Renal Failure cards Flashcards
1
Q
AKI Causes
A
1) Pre-Renal
- Are those that reduce blood flow & lead to decrease glomerular perfusion & filtration *
- Hypovolemia, decrease cardiac output, decreased peripheral resistance, vascular obstruction (account for 55 – 60% of cases) - Examples: antihypertensive, arrhythmias, ascites, burns, dehydration, diuretic overuse, hypo-al\ buminemia, heart failure, MIs, PEs, Sepsis, trauma, tumour
2) Intrinsic (intra-renal)
- Are conditions that cause direct damage to the renal tissue resulting in impaired nephron function Prolonged ischemia or nephrotoxins – hemoglobin (haemolysed cells) myoglobin (necrotic tissue) – these will cause obstructions and destroy cells (35 – 40% of cases) *
- Examples: acute glomerulonephritis, acute tubular necrosis, acute pyelonephritis, crush injuries, myopathy, scleroderma, sickle cell disease, lupus, transfusion reaction
3) Post-Renal
- Mechanical obstruction of urinary flow – urine refluxed into the renal pelvis (accounting for 5% of cases) *
- Example: bladder obstruction, prostatic hypertrophy, ureteral obstruction
2
Q
4 phases of AKI
A
Clinical manifestations of AKI
Initiation (onset) phase
- begins at the time of the insult and continues until behaviours (signs & symptoms) become apparent (hours to days)
Oliguric (anuric) phase:
- is the reduction of urine output to 400ml/24 hrs. Usually within 1-7 days from the insult
Diuretic phase:
- will start with 1-3L/day and can increase to 3-5L/day (this phases may last for 1 -3 weeks)
- *Kidneys have ability to excrete waste but not concentrate the urine.
- *With large losses of fluid & electrolytes watch for hyponatremia, hypokalemia & dehydration.
Recovery phase:
- begins when the filtration rate increases, allowing BUN & Cr levels to decrease & electrolyte balance to maintained (this phase can take up to 12 months)
3
Q
Signs and Symptoms
A
Body System: Urinary
Clinical Manifestation:
- * Decrease urine output
- * Proteinuria
- * Casts
- * Decreased specific gravity
- * Increase urinary sodium
Body System: Hematologic
Clinical Manifestation:
- * Anemia (develop within 48 hours) from decrease EPO production of kidneys
- * Susceptible to infections
- * Leukocytosis
- * Defect in platelet function
Body System: Cardiovascular
Clinical Manifestation:
- * Fluid overload
- * Congestive Heart failure
- * Hypotension (early)
- * Hypertension (with fluid overload)
- * Pericarditis
- * Pericardial effusion
- * Cardiac arrhythmias
Body System: Respiratory/Gastrointestinal
Clinical Manifestation:
- * Pulmonary edema
- * Kussmaul respirations
- * Pleural effusions
- * N & V * Anorexia
- * Stomatitis
- * Bleeding
- * Diarrhea
- * Constipation
Body System: Neurologic/Metabolic
** these levels, if not control, are an indication for dialysis
Clinical Manifestation
- * Lethargy
- * Seizures
- * Memory impairment
- * Increase Urea (BUN)
- * Increase Creatinine
- * Increase Potassium
- * Increase Phosphate
- * Decrease Sodium
- * Decreased pH (acidosis)
- * Decrease bicarbonate (acidosis)
- * Decrease calcium
- * Kidneys convert Vitamin D to its active form therefore cannot absorb calcium
4
Q
AKI Nursing Care
A
Nursing Care
- Important to monitor V/S, especially B/P & HR (because they are vital)
- * Be aware of blood tests, scans, U/A etc…
- Intake and Output of all fluids (PO & IV)
- Fluid restriction (600 ml + previous 24 hour fluid loss)
- * Weight patient daily Diet: high-caloric, low protein, potassium and sodium
- General appearance: skin colour-GREY, peripheral edema, neck vein distention and bruises
- * Maintain electrolyte balance (POTASSIUM) Stay away from potassium –high K banana coconut water foods and sport drinks!
5
Q
AKI Nursing Interventions
A
Treatment of Hyperkalemia: Stabilize myocardium from decrease calcium
- Calcium gluconate IV : it will raise threshold at which dysrhythmias will occur (buy you time)
- Shift Potassium from increase potassium
- Regular insulin IV (given with dextrose) and/or sodium bicarbonate IV will move potassium back into cells (buy you time)
- Remove Potassium Cation exchange resins – sodium polystyrene sulphonate (Kayexalate) is administered by mouth or retention enema.
-It is mixed with sorbitol to produce osmotic diarrhea, allowing evacuation of potassium rich stool. >youre getting rid of it Use of large doses of furosemide (Lasix)
6
Q
CKD
A
Etiology
Many systemic disease can stress the renal system and disrupt normal elimination:
- * Obstructions from various conditions: tumours, chronic inflammations (chronic glomerulonephritis, polycystic kidney)
- * Exposure to strong nephrotoxins (or repeated exposure to these)
- * Other systemic disease processes: diabetes, hypertension, heart failure, sickle cell, lupus erythematosus
7
Q
CKD Stages
A
CKD:
Stages I to V
Stage I:
- slight diminished function (GFR - ˃ 90ml/min/1.73m2) 60%-89% GFR of our kidney function
- Action: Diagnosis and treatment of comorbidities
- * (would want to formulate plan to treat causative factors: HTN & DM)
- * Life style changes by controlling blood sugar and blood sugar
Stage II: indicates a mild reduction (GFR - 60-89ml…)
- 30%-60% GFR of our kidney function
- Action: estimation of progression
Stage III: indicates a moderate reduction (GFR – 30-59 ml…)
- 15%-30% of GFR
- Action: Evaluation and treatment of progression
Stage IV: indicates a severe reduction (GFR – 15-29 ml…)
15% or
- Action: Preparation for renal replacement therapy
Stage V: indicates a GFR of less then 15 ml…
- * Toxins cannot get out of body no urine, no metabolism * Hemodialysis – CAPD *
- (End-stage renal disease – ESRD) * Action: Renal replacement therapy if uremia present
8
Q
CKD Manifestation
A
Urinary system:
- In early stages you have polyuria – kidney unable to concentrate urine
- * Because of this the specify gravity of urine becomes fixed at 1.010
- * As CKD worsens oliguria develops and eventually anuria (urine output is 40ml / 24 hours)
- Bladder Sweat!
