Renal Disorders Flashcards by Kelsey Klipfel

if left untreated will spiral out of control to ESRD causing dialysis; some reversible if treated appropriately

All renal diseases -

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How control BP
Increased fluid volume
Issues when think not getting enough fluid = increase BP and cause more damage

Renin Angiotensin Aldosterone System (RAAS)

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GFR/E-GFR greater than 90
GFR - taken from 24-hour urine to see mL/hr urine\ being put through kidney through greater than 90 without proteinurea looks at normal GFR; E-GFR - serum
GFR/E-GFR <90

Renal diet/restrictions

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High calories
Normal to increased fluid volume 2-4 liters per day = keep kidneys flushing
May need a dietitian consult
Modification of Diet in Renal Disease (MDRD) equation - changing renal diet depending on scenario for each pt; need have dietician seeing them
Each renal process requires differing dietary additions/subtractions.

GFR/E-GFR greater than 90

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Protein spilling
High calories - prevent protein breakdown
Low protein
Low sodium - less fluid
Do not use salt substitute - contain Potassium
Potassium restrictions
Phosphorus restrictions
Magnesium restrictions
Fluid Restrictions
Prepackaged food are high in sodium as a preservitive
Down to level Dialysis requires even greater restrictions
Dietitian consultation is a must!
Lab values and fluid status guide treatment

GFR/E-GFR <90

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Genetic disorder characterized by the growth of numerous fluid-filled cysts in the kidneys
Fluid-filled sacs bursting all over it; destroy the nephrons (funx unit of kidney)
Cyst growth- destroy nephrons

Pathophysiology - Polycystic kidney disease (PKD)

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Abdominal distention - size of a football
Flank pain
Increased abdominal girth
Hematuria - from rupturing cyst
Constipation - Kidney failure stops lot fluid from going through kidney or reabsorped by the kidney - fluid pumped into SI and allows for stool to flow freely - stool softeners, high fiber diets to get fluid in

Clinical Manifestations - Polycystic kidney disease (PKD)

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Genetic testing for family - autosomal dominant genetic disease - see if hx
Personal history - HTN
Labs
Urinalysis - shows proteinurea (glomerular destruction), BUN, creatinine, K, electrolytes, GFR - see where at on scale kidney destruction
Proteinuria
Ultrasound - cheap and easy; size kidneys within abdominal compartment

Diagnostics - Polycystic kidney disease (PKD)

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Managing blood pressure
RAAS - not get fluid - not filter; RAAS still push out and raise BP - HTN
Antihypertensive
ACE-I (lisinopril) or ARB (usually only if not tolerate ACE-I)
Managing pain - opioid
Preventing constipation
Slowing progression - not compounding with HTN, hypotension, lack of fluid
Graft or shunt placement - for dialysis; temp dialysis/quinton catheter; AV graft in arm
Renal replacement
Dialysis - hemo or peritoneal
Transplant - do transplant this but no matter what have PKD - slower progressive disease; hoping new kidney with good care will outlast the pt

Med-surg - Polycystic kidney disease (PKD)

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Excess Fluid Volume - BIG
Risk for electrolyte imbalance - elevated K, Mg, phosphorous, low Ca - leak from bones causing weak and brittle bones - telemetry - tall peak T waves with hyperkalemia
Health Promotion
Dietary adjustments
Weight maintenance - not overweight because super HTN, super thin - breaking down protein causing more kidney damage
Smoking cessation
Exercise - keep bowels running well
Limitation of alcohol

N. diagnosis - Polycystic kidney disease (PKD)

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Weight DAILY; same amt clothing, machine, time - SAME AT HOME; best way quickly assess for gain/loss fluid
Assessment
Fluid overload - pulm edema, reg edema, HTN
Lab values (Cr, BUN, Electrolytes, GFR)
Neurological states - PKD - weaker blood vessels in head and HTN from RAAS sys can have easier stroke or hypertensive encephalopathy
Fluid/Na restrictions
Dietary restrictions
Pain Management
Medication administration - do good job with this is imp

