Unit 1 Flashcards
How is fluid volume managed for the patient with chronic kidney disease?
Strict I’s and O’s
Daily weight (1 kg = 1 L of fluid)
ESA’s
Diuretics
Burning and gnawling pain in upper abdomen Nausea and vomiting Unexplained weightloss Signs of diabetes mellitus Fatigue Steatorrhea stools
These are manifestations of?
Chronic pancreatitis
Renal artery stenosis
Heart attack
Heart failure
Infection (sepsis)
Prerenal/Intrarenal/Postrenal?
Prerenal
True/False: A consent is needed for a patient that requires hemodynamic monitoring.
True
Normal Hct level? (inlude male to female)
37-52 %
What are the late signs and symptoms of Hepatic Encephalopathy?
Altered level of consciousness
Impaired thinking processes
Neuromuscular problems
Normal Calcium level?
8.5-10
Normal Potassium level?
3.5-5
Nursing interventions for Stage 5 Chronic Kidney Disease?
Implement renal replacement therapy or kidney transplantation.
Normal BUN level? (include male to female)
10-20
How does the nurse manage TTP?
Remove the plasma and give fresh frozen plasma. Aslo give ASA an alprostadil.
Tachycardic Hypotensive Systolic BP less than 90 or less or 30 less than the patients normal Urine output - 0.5-1 mL/kg/hr Cold/ clammy skin with poor peripheral pulses Agitation Confusion Restlessness Pulmonary congestion Tachypnea Continuing chest discomfort
Are all signs of what?
Cardiogenic shock
When is a splenectomy necessary for a patient with ITP?
When it is the cause… however it puts the patient at risk for infection.
Normal Magnesium level? (from book)
1.3-2.1
What happens in HIT?
Antibodies activate platelets in the presence of heparin which can cause a thrombus.
What are the early manifestations of cirrhosis?
Fatigue Weight loss Anorexia Nausea and vomiting Abdominal pain
How many times a week will a patient have to go to hemodialysis?
3-4 times a week
What drugs should patients with cirrhosis avoid ?
Opioid analgesics Sedatives Barbituates NSAIDs OTC Meds/Herbs
What is the purpose of hemodynamic monitoring?
More accurate measurement of vascular capacity, blood volume, pump effectiveness and tissue perfusion.
When should a patient with chronic pancreatitis take their enzyme replacement?
With meals and snacks but avoid mixing it (literally mixing) with protein.
How is cirrhosis diagnosed?
Abnormal liver enzymes.
What happens to BUN during AKI?
Increases 10-20 at same pace as Cr
What are the signs and symptoms of DIC?
Massive pain Stroke like symptoms Dyspnea Tachycardia Bowel necrosis Decrease kidney function
Blood or fluid loss Blood pressure meds resulting in hypotension ASA/ibuprofen/Naproxen Severe burns Severe dehydration
Prerenal/Intrarenal/Postrenal?
Prerenal
What if a patient comes back from hemodialysis tired and tachycardic?
Its okay, lay them flat, tell them to rest, put them on safety precautions.
What happens to Hct during AKI?
Decreases down to 20%
What can Nephrotic Syndrome lead to if left untreated?
End Stage Kidney Disease
How do the 3 compensatory responses for prerenal and postrenal AKI help?
By increasing blood volume and improving kidney perfusion
What does hemodynamic monitoring give more accurate measures of?
Blood pressure
Heart function
Volume status
Normal phosphorus level? (from book)
3.0-4.5
What are the manifestations of disequilibrium syndrome?
Restlessness
Headache
Decreased LOC
Seizures, coma, death
What are the advantages of peritoneal dialysis?
Flexible schedule
Few hemodynamic changes
Less dietary and fluid restrictions
What medication is given during hemodialysis to prevent clotting?
Heparin
Where is the access for peritoneal dialysis?
Intra-abdominal catheter
When is the balloon on the catheter for hemodynamic monitoring deflated?
