9

Cause: Excessive Urea Stomatitis with exudates & ulcerations Uremic fetor (Urine odor to breath) Anorexia, nausea, vomiting Diabetic gastroparesis GI bleeding Constipation significant problem Phosphate-binding medications are constipating Cannot be managed by increasing PO fluids, or taking Magnesium or fiber / bulk forming laxatives Probiotics, stool softeners, use of footstool when defecating

Answer 10

CNS depression Lethargy, apathy Decreased ability to concentrate Fatigue, irritability Altered mental ability (late sign) Seizures Coma Hypertensive encephalopathy Peripheral neuropathy Restless legs syndrome Paresthesias Motor involvement Foot drop Muscle weakness & atrophy Loss of deep tendon reflexes Muscle twitching, jerking, asterixis, & nocturnal leg cramps

Answer 11

Carbohydrate intolerance Peripheral insulin antagonism Impaired insulin secretion Prolonged insulin half-life Abnormal circulating insulin ** Short acting insulin functions as longer acting ** Patients on dialysis may need less insulin for glucose control Elevated triglycerides Metabolic acidosis Pericarditis

Answer 12

Normal pH: 7.35 – 7.45 Normal Base Excess: 0 +/- 3 mEq / L Calculated with ABG results using pH, PC02 & HCT Represents amount of buffering ions in blood Largest = HCo3- Hemoglobin, Proteins, Phosphates, Etc… Negative (-) BE indicates metabolic (lactic) acidosis Positive (+) BE indicates metabolic alkalosis or compensation to respiratory acidosis

Answer 13

Infertility & decreased libido Experienced by both sexes: Low sperm counts, amenorrhea Sexual dysfunction; Physical, psychological, & medication side effects Pregnancy during dialysis poses significant risk to mother & fetus Pruritus Calcium-phosphate deposits Sensory neuropathy May be intense Leads to bleeding or infection Uremic frost Urea crystalizes on skin BUN > 200 mg/dL

Answer 14

Adequate calories 30 – 35 kcal / Kg Primarily from Carbs & Fat (30 – 40% to prevent / reduce catabolism) Protein 0.8 – 1.0 Gm / Kg / day Avoid high-protein, fad diets Greater needs in end-stage K+ / Na+ regulated to plasma levels Restrict Na+ to prevent edema Phosphate restriction 1 gram per day Avoid foods high in phosphate (Meat & dairy) Most foods high in phosphate are high in protein Phosphate binders essential with dialysis

Answer 15

Overall goals Preserve existing kidney function Reduce risks of CV disease Prevent complications Provide for comfort Early recognition and treatment important Nephrology referral Identify & treat reversible causes Management Stage 1 to 4: Control: HTN Hyperparathyroidism CKD-MBD Anemia Dyslipidemia Correct ECF overload or deficit RRT Treat CV disease Nutritional therapy Drug therapy

Answer 16

Antihypertensives Diuretics Calcium Prophylactic antibiotics Vitamins, Minerals & Phosphate binders

Answer 17

Slow progression or delay onset of Diabetic nephropathy (Example: Captopril) Dilate arterioles & veins Reduce blood volume (effect on kidneys) Reduce glomerular filtration pressure Suppress formation of Angiotension II 1st dose hypotension Hyperkalemia Vasodilation Increase bradykinin (Inhibit Kinase II) Cough & angioedema

Answer 18

Prevent Angiotension II mediated vasoconstriction & release of Aldosterone Produce effects similar to ACE inhibitors No cough No angio-edema Diabetic nephropathy Irbesartan (Avapro) Losartan (Cozaar)

Answer 19

Furosemide (Lasix) Blocks re-absorption of Na+ & Cl- at ascending LOH Diuresis despite low renal blood flow & GFR Onset: 5-minutes Duration: 2-hours Hypotension Hypokalemia Ototoxicity (IVP: 20 - 40 mg over 1 - 2 minutes) Mannitol (5% - 25%) Creates osmotic force within nephron Diuresis of fluid only Onset: 30 – 60 minutes Duration: 6 – 8 hours Edema May precipitate CHF / Pulmonary edema Observe for crystals Filter needle

Answer 20

Statins (HMG-CoA reductase inhibitors) Most effective for lowering LDL Atorvastatin (Lipitor) Fibrates (Fibric acid derivatives) Used to lower triglyceride levels & increase HDL Gemfibrozil (Lopid)

Answer 21

Calcium Cinacalcet (Sensipar) Increases sensitivity of Ca+ receptors in parathyroid glands Subtotal or total parathyroidectomy Vitamin D: Calcitriol (Rocaltrol) 0.5 – 1.0 mcg / daily Treats hypoparathyroidism & hypocalcemia Serum phosphate must be lowered before Calcium or Vitamin D is administered Avoid aluminum & magnesium preparations Folic Acid Phosphate binders (Reduce intestinal absorption) Bind phosphate in bowel & then excrete Ca+ based Calcium carbonate (Caltrate) Calcium acetate (PhosLo) Ca+ free Sevelamer (Renagel) – Lowers cholesterol & LDL