N. interventions - teaching and do within hospital - Polycystic kidney disease (PKD)

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Inflammation glomeruli
Common etiology
Post infection
Infection treated
Group A beta-hemolytic streptococcal; Autoimmune disease (SLE)
Diabetic Glomerulosclerosis
Lyses blood cells that lodge in the kidney and cause nephronal and glomeruli breakdown allowing lot diff fluids not be allowed through and other things cannot go through either; stuff cannot be reabsorped either
Acute or chronic
Complications
Hypertensive encephalopathy - loss LOC - extremely HTN and flaming things in head
Heart failure (heart failing due to ischemia or hypertrophic myopathy or heart not able to push that amount of fluid around the body)/pulmonary edema

Patho - Glomerulonephritis

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Azotemia
an abnormal concentration of nitrogenous wastes in blood
Elevated BUN,CR
Edema/hypertension
Fluid volume excess - in lungs, hands, feet, HTN
Hematuria - blood cells breaking down and out into glomeruli
Proteinuria (upper limit 3 g)/Decreased serum albumin - peeing out large protein molecules - mainly albumin - swollen up really big
Severe: AKI - treated in ICU; Oliguria

CM - Glomerulonephritis

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Urinalysis
Hematuria
Proteinuria
Destructive points in glomeruli
EKG
High potassium
Tall peak T waves
CXR - fluid in lungs
Laboratory values
(BUN, CR, Electrolytes, Protein)
CT/MRI
Sizing of kidneys
Biopsy
Cause

Diagnosis - Glomerulonephritis

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Antihypertensive medications - protein spilling: ACE-I (lisinopril)
Immunosuppressant - SLE
Antibiotics
Diuretics - flush and get kidneys moving
EKG
Dialysis - down to certain level
Epogen - stimulate bone marrow to make RBC; to replace EPO
Laboratory values
BUN,CR, electrolytes, protein
Sometimes - E-GFR, GFR - acute process - treating with fluids and diuretics - GFR not correct

Med-surg - Glomerulonephritis

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Excess Fluid Volume
Risk for electrolyte imbalance
Risk for confusion - hypertensive encephalopathy, buildup waste in blood, lower/elevated Na
Imbalanced nutrition, less than - calorie destruction - destruction protein
Acute pain

N. diagnosis - Glomerulonephritis

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Administer medications
Monitor I&O/labs
Assess fluid status - not fluid overloaded/underloaded - euvolemic (equal)
Daily weight - most IMP; fastest way assess if pt gaining/losing fluid
Fluid/Na restriction
High carb diet- energy prevent catabolism of protein
Assess for pain and treat
Monitor for further complications

N. interventions - Glomerulonephritis

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Serious/horrible damage to glomerular capillary membrane
Increased glomerular permeability and loss of protein in urines (big things go through it) - including albumin - urinate out large amounts protein
Due to altered immunity and inflammation
Acute versus chronic

Patho - Nephrotic syndrome

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HALLMARK: Proteinuria greater than 3.5 g/day
Hypoalbuminemia - serum - inverse; gone out through renal sys; without albumin little control over oncotic pressure and goes into third space -
Massive edema/periorbital edema/anarsarka - edema upon edema
Hypertension - RAAS - certain amount pressure - left with bunch RBCs - pump sludge around body and get HTN

CM - Nephrotic syndrome

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Thromboembolism - sludge - clump together easier and get clots easier
Pulmonary edema - fluids going someplace where no pressure; fluid in lungs
Hyperlipidemia - liver gets overzealous - needs protein and shooting out lot protein - pee it out - not good for kidney but at same time as pulls protein also takes fats (lipids esp) but no place to go so get seriously high lipid levels - statin: ZOCOR

Complications - Nephrotic syndrome

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Urinalysis - protein in urine
Protein electrophoresis - separate out proteins by charge
Immunoelectrophoresis
Categorize type proteins and antibiodies
Needle biopsy of the kidney
Confirm diagnosis

Diagnostics - Nephrotic syndrome

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Treat underlying cause - inflammatory process: decrease (steroids); immune: suppress - increased risk for infection now - hopefully treated infection before nephrotic syndrome
Slow progression to CKD
Relieve symptoms - pain management
Diuretics- decrease edema
ACEI-reduce protein loss
Antihyperlipidemic - liver
Heparin Therapy - thin blood in vessels so easier to circulate

