Renal Disorders

Question 1

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

Answer 1

All renal diseases -

Question 2

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

Answer 2

Renin Angiotensin Aldosterone System (RAAS)

Question 3

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

Answer 3

Renal diet/restrictions

Question 4

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.

Answer 4

GFR/E-GFR greater than 90

Question 5

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

Answer 5

GFR/E-GFR <90

Question 6

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

Answer 6

Pathophysiology - Polycystic kidney disease (PKD)

Question 7

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

Answer 7

Clinical Manifestations - Polycystic kidney disease (PKD)

Question 8

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

Answer 8

Diagnostics - Polycystic kidney disease (PKD)

Question 9

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

Answer 9

Med-surg - Polycystic kidney disease (PKD)

Question 10

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

Answer 10

N. diagnosis - Polycystic kidney disease (PKD)

Question 11

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

Answer 11

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

Question 12

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

Answer 12

Patho - Glomerulonephritis

Question 13

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

Answer 13

CM - Glomerulonephritis

Question 14

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

Answer 14

Diagnosis - Glomerulonephritis

Question 15

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

Answer 15

Med-surg - Glomerulonephritis

Question 16

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

Answer 16

N. diagnosis - Glomerulonephritis

Question 17

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

Answer 17

N. interventions - Glomerulonephritis

Question 18

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

Answer 18

Patho - Nephrotic syndrome

Question 19

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

Answer 19

CM - Nephrotic syndrome

Question 20

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

Answer 20

Complications - Nephrotic syndrome

Question 21

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

Answer 21

Diagnostics - Nephrotic syndrome

Question 22

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

Answer 22

Med-surg - Nephrotic syndrome

Question 23

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

Answer 23

N. diagnosis - Nephrotic syndrome

Question 24

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

Answer 24

N. interventions - Nephrotic syndrome

Question 25

Almost always Adenocarcinoma kidney
Replaces healthy kidney tissue with cancerous tissue

Answer 25

Patho - Renal cell carcinoma

Question 26

Gender –men greater than women
Obesity
Smoking
PKD
Occupational chemicals

Answer 26

Risk factors - Renal cell carcinoma

Question 27

Palpable abdominal/flank mass
Painless hematuria
Dull pain

Answer 27

CM - Renal cell carcinoma

Question 28

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

Answer 28

Staging - Renal cell carcinoma

Question 29

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

Answer 29

Diagnostics - Renal cell carcinoma

Question 30

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

Answer 30

Med-surg - Renal cell carcinoma

Question 31

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

Answer 31

N. diagnosis - Renal cell carcinoma

Question 32

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

Answer 32

N. interventions - Renal cell carcinoma

Question 33

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

Answer 33

Acute kidney injury (AKI)

Question 34

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

Answer 34

Reversible causes - Acute kidney injury (AKI)

Question 35

Pre-renal
Intra-renal
Post-renal

Answer 35

Different types AKI - Acute kidney injury (AKI)

Question 36

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

Answer 36

Pre-renal - Acute kidney injury (AKI)

Question 37

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

Answer 37

Intra-renal - Acute kidney injury (AKI)

Question 38

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

Answer 38

Post-renal - Acute kidney injury (AKI)

Question 39

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

Answer 39

Diagnostics - Acute kidney injury (AKI)

Question 40

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

Answer 40

Med-surg - Acute kidney injury (AKI)

Question 41

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

Answer 41

N. diagnosis - Acute kidney injury (AKI)

Question 42

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

Answer 42

N. interventions - Acute kidney injury (AKI)

Question 43

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

Answer 43

Health Promotion/prevention - Acute kidney injury (AKI)

Question 44

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

Answer 44

Patho - Chronic kidney disease (CKD)

Question 45

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

Answer 45

Risk factors/etiology - Chronic kidney disease (CKD)

Question 46

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

Answer 46

Diagnostics - Chronic kidney disease (CKD)

Question 47

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

Answer 47

Med-surg - Chronic kidney disease (CKD)

Question 48

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

Answer 48

N. diagnosis - Chronic kidney disease (CKD)

Question 49

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

Answer 49

N. interventions - Chronic kidney disease (CKD)

Question 50

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

Answer 50

N. edu - Chronic kidney disease (CKD)

Question 51

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

Answer 51

Hemodialysis - 2 diff access devices

Question 52

NEVER use AV Graft or Dialysis Catheter for infusion!

Answer 52

Dialysis

Question 53

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

Answer 53

Dialysis types

Question 54

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

Answer 54

Peritoneal dialysis

Question 55

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

Answer 55

Hemodialysis & CRRT

Question 56

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

Answer 56

Kidney transplant - Candidate

Question 57

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

Answer 57

Kidney transplant - Donor

Question 58

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

Answer 58

Kidney transplant - Preoperative

Question 59

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

Answer 59

Kidney transplant - Postoperative

Question 60

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

Answer 60

Kidney transplant - N. diagnosis

Question 61

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

Answer 61

Kidney transplant - N. interventions