Electrolyte/acid-base system
- Potassium (hyperkalemia), sodium (usually restricted), calcium , phosphate & magnesium (both are usually not a problem)
Acid-base (metabolic acidosis)
- * Impaired ability of kidney to excrete acid load (mostly ammonia) but also from the defective reabsorption and regeneration of bicarbonate (the bone will be demineralized which will buffer this effect and respirations….)
Metabolic disturbances:
- * Waste product accumulation (serum creatinine will be less on and older adult than in a younger person)
- Why? Altered carbohydrate metabolism (impaired glucose use due to cellular insensitivity to action of insulin)
- Elevated triglycerides (altered lipid metabolism)
- *do not give insulin because kidney wont be able to metabolize
Hematological System:
Anemia – very common since there is a decrease of the production of erythropoietin (from the kidney) which is needed to stimulate the bone marrow
- * But also because of nutritional issues, an increase in hemolysis (blood samples, loss of blood in dialyzer)
- Insufficient iron stores (loss of folic acid with dialysis)
- Bleeding tendencies – with uremia you have defect in platelet function but also alterations in coagulation system Infection – leukocyte function and altered immune response (there is a diminished inflammatory response which means a decrease in WBC accumulation at infection site)
Cardiovascular System:
- * CVD is the leading cause of death in CKD patients
- * Hypertension – made worst by Na retention and increase in extracellular fluid. In some people increase in renin production. Will lead to CHF.
- * Elevated triglyceride levels (diabetes if patient has)
- * CHF can lead to pulmonary & peripheral edema
- * Cardiac dysrhythmias from hyperkalemia, hypocalcemia
- * Uremic pericarditis can develop and lead to pericardial effusion - tamponade GI System: every part of the GI system is affected as a result of inflammation of the mucosa by excessive urea
- * Mouth ulcers
- * Stomatitis
- * Uremic fetor (a urinous odour of the breath)
- * Anorexia, nausea, vomiting
- * GI bleeding due to irritation but also because of platelet defect
- Diarrhea because of hyperkalemia, but also constipation due to ingestion of iron salts (can be worsen due to limited fluid intake) Integument system: you may see a yellow-grey discoloration of the skin (retention of urinary pigments)
- * Skin is pale due to anemia and is dry and scaly because of decrease in oil and sweat gland activity
- * Pruritus is due to dry skin, calcium-phosphate deposits in the skin (itching is so intense that will break skin) * Hair is dry and brittle * Nails are thin, brittle and ridged
9
Q
CKD Nursing Interventions
A
- * Close monitoring of V/S
- * Monitor and request blood work PRN: CBC, Lytes, Cr, BUN, other specific values
- * Nutritional assessment: types of foods, tolerance, promote patient monitoring, high quality protein
- Fluid restrictions: 600ml plus past 24 hr. output, weight QD or three times per week
- Monitor & teach S & S of heart failure: Pulmonary Edema Monitor & teach S & S hypoglycemia
10
Q
Hemodialysis
A
- * To correct acidosis and remove fluid
- * To remember – glucose small enough to go through filter!
- * All the complications from a central line: pneumothorax & hemothorax post-insertion, also bleeding, occlusion, infection and thrombosis (even with Heparin use)
- minimal urinary output
- fluid restriction-on antihypertensive drugs because all the volume in body will make heart work harder
- pt on diuretic to get a lot of fluid out-anything going in the mouth is not getting filtered
- pt cant take iron and potassium
11
Q
CAPD
A
- * No vascular access is needed; the peritoneum is used as a semi permeable membrane
- * Can be used for AKI and CRF
- * Soft catheter is inserted surgically into the abdomen near the umbilicus & is held in place by a cuff
- * Different concentration of dialysate (attracts excess fluid) are infused on a schedule, left to dwell to “ pull off” waste and fluid, and drained
- * Extreme care in verifying correct fluid (concentration), temperature, aseptic technique when connecting and disconnecting, accurate timing * Accurate calculation of I/O do dialysate
Peritoneal Dialysis: complications
Post-insertion of catheter:
- * Bleeding and infection (cloudy and smelly)
Long term complications:
- * Infection
- * Low albumin levels (loss in peritoneal fluid)
- * Scarring of peritoneum
- * Elevated serum glucose (dialysate is glucose)
- * Hernias of the abdomen and groin
- * Nutrition and elimination problems
Medical Treatments
- * Drugs: diuretics (in early disease) and corticosteroids, but drugs also to control underlying issues
- * Lasix and Mannitol (stimulate excretion & control edema)
- * Antihypertensive (C++blockers and ACE inhibitors)
- * Calcium suppl. & phosphorous binders ( Calcitrol, Vit. D, calcium carbonate)
- * Vitamins/Minerals (Vit. D, B, Fe, folic acid)
- * Sodium Bicarbonate
- * Erythropoietin