Once it reaches the pulmonary artery
What are the complications of peritoneal dialysis?
Protein loss Peritonitis Hyperglycemia Respiratory distress Bowel perforation Infection Weight gain during dwell time
No blood pressures No needle sticks Palpate and auscultate Checking distal pulses and cap refill Assessing ROM Monitoring for infection No tight bandages Teaching patient no heavy weight lifting or carrying
This is nursing care for what?
AV fistula or graft
What happens during biliary obstruction?
Production of bile is decreased. Without bile, vitamin K cannot be absorbed. Without vitamin K, clotting factors, II, VII, IX and X are not produced. This leads to bleeding and easy bruising.
A complex cognitive syndrome that results from liver failure and cirrhosis.
Hepatic Encephalopathy
Chronic Kidney Disease Assessment:
Skeletal
Osteodystrophy
Multiple myeloma
TTP (clotting disorder)
Vasculitis
Kidney ischemia
Prerenal/Intrarenal/Postrenal?
Intrarenal
What are the signs/ symptoms of actue pancreatitis?
Pain in epigastric/LUQ Boring pain Sudden onset Pain that radiates to back, left shoulder and flank area Jaundice Nausea and vomiting
What respiratory complications are often assessed for a patient with acute pancreatitis?
Pneumonia (because they are laying in bed)
Pleural effusion (fluid outside of lungs)
Atelectasis ( collapsed lung)
Dyspnea
GFR for Stage 2 Chronic kidney disease?
60-89mL/min
Where is the access for hemodialysis?
Vascular access route
Crackles
Dependent/ generalized edema
Decreased O2 saturation
Increased Respiratory Rate
These are clinical manifestations of what?
Fluid volume overload
How does the liver feel during the late stages of cirrhosis?
Shrinks
What happens to Cr during CKD?
Increase 0.5-1 every 1-2 years
GFR for Stage 4 Chronic kidney disease?
15-29mL/min
Describe postrenal (AKI)
Urine flow obstruction
What are the physical appearance of patients with ITP?
Ecchymoses or petechial rash on arms, legs and upper chest or neck.
When is protein restriction indicated for a patient with CKD?
When the GFR is reduced.
How does hemodynamic monitoring work?
The catheter receives the pressure waves from the heart or the great vessels. The transducer concerts the mechanical energy into electrical energy, which is displayed as waveforms or numbers on the monitor.
DIC that happens rapidly and is often seen in patients with sepsis.
Acute DIC
How does the liver feel during the early stages of cirrhosis?
Enlarged, firm or hard
What happens to BUN during CKD?
Increase – can reach 180-200 before manifestations develop
What is the best way to monitor kidney function?
Monitoring lab values
How will the bruit sound if a clot is present?
There will be no sound
What are the three causes of Acute Kidney Injury?
Prerenal
Intrarenal
Postrenal
Normal Hgb level? (include male to female)
12-18
Massive proteinuria Hypoalbuminemia Edema Lipiduria Hyperlipidemia Increased coagulation Reduced kidney function
These are all manifestations of?
Nephrotic Syndrome
What causes cirrhosis?
Hepatitis C
Alcohol
Biliary obstruction
Hepatotoxic drugs and chemicals
Chronic Kidney Disease Assessment:
Urine
Different for each patient or kidney function
Gram - sepsis Liver disease Burns Extensive surgeries Trauma Metabolic acidosis Prosthetic devices Cancers
are all what?
Triggers for DIC
Which coagulation disorder is most emergent?
DIC
How do you treat ascites?
Low sodium
Paracentesis
How do you assess an AV fistula?
Bruit and Thrill
Chronic Kidney Disease Assessment:
Hematologic
Anemia
Bleeding abnormalities
Nursing interventions for Stage 2 Chronic Kidney Disease?
Reduce risk factors
Why are diuretics not given to patients in end stage kidney disease?
