Week 3 - Renal Flashcards
Kidney Function
_________
- Excretory waste
_________
- Body H2O regulation
- Electrolyte balance
- Acid-base balance
_________
- Erythropoietin
- RAAS
- Vitamin D
Filtration
- Excretory waste
Homeostasis
- Body H2O regulation
- Electrolyte balance
- Acid-base balance
Hormonal
- Erythropoietin
- RAAS
- Vitamin D
Kidney Lingo
- Acute Kidney Injury (AKI)
- Acute Renal Failure (ARF)
- Chronic Renal Insufficiency (CRI)
Chronic Kidney Disease (Stages 1 – 5) (CKD)
- Oliguria
- Anuria
- End Stage Renal Disease (ESRD)
- Acute Kidney Injury (AKI)
- Acute Renal Failure (ARF)
- Chronic Renal Insufficiency (CRI)
Chronic Kidney Disease (Stages 1 – 5) (CKD)
- Oliguria
- Anuria
- End Stage Renal Disease (ESRD)
Kidney Lingo cont.
Renal __________ Therapy (RRT)
- Hemodialysis (HD)
- Peritoneal Dialysis (PD)
__________ Renal Replacement Therapy (CRRT)
-Continuous Venous-Venous Hemofiltration (CVVH)
-Continuous Arterial Venous Hemofiltration (CAVH)
-Sustained Low-Efficiency Daily Dialysis (SLEDD)
- ___________ Renal Transplant (CRT)
- Living-related Renal Transplant (LRRT)
Renal Replacement Therapy (RRT)
- Hemodialysis (HD)
- Peritoneal Dialysis (PD)
Continuous Renal Replacement Therapy (CRRT)
-Continuous Venous-Venous Hemofiltration (CVVH)
-Continuous Arterial Venous Hemofiltration (CAVH)
-Sustained Low-Efficiency Daily Dialysis (SLEDD)
- Cadaveric Renal Transplant (CRT)
- Living-related Renal Transplant (LRRT)
Markers of Kidney Function
Serum BUN - (Not so reliable)
- Protein breakdown
- ________ mg/dl
Serum Creatinine (Cr) - (Pretty good)
- Muscle breakdown
- ____________ mg/dl – male
- ____________ mg/dl – female
Glomerular Filtration Rate (GFR) - (Best!)
- Creatinine Clearance
- Normal: about ____ ml / min
Urine Output (Sometimes)
Serum BUN - (Not so reliable)
- Protein breakdown
- 10 to 20 mg/dl
Serum Creatinine (Cr) - (Pretty good)
- Muscle breakdown
- 0.6 to 1.2 mg/dl – male
- 0.5 to 1.1 mg/dl – female
Glomerular Filtration Rate (GFR) - (Best!)
- Creatinine Clearance
- Normal: about 125 ml / min
Urine Output (Sometimes)
GFR: What is It?
- An indicator of ________________ calculated from the serum __________ level using the patient’s age, weight, gender, and body size, i.e. creatinine clearance
- Cockcroft-Gault formula: an est. of CrCl
- Normal: about ____ ml/min in young healthy adults
- An indicator of kidney function calculated from the serum creatinine level using the patient’s age, weight, gender, and body size, i.e. creatinine clearance
- Cockcroft-Gault formula: an est. of CrCl
- Normal: about 125 ml/min in young healthy adults
Azotemia vs. Uremia
__________
- Elevated BUN, Creatinine
Uremia (___________)
- Mental status changes, lethargy, stupor
- Anorexia, nausea, metallic taste
- Tremor, pruritus, asterixis
- Coagulapathy and bleeding
- Pericardial and pleural rubs
Azotemia
- Elevated BUN, Creatinine
Uremia - symptoms due to waste products
- Mental status changes, lethargy, stupor
- Anorexia, nausea, metallic taste
- Tremor, pruritus, asterixis
- Coagulapathy and bleeding
- Pericardial and pleural rubs
Urine Output
- Oliguria < ___ ml / day
- Anuria < ___ ml / day
- Normal u/o ≠ Normal renal function
- AKI can be oliguric or non-oliguric
- Dialysis pts can be oliguric or non-oliguric
- Oliguria < 400 ml / day
- Anuria < 100 ml / day
- Normal u/o ≠ Normal renal function
- AKI can be oliguric or non-oliguric
- Dialysis pts can be oliguric or non-oliguric
Categories of AKI
Pre-renal AKI - __ Circulating Volume
- _____volemia
- ________ cardiac output
- ________ peripheral vascular resistance – e.g. Sepsis
- ________ renovascular blood flow – e.g. thrombosis in renal artery
Pre-renal AKI - ↓ Circulating Volume
- Hypovolemia
- Decreased cardiac output
- Decreased peripheral vascular resistance – e.g. Sepsis
- Decreased renovascular blood flow – e.g. thrombosis in renal artery
Intra-renal – ___________ to Kidney
Acute Tubular ________ (ATN)* [majority]
- Prolonged _________
–Hemorrhage
–Dehydration
- Nephrotoxic injury
–Tumor lysis
–Medications – (e.g. Amphoterocin B., Aminoglycosides)
–Contrast Dye
–Rhabdomyolysis
Intra-renal – Direct Damage to Kidney
Acute Tubular Necrosis (ATN)*
- Prolonged ischemia
–Hemorrhage
–Dehydration
- Nephrotoxic injury
–Tumor lysis
–Medications – (e.g. Amphoterocin B., Aminoglycosides)
–Contrast Dye
–Rhabdomyolysis
________ Induced Nephropathy
Who’s at risk: those who have chronic renal insufficiency, elderly, dehydration, diabetics
What can we do about it: use lower amounts of dye, hydration to flush out dye, space out procedure to use less dye, etc.
Contrast Induced Nephropathy
Who’s at risk: those who have chronic renal insufficiency, elderly, dehydration, diabetics
What can we do about it: use lower amounts of dye, hydration to flush out dye, space out procedure to use less dye, etc.
Rhabdomyolysis
Syndrome – ____________ cell breakdown
Causes
- Traumatic – crush _______
- Nontraumatic (more common)
-Exertional – weightlifting, running
-Non-exertional
- Statins**
- S/S
- Lab Work (e.g. CK, myoglobin)
Rhabdomyolysis
Syndrome – skeletal muscle cell breakdown
Causes
- Traumatic – crush injuries
- Nontraumatic (more common)
-Exertional – weightlifting, running
-Non-exertional
- Statins**
- S/S
- Lab Work (e.g. CK, myoglobin)
Post Renal – ________ __________ of Urine
- Backward pressure inside or outside the system
- BPH / Prostate cancer (most common)
- Bladder cancer
- Nephrolithiasis
-Spinal cord disease (neurogenic bladder) - Strictures
- Trauma
Blocks Outflow
Phases of AKI
___
___
___
- Oliguria
- Diuretic
- Recovery
Assessment of Oliguric Phase
- Occurs 1-7 days after injury and lasts _____ days
- UO < ____ ml /24 hours*
- Sp. Gr. Fixed at 1.010
- __________ imbalances - K, Ca, Mg, PO4
- __________ imbalances
- Occurs 1-7 days after injury and lasts 10 to 14 days
- UO < 400 ml /24 hours*
- Sp. Gr. Fixed at 1.010
- Electrolyte imbalances - K, Ca, Mg, PO4
- Acid-base imbalances
Assessment of Diuretic Phase
- Lasts ___ weeks
-U.O. gradual ↑ to 1-3 L/day up to 5 L - Electrolyte imbalances
- Hypo_________ & _________ are main concerns
- Lasts 1-3 weeks
-U.O. gradual ↑ to 1-3 L/day up to 5 L - Electrolyte imbalances
- Hypotension, hypovolemia are main concerns
Assessment of Recovery Phase
- Lasts 1-2 weeks but could take up to ______
- Begins when GFR ↑ so that BUN, serum Cr levels start to _________ and then ↓
- U.O., electrolytes, acid-base continue to stabilize and then return to normal
-Some progress to _____________
- Lasts 1-2 weeks but could take up to one year
- Begins when GFR ↑ so that BUN, serum Cr levels start to stabilize and then ↓
- U.O., electrolytes, acid-base continue to stabilize and then return to normal
-Some progress to Chronic Renal Failure
Treatment and Management of AKI
-Treat precipitating ______
-Avoid __________ agents (if possible)
-Nephrology consult
-Fluid __________ (600 mL plus previous 24-hr fluid loss)
Nutritional therapy
- Adequate _______ intake (0.8–1 g/kg/day)
-Enteral nutrition or parenteral nutrition
- Dietary restrictions (potassium, phosphate, sodium)
- Measures to lower __________ (if high)
- Calcium supplements or phosphate-binding agents
-Dialysis (if necessary) - Continuous RRT (if necessary)
-Treat precipitating cause
-Avoid nephrotoxin agents (if possible)
-Nephrology consult
-Fluid restriction (600 mL plus previous 24-hr fluid loss)
Nutritional therapy
- Adequate protein intake (0.8–1 g/kg/day)
-Enteral nutrition or parenteral nutrition
- Dietary restrictions (potassium, phosphate, sodium)
- Measures to lower potassium (if high)
- Calcium supplements or phosphate-binding agents
-Dialysis (if necessary) - Continuous RRT (if necessary)
Chronic Kidney Disease (CKD)
-Kidney damage or GFR < __ ml/min per 1.73m² for ________ or longer
- Kidney damage is defined as pathologic abnormalities or markers of damage,
including abnormalities in blood or urine tests or imaging studies
-Kidney damage or GFR < 60 ml/min per 1.73m² for 3 months or longer
- Kidney damage is defined as pathologic abnormalities or markers of damage,
including abnormalities in blood or urine tests or imaging studies
The Facts about CKD
- 26 million Americans and another 20 million are at increased risk.
