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Nursing 172 > Week 13: Chp 62: Chronic Kidney Disease > Flashcards

Week 13: Chp 62: Chronic Kidney Disease Flashcards

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1
Q

Most common causes of Chronic Kidney Disease?

A

diabetes and hypertension

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2
Q

Risk factors for CKD

A
  • diabetes and hypertension
  • hyperlipidemia, smoking, use of recreational drugs, NSAIDs, obesity, glomerulonephritis, disorders such as PKD, lupus, and atherosclerosis
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3
Q

What id CKD

A

progressive, irreversible loss of kidney function

  • slow increases in BUN and creatinine
  • longer, more insidious onset than AKI
  • usually caused by long-term disease or medical comorbidities such as hypertension, diabetes, lupus, PKD, and pyelonephritis
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4
Q

What is the difference between AKI and CKD?

A

AKI is usually caused by an event that leads to kidney injury (dehydration, hypovolemia, surgery, infection, medications, injury or trauma); usually reversible
-CDK is usually caused by a long-term disease that leads to decreased renal function over time (uncontrolled diabetes, uncontrolled hypertension, malnutrition, polycystic kidney disease (PKD)); irreversible

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5
Q 
The risk factor or factors most often associated with CKD include which of the following? 
A. Hypertension
B. Diabetes mellitus
C. Malnutrition
D. Peripheral vascular disease
E. Smoking
A

A. Hypertension

B. Diabetes Mellitus

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6
Q

Clinical features

A
  • anemia
  • calcium and vitamin D deficiencies
  • Oliguria
  • Azotemia
  • hypertension
  • decreased GFR
  • fluid retention
  • uremia
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7
Q

Alterations in sodium and fluid balance result in what?

A

hypertension, heart failure, and pulmonary edema

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8
Q

Altered potassium excretion can result in?

A

lethal arrhythmias

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9
Q

Impaired metabolic waste elimination results in?

A

uremia and GI symptoms such as nausea, vomiting, and anorexia

  • neurological symptoms such as headache, lethargy, fatigue, confusion
  • without treatment, seizures and coma
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10
Q

Altered calcium and phosphorus levels result in?

A

bone breakdown and osteodystrophies or defective bone development

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11
Q

Decreased acid clearance and bicarbonate production result in?

A

metabolic acidosis

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12
Q

What endocrine and reproductive dysfunctions occur in CKD?

A

infertility, amenorrhea, hyperparathyroidism, and thyroid abnormalities

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13
Q

Decreased production of erythropoietin results in?

A

chronic anemia

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14
Q

Diagnosis of CKD

A

based on consistently elevated serum creatinine levels and decreased creatinine clearance, both of which are impacted by the GFR

  • persistent presence of protein/albumin in the urine
  • Urinalysis can detect RBCs, WBCs, protein, casts, and glucose
  • Imaging studies such as renal ultrasound, CT scans, and renal biopsy can provide status on kidney function and structure
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15
Q

Chronic kidney disease can be staged based on what?

A

GFR and protein in the urine

-6 stages delineated by GFR and 3 stages delineated by albuminuria or the albumin-to-creatinine ratio (ACR)

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16
Q

The nurse understands that CKD is characterized by which of the following?
A. a rapid decrease in urine output with a CKD-elevated BUN
B. progressive, irreversible destruction to the kidneys
C. abrupt increasing creatinine clearance with a decrease in urinary output
D. confusion and somnolence leading to coma and death

A

B. progressive, irreversible destruction to the kidneys

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17
Q

Treatment for CKD

A
  • measures to remove the waste products should be immediately implemented; managed through renal replacement therapies (RRTs)
  • support the remaining function of the kidneys, treat the patients clinical manifestations, and prevent any complications
  • medication and nutrition management
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18
Q

Preventative and maintenance therapies focus on maintaining and controlling what?

