Topic 9: CKD & Dialysis Flashcards
CKD
involves progressive, irreversible loss of kidney function. Defined as wither presence of kidney damage or decreased GFR less than 60mL/min for longer than 3 months
Last stage of kidney disease is end-stage renal disease (ESRD), occurs when the GFR is
less than 15mL/min
leading causes of CKD
diabetes and HTN
Clinical Manifestations of CKD
· Retained urea, creatinine, phenols, hormones, electrolytes, water
· Uremia: a syndrome in which kidney function declines to a point that symptoms may develop in multiple body systems (occurs when GFR is 15mL/min or less)
· Difficulty with urine retention OLIGURIA
Increased BUN and Creatinine (waste product accumulation
· Kussmauls breathing (with severe acidosis)
· Dyspnea (fluid overload, pulmonary edema, etc.)
Increased BUN manifestations
N/V, lethargy, fatigue, impaired thought process, HA
CKD alters carbohydrate metabolism which means
client may present with Moderate hyperglycemia and hyperinsulinemia
most patients with CKD die from
CVD: increased LD and Low HDL
electrolyte imbalances associated with CKD
hyperkalemia
hypernatremia
hyperphospatemia
hyperkalemia can lead to
can lead to fatal dysrhythmias
Impaired sodium excretion for CKD can lead to
edema, HTN and HF
in CKD kidneys are unable to excrete acid which means
Metabolic acidosis
why is anemia a manifestation in CKD
due to decreased production of ERYTHROPOETIN
neurologic changes in CKD (Result of increased nitrogenous waste products)
lethargy, apathy, decreased ability to concentrate, fatigue, irritability, altered mental status
· CKD mineral and bone disorder
o Kidney is not turning vitamin D into its activated form, decreased vitamin D means decreased serum calcium levels
o This means hyperphosphatemia
o Increase risk for BONE FRACTURE
· Uremic frost
o Rare condition in which urea crystalizes on the skin
o Usually only seen when BUN levels are really high
what is usually the first sign of kidney damage
Persistent proteinuria (dipstick evaluation)
diagnostic assessment for CKD
· Renal ultrasound, renal san, CT scan
· Renal biopsy
· BUN, creatinine and creatinine clearance levels
· Serum electrolytes
· Lipid profile
· Urinalysis
· Protein-to-creatinine ratio in first morning voided specimen
· Hematocrit and hemoglobin levels
stage 1 CKD
GFR >90
stage 2 CKD
GFR 60-89
stage 3a CKD
GFR 45-59
stage 3b CKD
GFR 30-44
stage 4 CKD
GFR 15-29
stage 5 CKD
GFR <15
Hyperkalemia Interventions
· Restricting high potassium food and drugs
· IV gluconate
· IV glucose and insulin
· Sodium polystyrene sulfonate (given to lower potassium un stage 4 CKD)
· Monitor for changes in ECG
HTN Interventions
· Weight loss
· Lifestyle changes (exercise, avoid alcohol and smoking)
· Diet: DASH Diet
· Antihypertensives
CKD-MBD Interventions
Limit dietary phosphorus
· Supplementing vitamin D (oral or IV calcitriol) giving phosphate binders
· Controlling hyperparathyroidism
diagnosis for CKD-MBD
· Gold standard for diagnosis is bone biopsy
Anemia Interventions
· Exogenous erythropoietin (use lowest possible dose to avoid thrombolytic events like MI, HF, stroke)
· EPO may lead to iron deficiency: iron supplementation is recommended
nutrition therapy CKD
· Protein must be high enough if patient is on HD or PD, but high protein diets can overburden diseased kidneys
· Fluid intake is usually as desired, but TEACH patients to limit fluid intake so that weight gain are no more than 1 t0 3 kg between dialyses (interdialytic weight)
· Restrict sodium
· Restrict potassium
· Restrict phosphorus
Foods high in phosphorus
milk, ice cream, yogurt, pudding
Health Promotion for CKD
· Ask patient about what medications they are taking as some may be nephrotoxic
· Weight and weight changes
· Patients with diabetes need to have their urine checked for albuminuria and changes in urine appearance
· Monitor creatinine, BUN, GFR if patient needs a potentially nephrotoxic drug
· MONITOR BP, treat HTN
Treat diabetes
patient teaching CKD
· Dietary sodium, potassium, phosphate restrictions
· S/S of electrolyte imbalances, especially high potassium
· Alternative ways to reduce thirst (sucking on ice cubes, lemons or hard candy)
patients with CKD should report
o Weight gain >4lb (2kg)
o Increasing BP
o SOB
o Edema
o Increasing fatigue or weakness, lethargy
Confusion
Dialysis
corrects fluid and electrolyte imbalances and removes waste products in kidney failure
Hemodialysis
· Blood taken out, “washed” and put back into the patient
· 3-4 times per week
access site for hemodialysis
AV Fistula and grafts
how long to AV grafts need to heal
2-4 weeks
Peritoneal Dialysis
access obtained by inserting a catheter through anterior abdominal wall
peritoneal dialysis catheter
· A Dacron cuff forms holding catheter in place
The tip of the catheter rests in the peritoneal cavity
Before Dialysis
· Assess fluid status (weights current and previous)
· VS
· ASSESS FISTULA (SHUNT)
· HOLD MEDS (especially if the cause lowered BP)
· IV heparin is added during dialysis to prevent clots
· Consent
assesing fistula/shunt
o Feel a THRILL (vibration)
o Hear a BRUIT (swoosh)
o Report to HCP if NOT present
what is added to dialysis to prevent clots
iv heparin
SAFETY for AV Fistula and Grafts
· Never perform BP, IV insertion, or venipuncture in the extremity with AV access
· Place signs in room and label band “No BP, blood draws, or IV in this arm”
Complications of Hemodialysis
· Hypotension
o Decrease fluid volume removed and infuse 0.9% saline
· Muscle cramps
o Reduce ultrafiltration rate and give fluids
· Loss of blood
o Hold firm pressure on access sites (remember heparin was given to reduce clots)
Disequilibrium Syndrome s/s
· Restless and disoriented!!!
· Causes brain cells to swell which increases ICP
Disequilibrium Syndrome intervention
· STOP/SLOW THE INFUSION AND REPORT TO HCP
Peritoneal Dialysis intervention
· Take weight and warm the solution
· Monitor for exit site infection
· Monitor for peritonitis
· Hernias may develop due to increased intrabdominal pressure
· Lower back pain
· Monitor for bleeding
· Monitor for pulmonary complications
Monitor for protein loss
peritonitis s/s
o Abdominal pain, rebound tenderness, cloudy peritoneal effluent with a WBC greater than 100 cells/uL