- Early detection can help prevent the progression of kidney disease to kidney _______.
- ______ disease is the major cause of death for all people with CKD.
- ________________ is the best estimate of kidney function.
- High risk groups include those with diabetes, hypertension and family history of kidney disease.
- ___________, Hispanics, Native Americans, and Elderly are at increased risk.
- Three simple tests can detect CKD: blood pressure, urine and serum creatinine.
- 26 million Americans and another 20 million are at increased risk.
- Early detection can help prevent the progression of kidney disease to kidney failure.
- Heart disease is the major cause of death for all people with CKD.
- Glomerular filtration rate (GFR) is the best estimate of kidney function.
- High risk groups include those with diabetes, hypertension and family history of kidney disease.
- African Americans, Hispanics, Native Americans, and Elderly are at increased risk.
- Three simple tests can detect CKD: blood pressure, urine and serum creatinine.
Common Causes of CKD
- ________ 43%
- ____ 23%
- Glomerulonephritis 12%
- Polycystic Kidney Disease 3%
- Other 19%
- Diabetes 43%
- HTN 23%
- Glomerulonephritis 12%
- Polycystic Kidney Disease 3%
- Other 19%
Clinical Manifestations of CKD
CKD Manifestations
o ______ product accumulation
o Hyperkalemia
o Calcium and phosphate alterations
o Magnesium alterations
o Metabolic ________
o Fluid retention
o Edema
o Defective carbohydrate metabolism
o Elevated triglycerides
o Waste product accumulation
o Hyperkalemia
o Calcium and phosphate alterations
o Magnesium alterations
o Metabolic acidosis
o Fluid retention
o Edema
o Defective carbohydrate metabolism
o Elevated triglycerides
CKD Manifestations cont.
- ______ and bleeding tendencies
-_________ Risk and increased incidence of cancer - _____ color changes, dry skin, pruritus
-Altered _______ ability and decreased ability to concentrate - Cardiovascular, respiratory and GI problems
Renal _____________
- Syndrome of skeletal changes
- Result of alterations in CA and PO4 metabolism
-Weak bones, increase fracture risk
- Anemia and bleeding tendencies
-Infection Risk and increased incidence of cancer - Skin color changes, dry skin, pruritus
-Altered mental ability and decreased ability to concentrate - Cardiovascular, respiratory and GI problems
Renal osteodystrophy
- Syndrome of skeletal changes
- Result of alterations in CA and PO4 metabolism
-Weak bones, increase fracture risk
Chronic Kidney Disease Overall Treatment
- Preserve existing kidney ________
- Treat S/S
- Prevent complications
- Correct extracellular fluid volume overload or deficit and _________ imbalances
- Drug therapy
- Nutritional therapy
- Preserve existing kidney function
- Treat S/S
- Prevent complications
- Correct extracellular fluid volume overload or deficit and electrolyte imbalances
- Drug therapy
- Nutritional therapy
Therapy: Hyperkalemia
- Calcium Gluconate IV
- Generally used with evidence of ECG changes
- Dietary Restriction
- Potassium intake is limited to 40 mEq/day
- Primarily used to prevent recurrent elevation, not for acute elevation
- Hemodialysis
- Most effective therapy to remove potassium
- Works within a short time
- Calcium Gluconate IV
- Generally used with evidence of ECG changes
- Dietary Restriction
- Potassium intake is limited to 40 mEq/day
- Primarily used to prevent recurrent elevation, not for acute elevation
- Hemodialysis
- Most effective therapy to remove potassium
- Works within a short time
Therapy: Hyperkalemia cont.
Regular Insulin IV
* Potassium moves into cells when insulin is given
* IV glucose given concurrently to prevent hypoglycemia
Sodium Bicarbonate
* Can correct acidosis and cause a shift of potassium into cells
Sodium Polystyrene Sulfonate (Kayexalate)
* Given by mouth or retention enema
* When resin is in the bowel, potassium is exchanged for sodium
* Produces osmotic diarrhea, allowing for evacuation of potassium-rich stool
* Removes 1 mEq of potassium per 1 g of drug
* Do not give to a patient with a paralytic ileus as bowel necrosis can occur
Regular Insulin IV
* Potassium moves into cells when insulin is given
* IV glucose given concurrently to prevent hypoglycemia
Sodium Bicarbonate
* Can correct acidosis and cause a shift of potassium into cells
Sodium Polystyrene Sulfonate (Kayexalate)
* Given by mouth or retention enema
* When resin is in the bowel, potassium is exchanged for sodium
* Produces osmotic diarrhea, allowing for evacuation of potassium-rich stool
* Removes 1 mEq of potassium per 1 g of drug
* Do not give to a patient with a paralytic ileus as bowel necrosis can occur
Therapy: HTN
-_______ loss
- Lifestyle changes
- Diet recommendations - ________ and fluid restriction
- __________ drugs
-Diuretics, β-Adrenergic blockers, CCB’s, ACE I’s, Angiotensin receptor blocker agents
-Weight loss
- Lifestyle changes
- Diet recommendations - Sodium and fluid restriction
- Antihypertensive drugs
-Diuretics, β-Adrenergic blockers, CCB’s, ACE I’s, Angiotensin receptor blocker agents
Therapy: Renal Osteodystrophy
- _________ intake restricted to <1000 mg/day
Phosphate binders
- Sevelamer hydrochloride (Renagel)
-Lowers cholesterol and LDLs
-Administer with each meal
-Side effect: Constipation
- Phosphate intake restricted to <1000 mg/day
Phosphate binders
- Sevelamer hydrochloride (Renagel)
-Lowers cholesterol and LDLs
-Administer with each meal
-Side effect: Constipation
Therapy: Renal Osteodystrophy cont.
Supplementing vitamin D
- Calcitriol (Rocaltrol)
- Serum phosphate level must be lowered before administering calcium or vitamin D
Supplementing vitamin D
- Calcitriol (Rocaltrol)
- Serum phosphate level must be lowered before administering calcium or vitamin D
Therapy: Renal Osteodystrophy cont.