Med-surg - Nephrotic syndrome

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Excess fluid volume (extracellular) - fluid volume not inside vessels but in third space - fluid volume deficit intside vessels
Imbalanced nutrition
Fatigue - lack good O2 carrying capability
Deficient knowledge
Risk for Infection - esp immunosuppression
Activity intolerance
Disturbed Body Image

N. diagnosis - Nephrotic syndrome

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Monitor I&O/edema/weight
Monitor for hypertension - reported and treated
Assess fluid/electrolyte balance
Cardiac and neuro status - thromboembolism - could cause stroke/MI/PE; hypertensive encephalopathy
Monitor for vascular dehydration
Pt education
Follow all med/dietary regimens/restrictions
Signs of complications

N. interventions - Nephrotic syndrome

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Almost always Adenocarcinoma kidney Replaces healthy kidney tissue with cancerous tissue

Patho - Renal cell carcinoma

Gender –men greater than women Obesity Smoking PKD Occupational chemicals

Risk factors - Renal cell carcinoma

Palpable abdominal/flank mass Painless hematuria Dull pain

CM - Renal cell carcinoma

Stage I Stage II In the kidney Stage III Has gone to lymph nodes Some metastasis Stage IV

Staging - Renal cell carcinoma

Laboratory Values Increased BUN/Creatinine Urinalysis may show RBC’s IV urography - KUB with IV contrast dye Cryptoscopic examination - go through urethra and ureters Renal angiogram - blood vessels around kidneys Ultrasonography - growth or size CT Scan - growth or size Biopsy - biggest diagnostic

Diagnostics - Renal cell carcinoma

Goal: Early tumor detection - easier treat earlier stages Pain management - opioids - educated keep bowels moving Surgery Nephrectomy - removal of a kidney; few times removal kidney appropriate; cancer and some unrelenting infections remove kidney Chemotherapy Radiotherapy Palliation

Med-surg - Renal cell carcinoma

Abdominal surgery, cancer surgery Risk for postoperative bleeding Knowledge deficit Acute Pain - esp after nephrectomy Risk for electrolyte disturbances - 2 to 1 kidney - hard to balance; may need dialysis Constipation

N. diagnosis - Renal cell carcinoma

Postoperative assessment - VS Incision care Line, Tubes, Drain care - with nephrectomy end up with drain Monitor for infection Pain management - GOOD I&O/Vital Signs/labs Patient education for discharge Activity, lifting, driving - not lift for at least 6 weeks after surgery Pain management Signs of infection FU appts - IMP

N. interventions - Renal cell carcinoma

Big overarching issue Rapid reduction in kidney function - failure to maintain fluid/electrolyte balance and acid–base balance Almost always AKI treated in ICU

Acute kidney injury (AKI)

Hypovolemia (high BUN with normal CR) Hypotension Heart failure Urinary obstruction Renal artery obstruction

Reversible causes - Acute kidney injury (AKI)

Pre-renal Intra-renal Post-renal

Different types AKI - Acute kidney injury (AKI)

Blood loss, volume loss; less volume to kidneys Hemorrhage Renal losses (diuretic agents, osmotic diuresis)

Pre-renal - Acute kidney injury (AKI)

Prolonged renal ischemia Renal obstruction, renal artery stenosis Nephrotoxic agents - NSAIDS (ibuprofen)

Intra-renal - Acute kidney injury (AKI)

Urinary tract obstruction Ureteral tract obstruction Something in way - backed up into kidney - causing hydronephrosis - destruction of kidney - not able to process - everything backed up

Post-renal - Acute kidney injury (AKI)

Laboratory assessment Increased Creatinine Normal 0.6 to 1.3 mg/dL Increased BUN Normal 10-20 mg/dl Electrolyte values Calcium low Everything else elevated Increased potassium (3.5-5.0 mEq/L) GFR not accurate

Diagnostics - Acute kidney injury (AKI)

Aggressive treatment in ICU Dialysis Remove/mitigate issue - Remove obstructions Fluid restriction or challenge fluid - give extra fluid force kidney go forward - if not work then restrict - restriction involves continuous renal replacement therapy in ICU - takes stress of kidneys allowing them to heal Electrolyte replacement or reduction Monitor weight Accurate indicator of fluid loss or gain Diuretics Lasix