Answer 22

Iron supplements If plasma ferritin <100 ng/mL Side effects: GI irritation, constipation May make stool dark in color Folic acid supplements Needed for RBC formation Removed by dialysis Avoid blood transfusions Increase development of antibodies May lead to iron overload Epoetin alfa (Epogen, Procrit) Darbepoeitin alfa (Aranesp) Given IV or SQ Expect increased H & H in 2 - 3 weeks Side effects: Thromboembolism, HTN

Answer 23

Weight gain between dialysis treatments Rationale for fluid restriction Measure of adherence 1 – 3 Kg advised (2.2 to 6.6 pounds)

Answer 24

Careful fluid replacement Calculated fluid restriction = 24-hour loss + 600 ml insensible Daily weights Fluid restriction (1000 – 1500 mL / Day) Diuretics Furosemide (Lasix) Bumetanide (Bumex) Mannitol

Answer 25

1000 – 1500 mL/day (Average fluid restriction for CKD) Acute Care RN responsible to supervise & maintain ordered fluid restriction from all sources: PO Enteral nutrition, & free water flushes Parenteral nutrition Maintenance IV Continuous IV medications (Ex: Heparin, Nexium) Intermittent IV medications (Ex: Antibiotics, others)

Answer 26

Temporary Dialysis Catheter Double-lumen, non-tunneled CVAD 13 – 20 cm long, 13G or less, No cuff, Rigid Permanent Dialysis Catheter (“PermCath”) Tunneled, cuffed at skin/exit site Arterio-venous Fistula (AVF) Arterio-venous Graft (AVG) HeRO Graft Used when other options have failed Bypasses venous system; blood flow directly from target artery from the heart More difficult to assess Thrill / Bruit d/t no venous anastomosis Peritoneal Dialysis Catheter

Answer 27

Insertion at internal jugular or femoral vein when immediate access needed Double lumen Blood removal Blood return Risks: Infection Dislodgment Malfunction

Answer 28

A-V Fistula A-V Graft Assess for bleeding / bruising (after Hemodialysis) Assess for patency Auscultate for “Bruit” Palpate for “Thrill”

Answer 29

Usually reflects lowest weight a patient can tolerate without intra-dialytic symptoms or hypotension Imprecise trial-and-error method Does not account for changes in nutritional status & lean body mass Difficult to determine over- or under-hydration Used to calculate ultra-filtration (UF) volume & rates for dialysis treatment

Answer 30

Weight resulting from Normal renal function Vascular permeability Serum protein concentration Body volume regulation Patients theoretically should be lower than physiologic to be prophylactic for inter-dialytic weight gain

Answer 31

Intermittent (Hemodialysis, Peritoneal dialysis) Continuous (CRRT) in Critical Care Toxins/fluids removed Acid-Base balance & electrolytes adjusted slowly in hemodynamically UNSTABLE patients Access: Double-lumen catheter in Jugular or Femoral veins Blood pump & anti-coagulation required Renal Transplantation

Answer 32

1972 Social Security Amendment - Medicare Coverage for all those: 65 or older Under 65 with certain disabilities (DM, HTN) & those who have received Social Security Disability (SSDI) for 2-years Any age with ESRD 1978: Congress established ESRD Network Organizations Program 1986: Program re-codified to 18 ESRD Network Organization areas, Funding for Renal Transplantation

Answer 33

Movement of fluid/molecules across semipermeable membrane from one compartment to another Used to correct fluid & electrolyte imbalances, & remove waste products in kidney failure Can be used to treat drug overdoses Two methods available Peritoneal dialysis (PD) Hemodialysis (HD) Nephrologist determines when to start; Usually uremia can no longer be adequately treated conservatively; GFR < 15 mL/min/1.73 m2 Uremic complications require dialysis ESRD treated with dialysis because Lack of donated organs Some patients are physically or mentally unsuitable for transplantation Some patients do not want transplantation

Answer 34

Diffusion; Movement of solutes from an area of greater concentration to an area of lesser concentration Osmosis; Movement of fluid from an area of lesser concentration of solutes to area of greater concentration Glucose in dialysate creates osmotic gradient to pull fluid from the blood Ultrafiltration; Water & fluid removal results when there is an osmotic gradient or pressure gradient across membrane, excess fluid moves into dialysate PD: Glucose in dialysate HD: Pressure gradient

Answer 35

Access obtained by inserting catheter through anterior abdominal wall Technique for placement varies; usually done via surgery PD may start right away or be delayed until site healed Aseptic technique important to avoid peritonitis