A
  • hyperkalemia
  • hypertension
  • anemia
  • dyslipidemia
  • renal osteodystrophies which involves managing phosphate levels, hyperparathyroidism, and hypocalcemia
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19
Q

Hyperkalemia: how to treat it

A

can be cleared via dialysis or by managing diet; restricting foods high in potassium
-when acutely elevated, medication therapy may be necessary to reduce the serum potassium level

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20
Q

For acute hyperkalemia, what are medication therpaies available?

A
  • IV calcium gluconate to stabilize the cardiac membrane
  • Intravenous glucose and insulin, Albuterol, or bicarbonate may be administered to stimulate the movement of potassium into the cell
  • Intravenous furosemide is administered to improve clearance through the kidneys
  • sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin, used to lower elevated serum potassium levels; it binds with potassium in the GI tract to allow excretion in the stool, diarrhea is expected with this treatment because it contains sorbitol, a sugar alcohol that exerts an osmotic laxative action that causes evacuation of the potassium from the bowel
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21
Q

How to manage hypertension

A
  • target BP 130/80
  • weight loss for obese
  • lifestyle changes such as exercise, avoidance of alcohol, smoking cessation, and diet modification and prescribed medication compliance
  • Medication therapy: diuretics, beta-adrenergic blockers, calcium channel blockers, ACE inhibitors, Angiotensin-receptor blocker agents
22
Q

Management of Anemia

A

Hemoglobin should be 11 to 12 g/dL and Hematocrit should be 33 to 36% for patients with CKD

  • erythropoietin can be produced and administered intravenously or subcutaneously
  • oral iron supplements if ferritin concentrations fall below 100 ng/mL; constipation is a side effect of oral iron supplements, requiring stool softeners; parenteral oral injection may be used if oral supplements do not increase levels
  • Supplemental oral folic acid is also given because folic acid is removed with dialysis (folic acid enhances formation of RBCs)
  • -blood transfusions are an option but should be used only if the patient is actively bleeding and is symptomatic with dyspnea, excess fatigue, tachycardia, palpitations, or chest pains
23
Q

Undesirable effects of blood transfusions

A

the suppression of erythropoiesis, which is stimulated in the face of hypoxia
-because each unit of blood contains about 250 mg of iron, there is a possibility of iron overload

24
Q

How to manage dyslipidemia

A

this is because of lipoprotein metabolism alterations in patient with CKD
-goal of lowering low-density lipoproteins (LDLs) below 100 mg/dL and maintaining a triglyceride level below 200 mg/dL
>statins are most effective for lowering LDL cholesterol levels
>fibrates (fibric acid derivatives) are most effective for lowering triglyceride levels and increase HDLs

25
Q

Treatment options for Osteodystrophies

A

include managing phosphate and calcium levels
>phosphate management= limiting dietary phosphorus, administering phosphate binders, and controlling hyperparathyroidism; phosphorus intake is restricted to less than 1000 mg/day

26
Q

Treatment for Osteodystrophies: Phosphate binders

A

are used to bind phosphate in the GI tract, which allows it to be excreted in the stool

  • must be administered with each meal to be effective because most phosphorus is absorbed within 1 hour after eating
  • constipation is a complaint with phosphate binders, so stool softeners may be added
  • some contain aluminum; excessive aluminum have been associated with dementia and bone disease so use in precaution
  • magnesium-containing antacids that can be used as phosphate binders should be avoided because magnesium is solely excreted via the kidneys
27
Q

Managing hyperparathyroidism

A

occurs because of excessive parathyroid stimulus due to decreased calcium levels in CKD
-calcimimetic agents are used to control hyperparathyroidism by increasing the sensitivity of the calcium receptors in the parathyroid glands
-as a result, the parathyroid glands detect calcium at lower serum levels and decrease PTH secretion
>PTH hormone and alkaline phosphate levels should be monitored

28
Q

Managing Hypocalcemia

A

this is present because of the inability of the GI tract to absorb calcium in absence of activated vitamin D
-management includes vitamin D and calcium supplementation
>regular monitoring is essential because hypercalcemia may occur if hyperparathyroidism and the release of calcium from bone are not controlled
-hypercalcemia can cause increased cardiac irritability and mortality in end-stage renal disease