Controlling secondary hyperparathyroidism
-________ agents
–Cinacalcet (Sensipar)
—↑ Sensitivity of calcium receptors in parathyroid glands
-Subtotal parathyroidectomy
Calcimimetic
Therapy: Anemia
____________
- Epoetin alfa (Epogen, Procrit)
- Administered IV or subcutaneously
- Increased hemoglobin and hematocrit in 2 to 3 weeks
______ supplements
- If plasma ferritin <100 ng/ml
- Side effect: Gastric irritation, constipation
- May make stool dark in color
- Do not give with PO4 binders
Erythropoietin
- Epoetin alfa (Epogen, Procrit)
- Administered IV or subcutaneously
- Increased hemoglobin and hematocrit in 2 to 3 weeks
Iron supplements
- If plasma ferritin <100 ng/ml
- Side effect: Gastric irritation, constipation
- May make stool dark in color
- Do not give with PO4 binders
Therapy: Anemia cont.
__________ supplements
- Needed for RBC formation
- Removed by dialysis
Avoid __________ [fluid overload]
Folic acid supplements
- Needed for RBC formation
- Removed by dialysis
Avoid blood transfusions [fluid overload]
Therapy: Dyslipidemia
HMG-CoA reductase inhibitors (________)
-Most effective for lowering LDL
Fibrates
- Fibric acid derivatives
- Most effective for lowering triglycerides
- Can also decrease HDLs
HMG-CoA reductase inhibitors (Statins)
-Most effective for lowering LDL
Fibrates
- Fibric acid derivatives
- Most effective for lowering triglycerides
- Can also decrease HDLs
Address Issues [kidney]
“Chronicity”
- Psychosocial implications
Quality of life
- Symptom Burden
- “It’s all about perspective”
End-of-life
- Renal Physicians Association & American Society of Nephrology – Clinical Practice Guidelines
Kidney End-of-Life Coalition
“Chronicity”
- Psychosocial implications
Quality of life
- Symptom Burden
- “It’s all about perspective”
End-of-life
- Renal Physicians Association & American Society of Nephrology – Clinical Practice Guidelines
Kidney End-of-Life Coalition
Which of the following tests is most accurate for the assessment of renal function?
a. Blood urea nitrogen.
b. Serum creatinine.
c. Creatinine clearance.
d. Urine output
c. Creatinine clearance.
[estimated GFR]
A patient is concerned about his elevated blood urea nitrogen (BUN) level. The nurse explains that which of the following could also influence the BUN levels?
a. Kidney stones.
b. Liver problems.
c. Anemia.
d. Dehydration.
d. Dehydration.
The nurse teaches a patient with chronic kidney disease about prevention of complications. What should the nurse include in the teaching plan?
a. Monitor for proteinuria daily with a urine dipstick.
b. Perform self-catheterization every 4 hours to measure urine.
c. Take calcium-based phosphate binders on an empty stomach.
d. Check weight daily and report a gain of greater than 4 pounds
d. Check weight daily and report a gain of greater than 4 pounds
Dialysis Indications (A-E-I-O-U)
- _________
- _________abnormalities
- _________(ethylene glycol)*
- _________(volume)
- _________
- Acidosis
- Electrolyte abnormalities
- Ingestion (ethylene glycol)*
- Overload (volume)
- Uremia
General Principles of Dialysis
- __________
- Movement of solutes from an area of greater concentration to an area of lesser
- __________
- Movement of fluid from an area of lesser concentration of solutes to an area of greater concentration of solutes
- Diffusion
- Movement of solutes from an area of greater concentration to an area of lesser
- Osmosis
- Movement of fluid from an area of lesser concentration of solutes to an area of greater concentration of solutes
General Principles of Dialysis - *____________
- Water and fluid removal
*Results when there is an osmotic gradient across the membrane
** peritoneal dialysisperitoneal dialysis
- Transmembrane pressure
** hemodialysis
Ultrafiltration
General Principles of Dialysis
Methods available:
* ___________ dialysis (PD)
* ______dialysis (HD)
* ___________ renal replacement therapy (CRRT)
- Peritoneal dialysis (PD)
- Hemodialysis (HD)
- Continuous renal replacement therapy (CRRT)
Peritoneal Dialysis
- Peritoneal membrane acts as the semipermeable membrane to filter out wastes
- Peritoneal access is obtained by ______________ through the anterior wall (tunneled)
inserting a catheter
Peritoneal Dialysis - Three phases of PD Cycle
- Called an “_________”
- Inflow (fill)
** Dialysate goes in - Dwell (equilibration)
** Diffusion & osmosis - Drain
** Effluent comes out
- Called an “exchange”
- Inflow (fill)
** Dialysate goes in - Dwell (equilibration)
** Diffusion & osmosis - Drain
** Effluent comes out
Peritoneal Dialysis - Effectiveness and Adaptation
- Immediate initiation
- Short training program
- Independence
- Ease of traveling
- Fewer dietary restrictions
- Greater mobility than with HD
- Immediate initiation
- Short training program
- Independence
- Ease of traveling
- Fewer dietary restrictions
- Greater mobility than with HD
Peritoneal Dialysis - Care of the PD patient
- Handwashing, good _________ & site care
- ________ technique
- Teach and monitor for signs of infection and complications
- Inflow (fill) slowly, gradually
- Warm dialysate for comfort
- High _______ diet
- Handwashing, good hygiene & site care
- Aseptic technique
- Teach and monitor for signs of infection and complications
- Inflow (fill) slowly, gradually
- Warm dialysate for comfort
- High protein diet
Peritoneal Dialysis Complications
- Cath site _________
- Peritonitis
- Abdominal pain
- Outflow problems
- Hernias
- Bleeding
- Pulmonary complications
- ________ loss
- Carbohydrate and lipid abnormalities
- Cath site infection
- Peritonitis
- Abdominal pain
- Outflow problems
- Hernias
- Bleeding
- Pulmonary complications
- Protein loss
- Carbohydrate and lipid abnormalities
A major advantage of peritoneal dialysis is:
a. the diet is less restricted and dialysis can be performed at home
b. the dialysate is biocompatible and causes no long–term consequences
c. high glucose concentrations of the dialysate cause a reduction in appetite, promoting weight loss
d. no medications are required because of the enhanced efficiency of the peritoneal membrane in removing toxins
a. the diet is less restricted and dialysis can be performed at home
Hemodialysis (HD)
- ___________ membrane in hemodialyzer machine used to filter out _________
- Vascular access needed
- In hospital or clinic
** Usually 3-4 hours per per session; 3 times per week - Home ** 6 times per week
- Artificial membrane in hemodialyzer machine used to filter out wastes
- Vascular access needed
- In hospital or clinic
** Usually 3-4 hours per per session; 3 times per week - Home ** 6 times per week
Hemodialysis
- HD requires rapid blood flow from a ______ blood vessel
- Obtaining vascular access is one of most difficult problems
- Types of access include:
- Arteriovenous fistulas
- Arteriovenous grafts
- Temporary vascular access
- HD requires rapid blood flow from a large blood vessel
- Obtaining vascular access is one of most difficult problems
- Types of access include:
- Arteriovenous fistulas
- Arteriovenous grafts
- Temporary vascular access
Vascular Access for Hemodialysis
Arteriovenous Fistula (AVF)
* Anastomosis of _________ & ________
* Matures in 6 weeks to a _______
* ________ access for HD
* Auscultate a bruit (rushing sound)
* Palpate a thrill (buzzing sensation)
Arteriovenous Fistula (AVF)
* Anastomosis of artery and vein
* Matures in 6 weeks to a few months
* Preferred access for HD
* Auscultate a bruit (rushing sound)
* Palpate a thrill (buzzing sensation)
Vascular Access for Hemodialysis cont.
Arteriovenous Graft (AVG)
* ________ material
* “bridge” between arterial and venous blood
* Useable in 2 to 4 weeks
* Higher risk of ________ and thrombosis
- Synthetic material
- “bridge” between arterial and venous blood
- Useable in 2 to 4 weeks
- Higher risk of infection and thrombosis
Vascular Access for Hemodialysis cont.
Fistula & Graft Management
* Never perform BP, IV insertion, or venipuncture on ___________
- Prone to __________ & _________
** Pain
** Redness
** Swelling
** Numbness
** Bruit and thrillB
** Pulses and cap refill
Fistula & Graft Management
* Never perform BP, IV insertion, or venipuncture on access arm!
