Week 3: Renal + Urinary Health Flashcards
Function of the Kidneys
Urine formation
Excretion of waste products
Regulation of electrolytes and acid-base balance
where are the kidneys located?
retroperitoneal space
RAAS System Low Aldosterone
low aldosterone = decreased Na retention, fluid volume, and blood pressure - increased urinary output (diuresis)
RAAS System High Aldosterone
Increased Na retention, fluid volume, blood pressure - decreased urinary output
- there is a decrease in urinary output because the water and sodium are increased aka staying in the kidney
Renal Nursing assessment
- Health history & family health history
physical expaminations (pain, GI, integumentary, urinary)
Lab values: Cr, BUN, eGFR, Hbg
Signs/symptoms of compromised kidney function
Comorbidities (diabetes, hypertension, neuromuscular disease)
Family history of kidney disease
Age
Older clients may have more comorbidities.
Medications (long term use may be nephrotoxic)
medications for renal injury
NSAIDs
Antibiotics
Loop diuretics (causes kidneys to work harder to excrete fluid)
Contrast dyes (hold metformin for 48 hours post dye)
Metformin (Type 2 diabetes med. Excreted by the kidneys)
Nephrotic drugs = cause damage to kidney’s over time
- Cautious with contrast dye for patients with diabetes, metformin should be held after the administration of contrast dye for 48 hours to allow the kidneys to function
neurogenic Bladder
difficult time emptying the bladder which causes upstream impacts on the kidneys
lack bladder control in your brain
micturition
normal voiding (30 mL / day or 1-2 L/day)
anurea
no urinary output
oliguria
low urinary output
polyurea
excessive urinary output
hematuria
blood in urine
proteinurea
protein in urine
azotemia
elevation of nitrous products such as BUN and creatinine in the blood and other secondary waste products
integument examination
Pruritus
itching
integument examination
physical examination: GI
nausea, vomiting, diarrhea, abdominal discomfort + distention
physical examination: neurological
Waste product buildup in the body interrupts normal neurological functioning
Early signs: lethargy, forgetfulness, mild confusion
Late signs: seizures, coma
Build-up of BUN – interrupts our normal neurological functioning – is going to cause uremic encephalopathy the early and late signs of this are above
Serum Creatinine (Cr)
Meaning: elevated values indicate poor function
Creatinine is a waste product of creatine phosphate which is a by-product of muscle breakdown.
Patients with HIGH serum creatinine levels likely have severe renal impairment – the nephrons are destroyed so they aren’t able to filter through and excrete that waste
Blood Urea Nitrogen (BUN)
elevated values indicate poor function
BUN = measures the amount of urea nitrogen in the body - also a waste product of protein metabolism. So when BUN or creatine values are HIGH we know the body is retaining waste
eGFR (estimated glomerular filtration
Decreased value indicates poor kidney function
Nursing role:
24-hour urine collection
Keep refrigerated
Document start and end time
Void at beginning of test and discard first urine specimen
At end, ask client to empty bladder
Blood draw
End of specimen collection
its a Measure of how our body is able to clear the creatine (if we are unable to excrete waste then eGFR would be decreased)
Kidney Dysfunction: Lab findings
Increased creatinine and BUN, decreased eGFR
Fluid volume deficit
High protein
Decreased renal perfusion
Fluid volume excess (end stage kidney failure/disease)
Kidney dysfunction Lab findings in end-stage renal
Increased or decreased Na (due to water retention, could cause either hyper or hypotension)
Increased K (due to cardiac arrythmias)
Decreased vitamin D
Increased phosphate
Decreased bicarbonate
Bone dysfunction (fall risk)
Hemoglobin (Hbg)
Decreased erythropoietin causes anemia
Do not use hematocrit (Hct) as a measure of RBC (can be impacted by fluid
volume imbalance)
Acute Kidney Injury (AKI)
Impacts renal function for less than 3 months
Sudden loss of renal failure
rapid decrease in U/O
Results in fluid, electrolyte, and pH imbalances (metabolic acidosis), waste buildup
** reversible
Chronic Kidney Disease (kidney failure)
progressive, permanent nephron degeneration, irreversible
Classifications of Acute kidney injury (AKI)
- Prerenal – hypoperfusion of kidneys (not enough blood flow - likely due to hypovolemia or anything that decreases BP, CO, total peripheral resistance)