29
Q

Managing Medications

A

CKD can cause delayed and decreased elimination of medications, leading to potentially toxic accumulation of medications in the circulatory system

  • Demerol (pain med to be avoided)
  • NSAIDs avoided
  • Aminoglycosides, penicillin, and tetracyclines can be nephrotoxic, thus requiring adjustments to the frequency or dose
  • medication administration times may need to be changed on patients on dialysis; water-soluble medications are filtered out in dialysis, resulting in decreased therapeutic benefit; many meds prescribed in the morning may need to be given after dialysis, anti-hypertensives and cardiac medications may need to be given after dialysis to avoid the hypotensive events that may occur because of fluid shifts during dialysis
30
Q

Nutrition

A
  • dietician should be consulted
  • diet is individualized
  • dietary proteins are restricted in patients with CKD because urea nitrogen and creatinine are end products of protein metabolism; if starting dialysis an increase in protein may be allowed
  • diet low in protein, and low in phosphorus that is supplemented with amino acids can slow the progression of renal failure
  • sufficient calories
  • water restrictions
  • sodium and potassium restrictions
  • phosphate limitations
31
Q

Nutrition: Sufficient calories

A

sufficient calories from carbohydrates and fats are needed to minimize the catabolism of body protein and to maintain body weight

  • required intake of carbs and fats should be 30 to 35 kcal/kg of body weight/day
  • with malnutrition or inadequate caloric intake, prepared products are available that are high in calories and low in protein, sodium and potassium; Nepro, Microlipid, Sumacal, Suplena, and Polycose
  • amino acids may also be supplemented
32
Q

Nutrition: Water restrictions

A

based on urine output and insensible water loss

  • careful monitoring of all liquid intake is important, including gelatin and ice cream that are liquid at room temperature
  • the fluid replacement must be distributed throughout the day to lessen the patients feelings of thirst
  • adjustments must be made to fluid intake to maintain weight gains of no more than 1 to 3 kg between dialysis treatment
33
Q

Nutrition: Sodium and potassium restriction

A
  • sodium may be restricted to 2 and 4 g depending on degree of edema and hypertension; avoid high-sodium foods such as cured meats, pickled foods, canned soups and stews, frankfurters, cold cuts, soy sauce, and salad dressings; salt substitutes should be avoided because of high potassium chloride content
  • potassium restriction of 2 to 4 g; high-potassium foods to avoid are oranges, bananas, melons, tomatoes, prunes, raisins, deep green and yellow vegetables, beans and legumes
34
Q

Nutrition: Phosphate

A

be limited to 1000 g/day

  • foods high in phosphate include dairy products (milk, ice cream, cheese, and yogurt) and some puddings
  • most foods high in phosphate are also high in calcium, so restricting phosphate also restricts calcium
35
Q

What does the clinical manifestations reflect in CKD

A

the derangements of all body systems seen with CKD

  • include: hypertension, heart failure, and pulmonary edema because of alterations in sodium and fluid balance
  • GI symptoms such as nausea, vomiting, and anorexia
  • Neurological symptoms such as headache, lethargy, fatigue, and confusion due to impaired metabolic waste elimination
  • altered calcium and phosphorous levels result in bone breakdown and osteodystrophies
  • endocrine and reproductive dysfunctions occur such as infertility, amenorrhea, hyperparathyroidism, and thyroid abnormalities
  • anemia is a result of decreased production of erythropoietin
36
Q

Nursing Diagnoses

A
  • excess fluid volume r/t renal failure and fluid retention
  • disturbed thought processes r/t the effects of uremic toxins in the CNS
  • fatigue r/t anemia, metabolic acidosis, and uremic toxins
  • potential complications: dysrhythmias arising from electrolyte imbalances
37
Q

Nursing Assessments

A
  • vital signs
  • assess pulmonary, cardiac, and peripheral vascular systems
  • monitor lab values
38
Q