They are not helpful for these patients
Nursing interventions for Stage 4 Chronic Kidney Disease?
Manage complications.
Discuss patient preferences and values.
Educate about options and prepare for renal replacement therapy.
True/False: As a nurse, you cannot question any nephrotoxic drugs the physician has ordered for your AKI patient.
FALSE!
What happens to phosphorus levels during AKI?
Increases
True/False: Patients with ITP need to be on bleeding precautions.
True!
What are two forms of renal replacement therapies?
Hemodialysis and peritoneal dialysis
An invasive system used in critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion.
Hemodynamic monitoring
The collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension.
Ascites
What is the criteria for oliguria?
100-400 mL of urine/day
What are the advantages of hemodialysis?
Most efficient way to clear out wastes
Short time needed for treatment
Choleylithiasis Chronic ETOH consumption High triglycerides Injury to the pancreas Toxic drugs
These are all causes of what?
Acute pancreatitis
GFR for Stage 3 Chronic kidney disease?
30-59mL/min
Nursing interventions for Stage 1 Chronic Kidney Disease?
Screen and reduce risk for: Uncontrolled hypertension DM Chronic kidney infection or UTI Family history of genetic kidney disease Exposure to nephrotoxic substanced
Nursing interventions for Stage 3 Chronic Kidney Disease?
Implement strategies to slow progression of disease
How do you identify the phlebostatic axis?
Position the patient supine.
Palpate the 4th intercostal space.
Follow the 4th intercostal space to the side of the chest.
Determine the midway point between the anterior and posterior.
Find the intersection between the midway point and the line from the 4th intercostal space and make it with an X.
What is a dialyzer?
The machine that filters the blood (the artificial kidney)
What happens to a platelets when a patient with ITP is taking corticosteroids?
The platelets will shoot up but as soon as the medication is stopped, the platelets will come back down.
When is sodium restricted for patients with CKD?
When there is little or no urine output.
What happens to Hgb during AKI?
Decreases
Why is a patient on 3-4 ml continuous flush NS when they are on hemodynamic monitoring?
Because it keeps the patient open.
What is the criteria for anuria?
<100 mL of urine/day
Which coagulation disorder has clotting throughout small blood vessels and clots block blood flow to organs?
DIC
What often occurs with Nephrotic Syndrome as a cause and/or effect?
Renal Vein Thrombosis
Where is the catheter for hemodynamic monitoring inserted?
Through a large vein (usually the internal jugular or subclavian) and directs it to the right atrium.
GFR for Stage 1 Chronic kidney disease?
> 90mL/min
What happens to potassium levels during AKI?
Increases
How long does hemodialysis take?
3-6 hours
What are the complications of hemodialysis?
Disequilibrium syndrome Muscle cramps Headache Itching Hemodynamic and cardiac reactions Infection
Nephrotic Syndrome diet
Normal GFR
Complete proteins are needed
What happens to kidney function in Chronic kidney disease?
It does not return
How is ITP diagnosed?
With a decrease in platelet count and an increase in Megakaryocytes.
DIC that happened slowly and last several weeks, thrombosis and clotting may predominate mainly seen with cancer.
Chronic DIC
What are some medications that patients with ITP take to suppress immune function?
Corticosteroids
Azathioprine
IV Immunoglobulin
Low doses of chemo
What are the 3 compensatory responses for prerenal AKI and postrenal AKI?
Constricting blood vessels
Activate the Renin-angiotension-aldosterone pathway
ADH is released
What are five complications of cirrhosis?
Ascites Portal hypertension Biliary obstruction Hepatic encephalopathy Gastroensophageal varices
What drugs are used to manage Nephrotic syndrome?
Suppressive therapy
Ace Inhibitors (decreases protein loss in urine)
Cholesterol lowering drugs (improves blood lipid levels)
Heparin (reduce vascular defects and improve kidney function)
Diuretics and Sodium restrictions (reduce edema and control hypertension
What components are involved for a pressure monitoring system for hemodynamic monitoring?