- Prone to infection and clotting
** Pain
** Redness
** Swelling
** Numbness
** Bruit and thrillB
** Pulses and cap refill
Vascular Access for Hemodialysis cont.
__________ vascular access
** Non-tunneled (vascath) & tunneled (permcath)
** Catheter in internal jugular or femoral vein
** No IV meds unless MD order
** Keep area and dressing clean, dry & intact
** Clamped correctly
Temporary
Hemodialysis System
- Blood flows through ___________ of small tubes in the dialysis hemofilter
** The fibers are __________
** _________ is pumped around the fibers
** Ultrafiltration, diffusion, and osmosis occur
- Blood flows through thousands of small tubes in the dialysis hemofilter
** The fibers are semipermeable
** Dialysate is pumped around the fibers
** Ultrafiltration, diffusion, and osmosis occur
Hemodialysis - Care of the HD Patient
* Assess fistula/graft/catheter every shift, as needed, and after ___
* Anticipate meds to be given or held before HD
* Assess fluid status
** weight, BP, peripheral edema, lung sounds
* Diet and fluid restrictions
- Assess fistula/graft/catheter every shift, as needed, and after HD
- Anticipate meds to be given or held before HD
- Assess fluid status
** weight, BP, peripheral edema, lung sounds - Diet and fluid restrictions
Hemodialysis
Assess during HD
* Frequent BP and HR
* Site Access
* Patient tolerance
Complications
* Hypotension
* Muscle cramps
* Loss of blood
* Infection
Assess during HD
* Frequent BP and HR
* Site Access
* Patient tolerance
Complications
* Hypotension
* Muscle cramps
* Loss of blood
* Infection
Hemodialysis practice Q
To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply):
a. Monitor the BP in the affected arm
b. Irrigate the graft daily with low-dose heparin
c.Palpate the area of the graft to feel a normal thrill
d. Listen with a stethoscope over the graft to detect a bruit
e. Frequently monitor the pulses and neurovascular status distal to the graft
c.Palpate the area of the graft to feel a normal thrill
d. Listen with a stethoscope over the graft to detect a bruit
e. Frequently monitor the pulses and neurovascular status distal to the graft
PD vs HD
Continual Renal Replacement Therapy (CRRT)
- Means by which fluids, uremic toxins, electrolytes are adjusted and removed _______ and continuously
- For hemodynamically ________ patients
- Alternative or adjunctive method for treating ARF/AKI
- Can be used in conjunction with HD
- Requires catheter access
- Means by which fluids, uremic toxins, electrolytes are adjusted and removed slowly and continuously
- For hemodynamically unstable patients
- Alternative or adjunctive method for treating ARF/AKI
- Can be used in conjunction with HD
- Requires catheter access
Continual Renal Replacement Therapy (CRRT) * CRRT versus HD
- Continuous rather than intermittent
- Less hemodynamic instability
- Does not require constant monitoring by HD nurse
- Does not require complicated HD equipment
- Continuous rather than intermittent
- Less hemodynamic instability
- Does not require constant monitoring by HD nurse
- Does not require complicated HD equipment
Kidney Transplantation Facts
- Over ________ people on the waiting list for a kidney transplant (as of 2016)
- Wait time depends on health, age, compatibility, and availability of organs
- Average wait time ____ years
- Over 17,000 kidney transplants performed in 2014
** 2/3 from deceased donors
** 1/3 from living donors
- Over 100,000 people on the waiting list for a kidney transplant (as of 2016)
- Wait time depends on health, age, compatibility, and availability of organs
- Average wait time 2-5 years
- Over 17,000 kidney transplants performed in 2014
** 2/3 from deceased donors
** 1/3 from living donors
Preferred Donation Terminology
- Donations are a “_____ of Life”
“________” or donation of organs instead of harvest
Mechanical or ventilator support instead of life support
deceased donation instead of cadaveric donation
- Donations are a “Gift of Life”
“recover” or donation of organs instead of harvest
Mechanical or ventilator support instead of life support
deceased donation instead of cadaveric donation
Kidney Transplantation
- Extremely successful
- 1-year graft survival rate
- 90% for deceased donor transplants
- 95% for living donor transplants
- Extremely successful
- 1-year graft survival rate
- 90% for deceased donor transplants
- 95% for living donor transplants
Kidney transplant vs. Dialysis
* _______ many of the pathophysiologic changes associated with renal failure
* Eliminates the dependence on _______
* Less restrictive than dialysis
* Less expensive than dialysis after the first year
- Reverses many of the pathophysiologic changes associated with renal failure
- Eliminates the dependence on dialysis
- Less restrictive than dialysis
- Less expensive than dialysis after the first year
Kidney Transplantation
Recipient Selection
* Candidacy determined by a variety of medical, psychosocial, and financial factors that vary among transplant centers
Recipient Selection
* Candidacy determined by a variety of medical, psychosocial, and financial factors that vary among transplant centers
Kidney Transplantation - Contraindications to transplantation
Malignancies
untreated _______ disease
chronic __________ failure
extensive vascular disease
chronic infection
unresolved psychosocial disorders
problems taking _________ meds
Malignancies
untreated cardiac disease
chronic respiratory failure
extensive vascular disease
chronic infection
unresolved psychosocial disorders
problems taking life long meds
Kidney Transplantation - Histocompatibility Studies
* Purpose of testing is to identify the ______________ (HLA) for both donors and potential recipients
Human Leukocyte Antigen
Kidney Transplantation - Donor Sources
- Compatible blood type deceased donors
- Blood related living donors
- Unrelated living donors
- Altruistic living donors
- Paired donation or “swap”
- Compatible blood type deceased donors
- Blood related living donors
- Unrelated living donors
- Altruistic living donors
- Paired donation or “swap”
Kidney Transplantation - Nursing Management
- Preoperative care
- No acute infection
- Labs & IV (may need dialysis for ↑K+)
- EKG
- CXR
- Emotional and physical preparation
- Immunosuppressive drugs
- Preoperative care
- No acute infection
- Labs & IV (may need dialysis for ↑K+)
- EKG
- CXR
- Emotional and physical preparation
- Immunosuppressive drugs
Kidney Transplantation Nursing Management
* Postoperative care
* Live donor
** Care is similar to laparoscopic nephrectomy
** Close monitoring of renal function
** Close monitoring of hematocrit
** Pain control, ICS, ambulation
** Acknowledgement of donation
- Postoperative care
- Live donor
** Care is similar to laparoscopic nephrectomy
** Close monitoring of renal function
** Close monitoring of hematocrit
** Pain control, ICS, ambulation
** Acknowledgement of donation
Kidney Transplantation Nursing Management
* Postoperative care cont.
Recipient
** First priority: maintain ______
** Large volumes of urine soon after transplanted kidney placed due to
– New kidney ability to filter BUNs
– Abundance of fluids during operation
– Initial renal tubular dysfunction
- Urine output replaced with fluids milliliter by milliliter hourly**
- Urine output closely measured
** Acute tubular necrosis can occur - May need dialysis
** Maintain catheter patency
F & E
Kidney Transplantation - Immunosuppressive Therapy
Goal
* Adequately suppress the ________ response but prevent overwhelming ________
** Balance rejection vs. infection
* Mitigate side effects
Goal
* Adequately suppress the immune response but prevent overwhelming infection
** Balance rejection vs. infection
* Mitigate side effects
Kidney Transplantation - Complications: Rejection
- Hyperacute (antibody-mediated, humoral) rejection
** Occurs _________ after transplantation
** Transplant removed
** Acute rejection
** Occurs ____________ after transplantation
** Additional immunosuppressive therapy
** Chronic rejection
** Occurs ____________ and is irreversible
** Supportive therapy and likely resume dialysis
- Hyperacute (antibody-mediated, humoral) rejection
** Occurs minutes to hours after transplantation
** Transplant removed
** Acute rejection
** Occurs days to months after transplantation
** Additional immunosuppressive therapy
** Chronic rejection
** Occurs over months or years and is irreversible
** Supportive therapy and likely resume dialysis
Kidney Transplantation * Infection
* Most common infections observed in the first month
** Pneumonia
** Wound infections
** IV line and drain infections
** Fungal, viral, yeast, bacteria
- Most common infections observed in the first month
** Pneumonia
** Wound infections
** IV line and drain infections
** Fungal, viral, yeast, bacteria
Kidney Transplantation - Complications
* Cardiovascular disease
* Malignancies
* Recurrence of original renal disease
* Corticosteroid-related complications
- Cardiovascular disease
- Malignancies
- Recurrence of original renal disease
- Corticosteroid-related complications
Summary
- Functions of the kidney – many!