Med-surg - Acute kidney injury (AKI)

Fluid Volume Excess Risk for Electrolyte disturbance Potential for injury Taking cues out what see Collaborative Interventions Monitor dialysis effectiveness/complications - monitor for if labs normalizing/graft bleeding Monitor EKG changes - tall peaked T waves associated with hyperkalemia Administer medications

N. diagnosis - Acute kidney injury (AKI)

Hourly urine output - IMP; 2 hrs longest go with reduced urinary output (<30 mL/hr or 0.5mL/kg/hr) Assess fluid overload Evaluate vital signs - Hypoperfusion/hypoxemia Laboratory values Elevated Potassium/Cr, BUN Monitor EKG Potassium Assess muscle function-Paralysis - high K and high Mg - lot in dialysis but anybody with renal failure and can lead to muscle weakness/paralysis Nutrition therapy Lower sodium, potassium, phosphorus Higher calories Reduced fluid potentially

N. interventions - Acute kidney injury (AKI)

Increased fluid (H2O) intake until GFR/something within assessment cannot do that; hydrate until cannot do Changes in urinary characteristics - cloudy, urinalysis with casts in it Avoid hypotension, maintain fluid balance - not over either Reduce exposure nephrotoxic agents - ibuprofen Monitor laboratory values - Potassium Closely watch Intake and Output Meticulous/GOOD care to patients with indwelling catheter Infections go all way up to kidney - pyelonephritis and cause renal failure Metformin and contrast dye - contrast dye with CT - take things mitigate: bicarb/acetylcysteine/extra fluids so not do extra damage to kidneys

Health Promotion/prevention - Acute kidney injury (AKI)

Not reversible; not recover; stay in place Progressive, irreversible disorder; kidney function does not recover Go into End-stage kidney disease (ESKD) - requires dialysis Azotemia Build up of nitrogen-based wastes in blood - also causes uremia Uremia Azotemia with symptoms: include muscle wasting, fatigue, N&V, tremor, anorexia, metabolic acidosis, shallow respirations Hemolytic Uremic syndrome RBC distruction

Patho - Chronic kidney disease (CKD)

Diabetes Hypertension Glomerulonephritis Pyelonephritis Polycystic Kidney Renal Cancer Hereditary Conditions Combination of morbidity increases the risk. - even just one of these but if have two increases risk morbidity - greater risk of developing CKD

Risk factors/etiology - Chronic kidney disease (CKD)

Laboratory assessment Cr (0.6-1.3 mg/dL) BUN (10-20 mg/dL) Potassium (3.5-5.0 mEq/L) Glomerular Filtration Rate (GFR) Stage I (Greater than 90) - NORMAL; presence of proteinurea - spilling; microalbuminea Stage II (60-89) - kidney declining Stage III (30-59) Moderate kidney damage; kidney declining Stage IV (15-29) Severe kidney damage; kidney declining Stage V (less than 15) complete Failure; requires dialysis Imaging assessment Kidney or CT scan

Diagnostics - Chronic kidney disease (CKD)

Dialysis - depend on where at in stage Diuretics/ fluid restrictions Laboratory assessments: Electrolytes; BUN/Creatinine; BNP (stretch receptor in heart and shows good view of how much fluid on board) Clinical assessments: Fluid Volume; Hypertension; Heart Failure Renal replacement therapies Anemia treatments: Epogen Antihypertensives (ACE-I lisinopril)/Electrolyte replacement Kidney Transplant - depend on where at in stage; may come down to this

Med-surg - Chronic kidney disease (CKD)

Excess Fluid Volume Risk for electrolyte imbalance Monitor for complications Decreased Cardiac Output Risk for infection goes up Risk for injury goes up Impaired urinary elimination

N. diagnosis - Chronic kidney disease (CKD)

Monitor Fluid overload/Daily Weight Lab values (BUN, CR, Electrolytes) Vital sign for HTN Heart (failure)/lungs (fluid)/neurological (HTN encephalopathy, build up nitrogenous waste) Fluid/Na restrictions Dietary restrictions Cardiac Monitor - tall peaked T waves Kussmaul respirations - deep rapid breaths; trying to blow off metabolic acid that body gotten from kidneys gotten no longer being able to create acid-base balance