Assessments: Vitals signs/ SpO2

A

hypertension may indicate fluid overload due to inadequate water removal
-oxygen saturation may be decreased in the presence of fluid overload/ pulmonary edema

39
Q

Assessments: assess pulmonary, cardiac, and peripheral vascular systems

A
  • rales may be present on auscultation because of fluid retention
  • peripheral edema and neck vein distention may be present because of fluid retention
40
Q

Assessment: Monitor Lab values

A
  • Serum potassium: hyperkalemia may be present in CKD because of decreased glomerular filtration
  • Serum sodium: may be increased or decreased depending on volume status
  • Serum Calcium and Phosphate: calcium levels are decreased due to the loss of vitamin D activation; phosphate and calcium levels are inversely related; decreases in calcium levels stimulate the parathyroid gland to release PTH, increasing phosphate; phosphate is also increased due to inadequate clearance in the kidneys
  • Hemoglobin and Hematocrit: hemoglobin and hematocrit levels are decreased because of decreased production of erythropoietin
  • Arterial pH: metabolic acidosis may be present because of decreased hydrogen ion excretion and decreased bicarbonate production
41
Q

Nursing Actions

A
  • maintain cardiac monitor
  • weigh the patient at the same time each day in the morning before dialysis, use the same scale and record and maintain the same clothing with weights
  • restrict fluids and sodium
  • administer prescribed medications as directed
  • skin care
  • proper positioning
  • renal diet; adequate protein level
42
Q

Action: maintain cardiac monitor

A

necessary to assess for ECG changes that might indicate hyperkalemia

43
Q

Action: weigh the patient at the same time each day in the morning before dialysis; use the same scale and record and maintain the same clothing with weights

A

provides accurate information regarding fluid status

-weight gain/loss guides the dialysis treatment plan; it helps in identifying the amount of fluid to be removed

44
Q

Action: restrict sodium and fluids

A

fluid and sodium restrictions are necessary because of the kidneys inability to remove excess fluid, placing the patient at risk of volume overload

45
Q

Action: administer the prescribed medications as directed

A
  • Medication to treat hyperkalemia: essential to maintain potassium within normal ranges to avoid potentially lethal cardiac dysrhythmias
  • Anti-hypertensives: to control hypertension
  • Phosphate Binders: bind phosphate in the GI system, allowing for excretion in the stool
  • Calcium supplementation: used when necessary to maintain normal calcium levels
  • Calcimimetic Agents: manage secondary hyperparathyroidism by increasing the parathyroid glands sensitivity to calcium, thus decreasing the release of PTH
  • Synthetic erythropoietin: replaces reduced erythropoietin levels that occur in CKD, helping maintain adequate hemoglobin and hematocrit levels
  • Folic acid and ferrous sulfate: replacement may be necessary to support RBC production; they are water-soluble vitamins that are lost during dialysis
  • Stool softeners: constipation is a side effect of many medications used in CKD, and so stool softeners help treat constipation
46
Q

Actions: skin care

A

edema decreases tissue perfusion and increases risk of decubitus ulcers

47
Q

Actions: Proper positioning

A

maintaining a semi-fowlers position eases work of breathing by facilitating the diaphragm to lower on inspiration

48
Q

Actions: renal diet; adequate protein levels

A

adequate caloric intake is necessary to avoid protein breakdown, which worsens the accumulation of nitrogenous wastes

49
Q

Nursing Teachings

A
  • do not miss dialysis appointments
  • dietary restrictions
  • clinical manifestations of CKD and complications
  • avoid nephrotoxic substances such as NSAIDs, contrast media, nephrotoxic antibiotics, and alcohol
  • daily weight
50
Q

Teaching: do not miss dialysis appointments

A

may result in acute and lethal fluid and electrolyte complications, especially hyperkalemia

51
Q

Teaching: dietary restrictions

A

adequate protein and limited salt and fluid are necessary to support the caloric needs of the body and reduce the occurrence of volume overload

Nursing 172 (120 decks)

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