- Acute Renal Failure / Chronic Renal Failure
** Diagnosis
** Management - Treatment Modalities
** HDHD
** PDPD
** CRRTCRRT - Transplantation
- Nursing Assessment and Care
- Functions of the kidney – many!
- Acute Renal Failure / Chronic Renal Failure
** Diagnosis
** Management - Treatment Modalities
** HDHD
** PDPD
** CRRTCRRT - Transplantation
- Nursing Assessment and Care
Kidney (Renal) Failure
Partial or complete impairment of kidney function that results in inability to ________________________ products and water.
Affects ________
Treatments and dietary changes are challenging.
Impacts lifestyle, occupation, family relationships, and self-image.
Partial or complete impairment of kidney function that results in inability to excrete metabolic waste products and water.
Affects all body systems.
Treatments and dietary changes are challenging.
Impacts lifestyle, occupation, family relationships, and self-image.
AKI
Ranges from slight deterioration to ______________
Rapid loss of kidney function with:
Rise in ________ and or reduction in _________
_______ BUN and K+
__________ – accumulation of nitrogenous waste
High ________ rate
Ranges from slight deterioration to severe impairment.
Rapid loss of kidney function with:
Rise in creatine and or reduction in urine output.
Elevated BUN and K+
Azotemia – accumulation of nitrogenous waste
High mortaliy rate
Cause of AKI can be categorized as prerenal, intrarenal (or intrinsic), and postrenal.
Low CO, can lead to low BP (hypotension) which put’s pt at risk for _________ AKI.
For patients post op, that are experiencing AKI, it’s important to maintain adequate __________.
__________ is a nephrotoxic medication that can cause direct damage to the kidneys (intrarenal)
Cause of AKI can be categorized as prerenal, intrarenal (or intrinsic), and postrenal.
Low CO, can lead to low BP (hypotension) which put’s pt at risk for prerenal AKI.
For patients post op, that are experiencing AKI, it’s important to maintain adequate hydration.
Gentamicin is a nephrotoxic medication that can cause direct damage to the kidneys (intrarenal)
J.K. is a 37-year-old man who fell off the roof of a house he was constructing.
He sustained severe lacerations of his face and left leg, with substantial blood loss.
What type of kidney injury is J.K at risk for?
What are the contributing factors?
What SS of renal involvement would you assess for?
Which type of kidney injury is J.K. at risk for?
Prerenal
What are the contributing factors for this?
Fluid volume loss from blood loss
Leads to decreased cardiac output and decreased renal perfusion
What signs and symptoms of renal involvement would you assess for?
See next slides.
Three phrases of AKI.
Oliguria – low ___________. During the oliguric phase, acidosis, hyperkalemia (monitor EKG) and fluid overload are likely to occur.
The diuretic phase isa stage in the progression of acute kidney injury (AKI) where urine output _____________This phase typically follows the oliguric phase, during which urine output is very low
Recovery phase - may take up to 12 months for kidney function to stabilize
Oliguria – low urine output. During the oliguric phase, acidosis, hyperkalemia (monitor EKG) and fluid overload are likely to occur.
The diuretic phase isa stage in the progression of acute kidney injury (AKI) where urine output increases significantly.This phase typically follows the oliguric phase, during which urine output is very low
Recovery phase - may take up to 12 months for kidney function to stabilize
AKI
Ensure adequate intravascular volume and cardiac output
Loop diuretics (e.g., furosemide [Lasix])
Osmotic diuretics (e.g., mannitol)
Closely monitor fluid intake during oliguric phase
Fluid restriction calculation: All fluid losses for previous 24 hours + 600 mL
Ensure adequate intravascular volume and cardiac output
Loop diuretics (e.g., furosemide [Lasix])
Osmotic diuretics (e.g., mannitol)
Closely monitor fluid intake during oliguric phase
Fluid restriction calculation: All fluid losses for previous 24 hours + 600 mL
Why do we give IV regular insulin and dextrose for hyperkalemia?
Insulin forces ___________________________
Insulin forces K out of the serum and back into the cells.
AKI Nursing assessment
Measure vital signs
Daily ______
Strict _________
Examine _______
Assess general appearance
Observe dialysis access site
Measure vital signs
Daily weights
Strict intake and output
Examine urine
Assess general appearance
Observe dialysis access site
AKI nutrition therapy
Maintain adequate _______ intake
Primarily ________ and fat
Adequate _______ (not high) to prevent breakdown
Restrict _______, K+, phosphate
Calcium supplements or phosphate-binding agents
Enteral/parenteral nutrition
Maintain adequate caloric intake
Primarily carbohydrates and fat
Adequate protein (not high) to prevent breakdown
Restrict sodium, K+, phosphate
Calcium supplements or phosphate-binding agents
Enteral/parenteral nutrition
Your kidneys and your parathyroid glands keep both phosphate and calcium at healthy levels. Your kidneys activate (switch on) vitamin D which is important for calcium balance. They also control the amount of phosphate that is absorbed from the foods you eat.
Within the body calcium and phosphate are __________ related: as blood calcium levels rise, phosphate levels fall. This is becausephosphate binds to calcium reducing the available free calcium within the bloodstream.
Calcium supplements such as Calcitriol, check phosphate levels before admin. Phosphate binding agents : Calcium carbonate:An inexpensive option that forms insoluble phosphate complexes in the gut.It’s available in products like Alka-Seltzer and Tums.
Sevelamer:A calcium-free anion exchange resin that can lower cholesterol.It’s available in products like Renvela and Renagel
Calcium acetate:An option that’s less calcium absorbent than calcium carbonate.It’s available in products like PhosLo, Phoslyra, Eliphos, or Calphron
Your kidneys and your parathyroid glands keep both phosphate and calcium at healthy levels. Your kidneys activate (switch on) vitamin D which is important for calcium balance. They also control the amount of phosphate that is absorbed from the foods you eat.
Within the body calcium and phosphate are inversely related: as blood calcium levels rise, phosphate levels fall. This is becausephosphate binds to calcium reducing the available free calcium within the bloodstream.
Calcium supplements such as Calcitriol, check phosphate levels before admin. Phosphate binding agents : Calcium carbonate:An inexpensive option that forms insoluble phosphate complexes in the gut.It’s available in products like Alka-Seltzer and Tums.
Sevelamer:A calcium-free anion exchange resin that can lower cholesterol.It’s available in products like Renvela and Renagel
Calcium acetate:An option that’s less calcium absorbent than calcium carbonate.It’s available in products like PhosLo, Phoslyra, Eliphos, or Calphron
Chronic Kidney Disease CKD
Progressive, _________ loss of kidney function
Greater than 26 million American adults have CKD; more ________ than AKI
Increased prevalence related to ______ population, increased _______, increased _________ and HTN
Over half a million Americans are receiving treatment for ESRD; high mortality rate
Leading causes
________—50%
Hypertension—25%
Other: glomerulonephritis, cystic diseases, urologic diseases
Persons with CKD are often ________ ; ~ 70% aware
Underdiagnosed and untreated
Progressive, irreversible loss of kidney function
Greater than 26 million American adults have CKD; more common than AKI
Increased prevalence related to aging population, increased obesity, increased diabetes and HTN
Over half a million Americans are receiving treatment for ESRD; high mortality rate
Leading causes
Diabetes—50%
Hypertension—25%
Other: glomerulonephritis, cystic diseases, urologic diseases
Persons with CKD are often asymptomatic; ~ 70% aware
Underdiagnosed and untreated
AKI VS CKD
AKI
-_______, common cause is acute reduction in ______ outout, potentially ________, cause of death is ______
CKD
-gradual over ______, common cause is diabetic _________, irreversible, cause of death is _______ disease
AKI
-sudden, common cause is acute reduction in urine outout, potentially reversible, cause of death is infection
CKD
-gradual over years, common cuase is diabetic neuropathy, irreversible, cause of death is heart disease
GFR stands for glomerular filtration rate, which isa measure of how well ______________.