N. interventions - Chronic kidney disease (CKD)

Antibiotic before dentistry - esp if thinking grow up into head from teeth or down into heart Medication dose reduction - as CKD develops need adjust meds Antacids with magnesium - Mg is high - not have clearance Antibiotics Antidiabetic Insulin Opioids Anticoagulants Diet Low protein Low sodium Potassium restriction Phosphorous restrictions Mg restrictions High calories - not allow protein break down - worse damage to kidney Fluid restriction Smoking cessation/Limitation of alcohol Exercise - GOOD Control of risk factors Treatment regimen Patient depression - many times after tied to dialysis treatment get very dialysis figure out what treatment means to them Treatment refusal

N. edu - Chronic kidney disease (CKD)

Tunneled dialysis catheter Blood pulled from the red arterial line and returned from the blue venus line - not in a artery at all - in veins - two diff places in catheter Catheter not accessed or used by appropriated trained dialysis pts - packed with certain heparin - not want push any into body - risk anticoag Arteriovenous (AV) Gravy Put into artery - pull blood off and then put into vein where can put blood back in Not accessed in but dialysis nurse

Hemodialysis - 2 diff access devices

NEVER use AV Graft or Dialysis Catheter for infusion!

Dialysis

Peritoneal Dialysis Hemodialysis Continuous Renal Replacement Therapy (CRRT) Form hemodialysis in ICU

Dialysis types

Catheter placed in abdominal/peritoneal cavity Semipermeable membrane allows exchange Complications Peritonitis, Leakage, Bleeding Two occasion of peritonitis no longer allowed - go to hemodialysis - start on hemodialysis stay on forever Nursing Maintain sterility Monitor output Bloody drainage or Straw color? - see color; blood present Measure output vs output - see how much more

Peritoneal dialysis

CRRT form of Hemodialysis CRRT continuous (ICU only) - runs constantly; does not stop; not tolerate fluid shifts well; low BP Hemodialysis in blocks of hours; diff forms; many times a week Check Bruit: AV Graft - hand over graft - feel buzzing and also stethoscope and hear for whoosh Dialysis Catheter Safe and sterile dressing - if catheter coming out - make sure and sterile Just monitor it only Never use for IV infusions Pharmacologic Therapy Dosage adjustments Nutritional/Fluid Therapy Psychosocial Needs of pt

Hemodialysis & CRRT

2-70 years-old >70 age on individual basis Free of uncorrectable cardiac disease Free of metastatic cancer, chronic infection, and ETOH and substance abuse In depth Evaluation of urinary system - make sure can void and clear to empty that bladder

Kidney transplant - Candidate

Living/Brain death/short-term Cadaver Match on tissue similarity Requirements Absence of systemic disease or infection No current active cancer No hypertension or kidney disease Adequate kidney function as determined by diagnostic studies

Kidney transplant - Donor

Immunologic studies – match with donor as quick as possible and exact as possible; rejection Must have same blood type Teaching – pre, during, post operative Anti-Rejection medication - staying on it and taking it in timely manner Dialysis 24 hours before surgery - may need couple times after surgery depending if kidney takes Blood transfusion from donor - shown to really help with rejection Must be ready for surgery within short time frame

Kidney transplant - Preoperative

Focused assessment Accurate I and O/hour x 48 hours Urinary output - NEED THIS Continuous bladder irrigation (CBI) - may need this Immunosuppressive drug therapy Complications Rejection - kidney rejection; looks like kidney failure Thrombosis Renal artery stenosis Not remove kidney unless cancer or unrelenting infections; if not need remove - place in pelvic floor off of common iliac vein and artery then hook into bladder

Kidney transplant - Postoperative

Ineffective Protection Risk for ineffective Renal perfusion Readiness for enhanced Decision-making Readiness for enhanced family process Readiness for enhanced Health management Readiness for enhanced Spiritual well-being Risk for Infection - immunosuppressive

Kidney transplant - N. diagnosis

Monitor for manifestations of rejection Increasing BUN, Creatinine, GFR, Electrolytes Watching Intake and Output Monitor for manifestations of infection Transplant medication

Kidney transplant - N. interventions