Catheter with an infusion system
A transducer
A monitor
What is the specific protein given to patients with AKI?
40 grams
What do you do if your patient comes back from dialysis and presents with symptoms of disequilibrium syndrome?
Call doctor and prepare to administer anti-convulsants and barbituates.
What is the equation for mean arterial pressure?
(SBP/[2 x DBP])/3
When does a patient with ESKD need more protein in their diet?
When they are receiving dialysis.
True/ False: hemodynamic monitoring does not need an informed consent.
False, because if though complications are uncommon, it does involve significant risks.
Nephrotic Syndrome diet
Decreased GFR
Dietary protein intake must be decreased
What is the fluid intake given to patients with AKI?
Urine output plus 500 mL
Normal Sodium level?
135-145
What is Cirrhosis?
Extensive and irreversible scaring of the liver which leads to hepatic inflammation and necrosis.
What happens to Cr during AKI?
Increase 1-2 ever 24-48 hours
Why are replacement enzymes for patients with chronic pancreatitis administered after antacids or H2 Blockers?
Because antacids and H2 Blockers will decrease the pH and decreased pH will inactivate the replacement enzyme.
What blood pressure medications are given to patients with chronic kidney disease?
ACE’s and CCB’s
What are the contraindications of peritoneal dialysis?
Active inflammatory GI disease
Ascites
Recent abdominal surgery
Chronic Kidney Disease Assessment:
GI
Foul breath
Mouth inflammation/ ulceration
What are the early signs and symptoms of Hepatic Encephalopathy?
Sleep disturbances
Mood disturbances
Mental status changes
Speech problems
What temperature should dialysate be kept at?
At room temperature.
Liver failure
Anaphylaxis
Bleeding/clotting
Atherosclerosis
Prerenal/Intrarenal/Postrenal?
Prerenal
Normal Cr level? (include male to female)
0.5-1.2
Why is protein restricted for a patient with a reduced GFR?
Because buildup of wast products from protein breakdown is the main cause of uremia.
What happens to sodium levels during AKI?
Can increase. decrease or stay normal
What are the signs and symptoms of TTP?
Anemia Weakness Chronic fatigue Confusion Low grade fever Bleeding Bruising
How do you manage a patient with DIC?
Treat underlying cause (example– treat sepsis with antibiotics)
Give heparin (to limit clotting)
Give RBCs and FFP when DIC is progressed.
Metallic taste in mouth Anorexia Nausea Vomiting Muscle cramps Uremic "frost" on skin Itching Fatigue and lethargy Hiccups Edema Dyspnea Parathesias
Key Features of what?
Uremia
Chronic Kidney Disease Assessment:
Skin
Yellow or darkened discoloration
Decreased turgor
Uremic Frost
Rash and ecchymosis
How does dialysis work?
It removes excess fluids and wast products and restores chemical and electrolyte balance.
Enlarged prostate
Kidney stones
Nerve damage to bladder nerves
Blood clots in urinary tract
Prerenal/Intrarenal/Postrenal?
Postrenal
What are the nursing interventions for a patient with HIT?
Stop the heparin
Give thrombin inhibitors
Treat active thrombosis
Prevent new thrombosis
Which coagulation disorder is an immune response that causes platelets to clump in capillaries?
TTP
Bladder cancer
Cervical cancer
Colon cancer
Prostate cancer
Prerenal/Intrarenal/Postrenal?
Postrenal
What are two classification Systems for severity and outcomes of Acute Kidney Injury?
RIFLE and KDIGO
Describe azotemia.
Retention of nitrogenous waste
Why does steatorrhea occur in patients with chronic pancreatitis?
Because fat cannot be broken down
What happens to calcium levels during AKI?
Decreases
Why is it important to implement interventions quickly in order to fix the underlying cause of AKI?