A GFR test is a blood test that estimates the amount of ______ that passes through the kidneys’ filters each _______.
A GFR test can indicate kidney disease.If your kidneys are damaged, they can’t filter blood as well, and ___________ levels can build up in your blood.
GFR stands for glomerular filtration rate, which isa measure of how well your kidneys filter blood.
A GFR test is a blood test that estimates the amount of blood that passes through the kidneys’ filters each minute.
A GFR test can indicate kidney disease.If your kidneys are damaged, they can’t filter blood as well, and creatinine levels can build up in your blood.
CKD labs for success - mnemonics
I ate twenty buns (8-20 BUN)
HIGH is DRY.
3 classifications of AKI are
Prerenal
Intrarenal
Postrenal
Intrarenal AKI
[causes are ___________ to kidney tissue]
Dehydration
Vasopressor
nephrotoxic drugs
inflammation
rhabdomyolosis
[causes are direct damage to kidney tissue]
Dehydration
Vasopressor
nephrotoxic drugs
inflammation
rhabdomyolosis
Prerenal AKI
[Cause - factors that reduce systemic ___________ , causing reduction in renal blood flow, decrease GFR ]
decreased CO
Vasodilation
Intravascular volume deficit
circulation
Postrenal AKI
[Cause is mechanical ________ to outflow]
BPH
Calculi
Trauma
Tumors
Blood clots
Neurogenic bladder
[Cause is mechanical obstruction to outflow]
BPH
Calculi
Trauma
Tumors
Blood clots
Neurogenic bladder
Stages of AKI - RIFLE
Risk
Injury
Failure
Loss
End-stage renal disease
[include chart]
AKI diagnostic tests
serum _______
urinalysis
GFR
Kidney ultrasonography
Renal scan
CT scan w/o _________
Renal biopsy
serum creatinine
urinalysis
GFR
Kidney ultrasonography
Renal scan
CT scan w/o contrast
Renal biopsy
CKD - _________ kidney damage
GFR <__ ml/min for over 3 months
CKD - irreversible kidney damage
GFR <60 ml/min for over 3 months
CKD risk factors -
CVD, DM, race
CKD S&S
Result of ________ substances - urea, creatinine, phenols, hormones, electrolytes, water
Result of retained substances - urea, creatinine, phenols, hormones, electrolytes, water
CKD diagnostic tests
Dipstick _______ evaluation
UA, US
Biopsy
Albumin / creatinine ratio
____
Dipstick protein evaluation
UA, US
Biopsy
Albumin / creatinine ratio
GFR
___________ is contraindicated in kidney failure [can be fatal]
Contrast dye
CKD nursing care
monitor ____
restrict _______, Na, K+, phosphate
Protein intake
monitor labs
restrict fluid, Na, K+, phosphate
Protein intake
CKD drug therapy
Increase ___
HTN
CKD - MBD
_______
Increase K+
HTN
CKD - MBD
Anemia
Peritoneal dialysis
Peritoneal access obtrained by inserting catheter through anterior ___________ [usually placed surgically]
PD initiated immediate or delayed for 2 weeks
Complications - ________, peritonitis, hernias, bleeding, pulmonary complications
Peritoneal access obtrained by inserting catheter through anterior abdomen wall [usually placed surgically]
PD initiated immediate or delayed for 2 weeks
Complications - infection, peritonitis, hernias, bleeding, pulmonary complications
hemodialysis
Vascular access sites
-AV _________, ______
-temporary vascular access
Dialyzers
-plastic cart with thousands of hollow tubes/fibers
-fibers are semipermeable membranes
Complications
-Low ____, blood loss, hepatits, muscle cramps
Vascular access sites
-AV fistulas, grafts
-temporary vascular access
Dialyzers
-plastic cart with thousands of hollow tubes/fibers
-fibers are semipermeable membranes
Complications
-Low BP, blood loss, hepatits, muscle cramps
Hemodialysis (HD)Vascular Access Sites
HD requires rapid blood flow and access to a _______ blood vessel.
Obtaining vascular access is one of most difficult problems
-Types of access
–Arteriovenous fistulas and grafts
–Temporary vascular access
HD requires rapid blood flow and access to a large blood vessel.
Obtaining vascular access is one of most difficult problems
-Types of access
–Arteriovenous fistulas and grafts
–Temporary vascular access
Continual renal replacement therapy (CRRT)
-Treat AKI - uremic ________________
Acid Base status / electrolyte are adjusted _______ & continuously
—can be used with HD
-Treat AKI - uremic toxins and fluids removed
Acid Base status / electrolyte are adjusted slowly & continuously
—can be used with HD
AV Fistulas and Grafts
Risks:
-Distal _______ (steal syndrome)
–Pain distal to access site
–Numbness or tingling of fingers
–Poor capillary refill
–Aneurysms
Safety alert for AVF and grafts
-No BP, venipunctures, or IV lines
–Post signs in room or labeled ________
-Prevent infection and clotting
Risks:
-Distal ischemia (steal syndrome)
–Pain distal to access site
–Numbness or tingling of fingers
–Poor capillary refill
–Aneurysms
Safety alert for AVF and grafts
-No BP, venipunctures, or IV lines
–Post signs in room or labeled arm band
-Prevent infection and clotting
Renal Drug therapy - Anemia
*_________ (EPO)
Epoetin alfa (Epogen, Procrit)
Darbepoeitin alfa (Aranesp)
Given IV or subcutaneously
Increased hemoglobin and hematocrit in _______ weeks
Side effects: __________, hypertension
Use lowest possible dose; contraindicated in uncontrolled _____
*Erythropoietin (EPO)
Epoetin alfa (Epogen, Procrit)
Darbepoeitin alfa (Aranesp)
Given IV or subcutaneously
Increased hemoglobin and hematocrit in 2 to 3 weeks
Side effects: thromboembolism, hypertension
Use lowest possible dose; contraindicated in uncontrolled HTN
BUN _______
CR ________
BUN 7-24
CR .7 - 1.4 mm/dl
AV Graft
Synthetic material surgically placed under skin to form bridge between ______________
Healing time __________
Synthetic material surgically placed under skin to form bridge between artery and vein
Healing time 2-4 weeks
Measuring with fain for dialysis pt
1 lb = ______ L (1 pint) of retained fluid
0.5 L
The glomerulus is the __________ part of the kidney
filtration
the best marker of kidney function is
GFR
Continuous ambulatory Peritoneal Dialysis VS APD Automated PD
Continuous
-person does exchange _______ throughout day
Automated
-machine (cycler) does usually during ______
Continuous
-person does exchange manually throughout day
Automated
-machine (cycler) does usually during sleep
AKI: Pre-, Intra-, Post-
- Pre-renal: before the kidneys
- Decrease in _____________
- Intra-renal: within the kidneys
- ____________ to the kidneys
- Post-renal: after the kidneys
- Urine _______ _________
- Pre-renal: before the kidneys
- Decrease in circulating blood volume
- Intra-renal: within the kidneys
- Direct damage to the kidneys
- Post-renal: after the kidneys
- Urine outflow blocked
Three Phases of AKI - 1
- _______
- Occurs 1-7 days after injury and lasts 10 to 14 days
- UO < 400 ml /24 hours*
- Sp. Gr. Fixed at 1.010
- Electrolyte imbalances
- K, Ca, Mg, PO4
- Acid-base imbalances
- Oliguria
- Occurs 1-7 days after injury and lasts 10 to 14 days
- UO < 400 ml /24 hours*
- Sp. Gr. Fixed at 1.010
- Electrolyte imbalances
- K, Ca, Mg, PO4
- Acid-base imbalances
Three Phases of AKI - 2
- __________
- Lasts 1-3 weeks
- U.O. gradual ↑ to 1-3 L/day up to 5 L
- Electrolyte imbalances
- Hypotension, hypovolemia are main concerns
Diuretic
Three Phases of AKI - 3
- _________
- Lasts 1-2 weeks but could take up to one year
- Begins when GFR ↑ so that BUN, serum Cr levels start to stabilize and then ↓
- U.O., electrolytes, acid-base continue to stabilize and then return to normal
- Some progress to Chronic Renal Failure
Recovery
Acute vs Chronic Kidney Disease
Acute
Sudden onset
50% nephron involvement
2-4 wk duration
Reversible (most of the time)
Caused by pre/intra/post
Many body systems involved
CRRT for maintaining hemodynamics
Chronic
Gradual onset
90-95% nephron involvement
Permanent
Fatal
Caused by HTN & DM
All body systems involved
HD, PD, maybe CRRT, Transplant for maintaining hemodynamics
Acute
Sudden onset
50% nephron involvement
2-4 wk duration
Reversible (most of the time)
Caused by pre/intra/post
Many body systems involved
CRRT for maintaining hemodynamics
Chronic
Gradual onset
90-95% nephron involvement
Permanent
Fatal
Caused by HTN & DM
All body systems involved
HD, PD, maybe CRRT, Transplant for maintaining hemodynamics
After the insertion of an arteriovenous graft in the right forearm, a patient reports pain and coldness of the right fingers. Which action should the nurse take?