Answer 36

Dextrose in dialysis solution; Osmotic agent Manual PD: 3-Phase Cycle (Called an “Exchange”) Volume depends on size of peritoneal cavity Inflow (fill); 2 to 3 Liters over 10-minutes Dwell (equilibration); 20 - 30 minutes to 8-hours (Individualized) Drain; 15 - 30 minutes Continuous Ambulatory Peritoneal Dialysis (CAPD) Manual exchange 4 x / Day Automated Peritoneal Dialysis (APD) Cycler delivers dialysate during sleep Times & controls fill, dwell, & drain phases Alarms & monitors for safety

Answer 37

Exit site infection Redness, tenderness, drainage Treated with antibiotics Peritonitis: Exit site or tunnel infection Abdominal pain, rebound tenderness Cloudy effluent with increased WBCs or bacteria, may have fever GI: diarrhea, vomiting, distention, hyperactive bowel sounds Treated with antibiotics Repeated infections may cause adhesions Hernias: Increased intra-abdominal pressure from dialysate Treatment: hernia repair Bleeding Common with initial catheter placement New; Active intraperitoneal bleeding; check BP & hematocrit Pulmonary complications Decreased lung expansion leads to atelectasis, pneumonia, or bronchitis Elevate HOB, repositioning & deep breathing Protein loss; Monitor nutrition Lower back problems Intraperitoneal infusion increases pressure Treatment: binders and exercise

Answer 38

Short training program; 3 to 7 days Advantages Simplicity Home-based program Increasing patient participation No need for special water systems Equipment set-up is relatively simple

Answer 39

Requires rapid blood flow & access to large blood vessel Obtaining vascular access is one of most difficult problems AV Fistula: Created in forearm or upper arm; Preferred access for HD Allows arterial blood to flow through vein; becomes “arterialized; Increases vein size & wall thickness Placed 3-months before HD; Needs to heal/mature “Thrill” & “Bruit” (High velocity blood flow) AV Graft: Synthetic material surgically placed under skin to form a “bridge” between brachial artery & antecubital vein Temporary vascular access

Answer 40

Healing: 2 to 4 weeks More likely to get infected or form clots If infected, may need removed Risks: Distal ischemia (Steal Syndrome) Pain distal to access site Numbness or tingling of fingers Poor capillary refill Aneurysms Safety alert for AVF & grafts No BP, venipunctures, or IV lines Post signs in room & labeled arm band Prevent infection & clotting HeRO Graft (Hemodialysis Reliable Outflow) Special bridge access used when other access options are exhausted Two pieces Reinforced tube to bypass blockages Dialysis graft anastomosed to an artery; placed under skin Bypasses venous system; blood flows from target artery to heart

Answer 41

Plastic cartridges that contain thousands of parallel hollow tubes or fibers; semipermeable membranes Blood is pumped from top into fibers Dialysate pumped from bottom & bathes outside of fibers Ultrafiltration, diffusion & osmosis occur When blood reaches end it is returned via single tube to patient

Answer 42

Fluid status assessed before HD treatment Weight, BP, peripheral edema, heart & lung sounds Last post-dialysis weight & current pre-dialysis weight determines amount of fluid to be removed Assess vascular access & temperature Two large bore needles placed in fistula or graft One to pull blood from circulation to HD machine Other to return dialyzed blood to patient Dialyzer/blood lines primed with NaCL to eliminate air; Heparin added to prevent clotting Dialysate delivery & monitoring system is used; VS every 30 - 60 minutes, Terminated with saline flush to return all blood to patient, Needles removed & firm pressure applied Most in community-based center; Dialyzed 3 - 4 hours, 3 days/week Other options; Short daily HD, Long nocturnal HD, Home HD

Answer 43

Hypotension; Hypovolemia, decreased CO & SVR; Light-headed, nausea, seizures, vision changes, & chest pain Treatment: Decrease volume of fluid removal & IV Normal Saline Muscle cramps; Decreased BP, hypovolemia, increased ultrafiltration, & low-sodium dialysate Treatment: Decrease ultrafiltration & give IV fluids Blood loss; Blood not rinsed from dialyzer, accidental separation of tubing, dialysis membrane rupture or bleeding after needles removed; Heparin Treatment: Rinse all blood back, avoid excess Heparin, hold pressure to access sites Hepatitis C (8% to 10% develop): Infection control precautions Hepatitis B: low incidence; administer vaccine

Answer 44

Cannot fully replace normal function of kidneys Can ease many of symptoms Can prevent certain complications CV disease carries high mortality rate Infectious complications 2nd leading cause of death Individual adaptation Positive Ambivalent Depressed Nursing goals: Help patient to: have a healthy self-image return to highest level of function

Answer 45

Battery operated Requires only 370 mL water Versus 40-gallons for HD Early model 11-pounds Latest model 2-pounds Device connected via one catheter surgically inserted in 20-minute procedure under a local anesthetic