Because fixing the problem quick can prevent end stage kidney disease and the need for life long therapy.
GFR for Stage 5 Chronic kidney disease?
<15mL/min
When fragile thin walled esophageal veins become distended and tortuous from increased pressure.
Esophageal varices
What happens to Magnesium levels during AKI?
Increases
Which platelet disorder?
The body creates the an antibody that covers the platelet and destroys it?
ITP
What is the main feature associated with Nephrotic Syndrome?
Severe proteinuria
more than 3.5 g of protein in a 24 hour urine sample
Why is the kidney function affected in patients with DIC?
Because the bleeding from multiple sites of the body decreases blood/fluid volume.
What are the nursing interventions for ascites paracentisis?
Do not move
Watch LOC
Watch respiratory rate
What are the complications associated with cirrhosis?
Portal hypertension Biliary obstruction Hepatic encephalopathy Hepatorenal Syndrome Ascites Esophageal varices Hemorrhage
Why are patients with CKD at a higher risk of digoxin toxicity?
Because the drug is excreted by the kidneys.
What is the specific amount of sodium given to patients with AKI?
60-90 grams
What is significant of polyuria and AKI?
Polyuria can be the start of recovery from AKI
Glomerunonephritis
Hemolytic uremic syndrome
Nephrotoxic drugs
Scleroderma
Prerenal/Intrarenal/Postrenal?
Intrarenal
Why are patients with CKD receiving erythropoietin stimulating agents?
Because it prevents anemia by stimulating red blood cell growth and maturation in the bone marrow.
What are the signs and symptoms of pancreatitis?
Jaundice Gray-Blue area on Flank/Abdomen Absent or decreased bowel sounds Ascites Fetal position
Describe the diet considerations for Cirrhosis
Small frequent meals High carbs High proteins Moderate fat Moderate vitamins
Describe Intrarenal (AKI)
Damage to Kindey
What is dialysate?
Fluid for exchanges
A persistent increase in pressure within the portal vein greater than 5 mm Hg.
Portal Hypertension
What are the lab values you will see in a patient with DIC?
Prolonged PT/PTT
Decreased Platelets
Decreased Fibrinogen
Positive D Dimer (indicates DVT)
Describe Prerenal (AKI)
Decrease in prefusion
What are the late manifestations of cirrhosis?
Ascites Clotting disorders Bruising GI Bleeding Jaundice Elevated ammonia levels Hepatic encephalitis
What are the negatives to the 3 compensatory responses for prerenal and postrenal AKI?
It will reduce urine output which can lead to oliguria and azotemia.
A condition of increased glomerular permeability that allows larger molecules to pass through the membrane into the urine and then be excreted.
Nephrotic Syndrome
What happens when the catheter for hemodynamic monitoring reaches the right atrium?
The physician will inflate the balloon and the catheter will advance with flow of blood through the tricuspid valve into the right ventricle, past the pulmonic valve until the tip reaches the pulmonary artery.
How do you assess a thrill?
Feel the vibration.
Why are calcium channel blockers given to patients with AKI?
because they prevent the movement of calcium into the kidney cells, maintain kidney cell integrity, and improve kidney blood flow.
Ingested toxins (alcohol/ cocaine)
Bleeding in the kidney
Local/ systemic infection
Prerenal/Intrarenal/Postrenal?
Intrarenal
What is the number one cause of chronic pancreatitis?
Alcoholism
What position must a patient be in to give off the most accurate numbers for hemodynamic monitoring?
Supine because they are laying on their spine.
What are the contraindications of hemodialysis?
Hemodynamic instability
Severe vascular disease that prevents access
Uncontrolled diabetes
What type of diet is needed for patients with chronic pancreatitis?
High protein.
How do you assess a bruit?
Listen to is “swoosh” sound
What are examples of vascular access complications?
Thrombosis or stenosis
Infection
Aneurysm formation
Ischemia to distal area