A. Remind the patient to take a daily low-dose aspirin tablet.
B. Report the patient’s symptoms to the health care provider.
C. Elevate the patient’s arm on pillows above the heart level.
D. Teach the patient about normal arteriovenous graft function.
B. Report the patient’s symptoms to the health care provider.
The patient’s problems suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevating the arm above the heart will further decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts.
The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan?
A. Augmenting fluid volume
B. Maintaining cardiac output
C. Diluting nephrotoxic substances
D. Preventing systemic hypertension
B. Maintaining cardiac output
The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient’s heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses could be correct.
Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse’s teaching about management of CKD has been effective?
A. “I need to get most of my protein from low-fat dairy products.”
B. “I will increase my intake of fruits and vegetables to 5 per day.”
C. “I will measure my output each day to help calculate the amount I can drink.”
D. “I need erythropoietin injections to boost my immunity and prevent infection.”
C. “I will measure my output each day to help calculate the amount I can drink.”
The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD.
Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
A. Blood pressure
B. Phosphate level
C. Neurologic status
D. Creatinine clearance
B. Phosphate level
Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. What should the nurse assess before administering the medication?
A. Bowel sounds
B. Blood glucose
C. Blood urea nitrogen (BUN)
D. Level of consciousness (LOC)
A. Bowel sounds
Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse’s decision to give the
medication.
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse’s teaching has been successful?
A. Split-pea soup, English muffin, and nonfat milk
B. Poached eggs, whole-wheat toast, and apple juice
C. Oatmeal with cream, half a banana, and herbal tea
D. Cheese sandwich, tomato soup, and cranberry juice
B. Poached eggs, whole-wheat toast, and apple juice
Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and cream is high in phosphate.
Which laboratory result should the nurse check before administering calcium carbonate to a patient with chronic kidney disease?
A. Serum potassium
B. Serum phosphate
C. Serum creatinine
D. Serum cholesterol
B. Serum phosphate
If serum phosphate is increased, the calcium and phosphate can cause soft tissue calcification. Calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered
A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
A. Urine volume
B. Creatinine level
C. Glomerular filtration rate (GFR)
D. Blood urea nitrogen (BUN) level
C. Glomerular filtration rate (GFR)
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status and protein intake. Urine output can be normal or high in patients with AKI and does not accurately reflect kidney function. Creatinine alone is not an accurate reflection of renal function
A patient will need vascular access for hemodialysis. Whic h statement by the nurse accurately describes an advantage of a fistula over a graft?
A. A fistula is much less likely to clot.
B. A fistula increases patient mobility.
C. A fistula can be used sooner after surgery.
D. A fistula can accommodate larger needles.
A. A fistula is much less likely to clot.
Arteriovenous (AV) fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility.
Which action will the nurse include in the plan of care to maintain the patency of a patient’s left arm arteriovenous fistula?
A. Auscultate for a bruit at the fistula site.
B. Assess the quality of the left radial pulse.
C. Compare blood pressures in the left and right arms.
D. Irrigate the fistula site with saline every 8 to 12 hours.
A. Auscultate for a bruit at the fistula site.
The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula.
A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?
A. Increased calories are needed because glucose is lost during hemodialysis.
B. More protein is allowed because urea and creatinine are removed by dialysis.
C. Dietary potassium is not restricted because the level is normalized by dialysis.
D. Unlimited fluids are allowed because retained fluid is removed during dialysis.
B. More protein is allowed because urea and creatinine are removed by dialysis.
When the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is encouraged. Glucose is not lost during hemodialysis. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
A. The patient leaves the catheter exit site without a dressing.
B. The patient plans 30 to 60 minutes for a dialysate exchange.
C. The patient cleans the catheter while in the bathtub each day.
D. The patient slows the inflow rate when experiencing abdominal pain
C. The patient cleans the catheter while in the bathtub each day.
Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?
A. Acetaminophen
B. Calcium phosphate
C. Magnesium hydroxide
D. Multivitamin with iron
C. Magnesium hydroxide
Since magnesium is excreted through the kidneys patients with CKD should not use over-thecounter products containing magnesium. The other medications are appropriate for a patient with CKD
A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). which information should the nurse report to the health care provider before giving the medication?
A. Creatinine 1.6 mg/dL
B. Oxygen saturation 89%
C. Hemoglobin level 13 g/dL
D. Blood pressure 98/56 mm Hg
C. Hemoglobin level 13 g/dL
High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when erythropoietin (EPO) is administerd to a target hemoglobin of greater than 12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider but will not affect whether the medication is administered.
Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?
A. Start continuous pulse oximetry.
B. Restrict the patient’s protein intake.
C. Restrict physical activity to bed rest.
D. Discontinue the urethral retention catheter.
C. Restrict physical activity to bed rest.
The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry.
A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?
A. The creatinine level is 3.0 mg/dL.
B. Urine output over an 8-hour period is 2500 mL.
C. The blood urea nitrogen (BUN) level is 67 mg/dL.
D. The glomerular filtration rate is less than 30 mL/min/1.73 m
B. Urine output over an 8-hour period is 2500 mL.
The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy.
A patient has arrived for a scheduled hemodialysis session. Which nursing action is
appropriate for the registered nurse (RN) to delegate to a dialysis technician?
A. Teach the patient about fluid restrictions.
B. Check blood pressure before starting dialysis.
C. Assess for causes of an increase in predialysis weight.
D. Determine the ultrafiltration rate for the hemodialysis.
B. Check blood pressure before starting dialysis.
Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN.
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?
A. The patient has an outflow volume of 1800 mL.
B. The patient’s peritoneal effluent appears cloudy.
C. The patient’s abdomen appears bloated after the inflow.
D. The patient has abdominal pain during the inflow phase.
B. The patient’s peritoneal effluent appears cloudy.
Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported
immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient.
The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?
A. The urine output is 900 to 1100 mL/hr.
B. The patient’s central venous pressure (CVP) is decreased.
C. The patient reports level 7 (0- to 10-point scale) incisional pain.
D. The blood urea nitrogen (BUN) and creatinine levels are elevated.
B. The patient’s central venous pressure (CVP) is decreased.
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant.
During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first?
A. Slow down the rate of dialysis.
B. Check the blood pressure (BP).
C. Review the hematocrit (Hct) level
D. Give prescribed PRN antiemetic drugs.
B. Check the blood pressure (BP).
The patient’s reports of nausea and dizziness suggest hypotension, so the first action should be to check the BP. The other actions may also be appropriate based on the blood pressure obtained.
A patient reports leg cramps during hemodialysis. What action should the nurse take?
A. Massage the patient’s legs.
B. Reposition the patient supine.
C. Give acetaminophen (Tylenol).
D. Infuse a bolus of normal saline.
D. Infuse a bolus of normal saline.
Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.
After receiving change-of-shift report, which patient should the nurse assess first?
A. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange.
B. Patient with stage 4 chronic kidney disease who has an elevated phosphate level.
C. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L.
D. Patient who has just returned from having hemodialysis with a heart rate of 110/min.
D. Patient who has just returned from having hemodialysis with a heart rate of 110/min.
The patient who has tachycardia after hemodialysis may be bleeding or excessively
hypovolemic and should be assessed immediately for these complications. The other
patients also need assessments or interventions but are not at risk for life-threatening
complications.
3 kidney functions
filtration
homeostasis (F&E balance)
hormonal
Peritoneal Dialysis (PD)
* Peritoneal membrane acts as the semipermeable membrane to filter out _______
* Peritoneal access is obtained by inserting a catheter through the ________ wall (tunneled)
- Exchange Cycle:
- Inflow – dialysate goes into peritoneal
- Dwell – diffusion and osmosis occur
- Drain – effluent is removed
- Types
- Continuous Ambulatory (CAPD)
- Automated (APD)
Peritoneal Dialysis (PD)
* Peritoneal membrane acts as the semipermeable membrane to filter out wastes
* Peritoneal access is obtained by inserting a catheter through the anterior wall (tunneled)
- Exchange Cycle:
- Inflow – dialysate goes into peritoneal
- Dwell – diffusion and osmosis occur
- Drain – effluent is removed
- Types
- Continuous Ambulatory (CAPD)
- Automated (APD)
Peritoneal Dialysis (PD) - Effectiveness and Adaptation
- Immediate initiation – after the two-week healing process
- Short training program
- Independence
- Ease of traveling
- Fewer dietary restrictions
- Greater mobility than with HD
- Immediate initiation – after the two-week healing process
- Short training program
- Independence
- Ease of traveling
- Fewer dietary restrictions
- Greater mobility than with HD
Peritoneal Dialysis (PD) complications
- Cath site infection
- Peritonitis - cloudy effluent
- Abdominal pain
- Outflow problems
- Hernias
- Bleeding
- Pulmonary complications
- Protein loss
- Carbohydrate and lipid abnormalities – due to high glucose in dyalisate
- Cath site infection
- Peritonitis - cloudy effluent
- Abdominal pain
- Outflow problems
- Hernias
- Bleeding
- Pulmonary complications
- Protein loss
- Carbohydrate and lipid abnormalities – due to high glucose in dyalisate
Peritoneal dialysis (PD) Care of the PD patient
- Handwashing, good hygiene & site care
- Aseptic technique
- Teach and monitor for signs of infection and complications
- Inflow (fill) slowly, gradually
- Warm dialysate for comfort
- High protein diet
- NO BATHTUB SITTING
- Handwashing, good hygiene & site care
- Aseptic technique
- Teach and monitor for signs of infection and complications
- Inflow (fill) slowly, gradually
- Warm dialysate for comfort
- High protein diet
- NO BATHTUB SITTING
Hemodialysis (HD) complications
- Hypotension
- Muscle cramps
- Loss of blood
- Infection
- Hypotension
- Muscle cramps
- Loss of blood
- Infection
Prerenal AKI
↓ CO = ↓ ___
↓ CO = ↓ BP
Intrarenal AKI - Commonly caused by _____________, and nephrotoxic medications. EX: _________
Intrarenal AKI - Commonly caused by cardiogenic shock, and nephrotoxic medications. EX: Gentamicin
Postrenal AKI
Tumors, kidney stones, enlarged prostate, neurogenic bladder, blood clots, _________ problems.
Tumors, kidney stones, enlarged prostate, neurogenic bladder, blood clots, structural problems.
WHAT CAN HAPPEN WITH AKI?
* __ urine output
* Edema
* Fatigue
* Nausea and vomiting
* ___
* Caused by fluid buildup and or metabolic acidosis
* ___________ respirations – deep rapid and labored breaths
- ↓ urine output
- Edema
- Fatigue
- Nausea and vomiting
- SOB
- Caused by fluid buildup and or metabolic acidosis
- Kussmaul respirations – deep rapid and labored breaths
- _________ for post-op patients
-* Most increased risk for AKI. - Monitoring serum _______ & _____ levels.
-* For patients with ↓ urine output and ↑ BUN and Creat., low perfusion = risk for ↓ CO = hypotension
- Hydration for post-op patients
-* Most increased risk for AKI. - Monitoring serum creatine and BUN levels.
-* For patients with ↓ urine output and ↑ BUN and Creat., low perfusion = risk for ↓ CO = hypotension
THREE PHASES OF AKI
Oliguric- decreased urine output, risk for metabolic _________ , hyper________ [cardiac monitoring R&R]
Diuretic
Recovery
Oliguric- decreased urine output, risk for metabolic acidosis, hyperkalemia [cardiac monitoring R&R]
Risk factors for CKD
CVD
DM
Race- african americans
Aging
CKD - pt will be at increased risk for ______ due to coping/ life style changes/ HD Etc. with this disease
depression
anxiety
AV Fistula VS Graft
which one is more at risk for blood clots?
Graft
AV graft [artificial] will often _____ during or after dialysis
clot
AV Fistulas and Grafts
Risks:
* Distal ischemia (steal syndrome)
*– Pain distal to access site
* –Numbness or tingling of fingers
* –Poor capillary refill
* Aneurysms
Safety alert for AVF and grafts
* No BP, venipunctures, or IV lines
* Post signs in room or labeled arm band
* Prevent infection and clotting
Risks:
* Distal ischemia (steal syndrome)
*– Pain distal to access site
*– Numbness or tingling of fingers
*– Poor capillary refill
* Aneurysms
Safety alert for AVF and grafts
* No BP, venipunctures, or IV lines
* Post signs in room or labeled arm band
* Prevent infection and clotting
Hyperkalemia therapies [NR 3.5-5]
◦ Temporary—move K+ into cells
◦ Insulin and sodium bicarbonate
◦ reduce dysrhythmias—stabilizes myocardium
◦ Calcium gluconate
◦ Remove K+ from body
◦ Sodium polystyrene sulfonate
(Kayexalate) or Patiromer (Veltassa)
◦ Dialysis
◦ Dietary restriction
◦ Temporary—move K+ into cells
◦ Insulin and sodium bicarbonate
◦ reduce dysrhythmias—stabilizes myocardium
◦ Calcium gluconate
◦ Remove K+ from body
◦ Sodium polystyrene sulfonate
(Kayexalate) or Patiromer (Veltassa)
◦ Dialysis
◦ Dietary restriction
NURSING INTERVENTIONS AND CARE [AKI/dialysis?]
- Monitor pt’s ________
- Administer medications to address ________
a. Epogen (Epoetin) - Monitor daily _______ and I/O
- Monitor lab values
a. Often will have to have phos added on to metabolic panel.
◦ Maintain adequate caloric intake
◦ Primarily carbohydrates and increase fat
◦ Adequate protein (not high) to prevent breakdown
◦ Restrict sodium, K+, phosphate
◦ Calcium supplements or phosphate-binding agents
◦ Enteral/parenteral nutrition
- Monitor pt’s blood pressure.
- Administer medications to address anemia
a. Epogen (Epoetin) - Monitor daily weights and I/O
- Monitor lab values
a. Often will have to have phos added on to metabolic panel.
◦ Maintain adequate caloric intake
◦ Primarily carbohydrates and fat
◦ Adequate protein (not high) to prevent breakdown
◦ Restrict sodium, K+, phosphate
◦ Calcium supplements or phosphate-binding agents
◦ Enteral/parenteral nutrition
CALCULATING WEIGHT GAIN IN PATIENTS ON DIALYSIS
Measuring with gain for dialysis patients:
1 lb = 0.5L (1 pint) of retained fluid
For a pt who has gained 35lbs in 3 days, approx. how much fluid retention does this equal?
17.5
35 pints