- Intrarenal – damage to kidney tissues
Comorbidities, medications, infections (typically UTI) - Postrenal – obstruction of urine flow
Tumour, clot, kidney stone
Phases of Acute Kidney Injury
Initiation – initial insult to kidney function
Oliguria – rapid reduction in urine output
Increased Cr, BUN, K
May present with pruritus and/or hyperkalemia
Diuresis – normal urinary output
Recovery – labs normalize (typically afer 3 months)
nursing role in preventing acute kidney injury
Monitor kidney function
Be aware of nephrotoxic drugs
Follow blood transfusion protocols (transfusion reactions can cause AKI)
Provide adequate hydration -
Surgery, contrast agents, chemotherapy, marginal kidney reserve (older adults)
Treat hypotension promptly
Prevent infection (especially UTIs)
S&S Acute kidney inury
Hyperkalemia (cardiac arrythmias, muscle weakness, diarrhea)
Metabolic acidosis (Kussmaul respirations)
Hypervolemia (edema, bounding pulses, lethargy, confusion, weight gain,
decreased urinary output)
Decreased erythropoiesis
Hemodynamic instability
Neurologic changes
Nursing Interventions: AKI
Monitor fluid and electrolyte balance
Promote pulmonary function
Infection prevention
Integument health
Edema and uraemic pruritus
Increased risk for breakdown
Psychosocial support
Goals of care for AKI
Treat the underlying cause of AKI
Dialysis to remove toxins/fluids
Diuretic medications
AKI: continuous renal replacement therapy (CRRT)
Filters extracellular fluid:
- Removes H2O, electrolytes, and solutes through hemofilter
- Clears urinary toxins
- typically used in ICU settings
Last effort, not a long-term treatment
CRRT = type of blood purification therapy that is used with patients who are experiencing acute kidney injury/ acute renal failure
Chronic Kidney Disease
No cure
Process:
Preventative measures are encouraged
Disease is diagnosed, goal is to slow the progress
Disease progresses to severe
Dialysis or transplant will occur
Death will eventually occur
Stages of Chronic Kidney Disease
Use the eGFR to stage kidney disease
Stage 1 – 90+, damage but normal function
Stage 2 – 60-89, mild decrease in function
Stage 3 – 30-59, moderate decrease in function
Stage 4 – 15-29, severe decrease in function
Stage 5 – less than 15, end-stage kidney disease
causes of chronic kidney disease
hypertension & diabetes
S&S of chronic kidney disease
Oliguria, hematuria, proteinuria
Hypervolemia (FVO)
Increased BP, pulmonary edema (crackles), JVD and bounding pulses, lethargy/confusion
Metabolic acidosis (pH less than 7.35)
Hyperkalemia
Cardiac arrythmias, muscle weakness, diarrhea
Hyperphosphatasemia (bone demineralization)
Hypocalcemia
Hypernatremia
Hemodynamic instability
Result of abnormal BP
Intestinal issues
Urea is converted into ammonia, which can cause ulceration and bleeding
Decreased hct and hbg
Melena or occult stool
Anemia
Measure Hbg, not Hct
Infection risk
Asepsis, catheter care
Integument
Uremic pruritis
Nursing Interventions: Chronic Kidney disease
Monitor fluid and electrolyte balance
- Hyperkalemia
- I&O monitoring, daily weights
- Monitor for hypertensive crisis
- Headache, nausea and vomiting, change in mental status o Avoid nephrotoxic medications
Infection prevention
- Integument health
- Edema and uraemic pruritus may cause increased breakdown
Psychosocial support
Patient education: chronic kidney disease
Control BG in diabetes
Control blood pressure in HTN
Diet
- Restrict fluid, Na, K, phosphates
- Consume low protein, high carb diet
Smoking cessation
Minimal alcohol intake
May need to lose weight
Encourage exercise
Avoid NSAID
PRILs : treatment for chronic kidney disease
Antihypertensives, ACE inhibitors
Action – treat HTN, lower BP
Side effects – drowsiness, dizziness, headache, persistent dry cough
Nursing considerations: Monitor for hypotension, Advocate for change in medication if patient is having trouble coping with dry cough
SARTANs - treatment for chronic kidney disease
Antihypertensives, ARBs
Action – treat HTN, lower BP
Side effects – dizziness, headache, nausea, vomiting, diarrhea
Nursing considerations: Monitor for hypotension, May be appropriate for patients who cannot tolerate PRILs
angiotensin 2 receptor blockers. Prevents RAAS from increasing blood pressure
Metformin: treatment for chronic kidney disease
Antihyperglycemic, biquanide
Action – treat hyperglycemia, lower BG
Side effects – stomach pain, GI upset, gas, bloating, NVD, constipation
Caution – hepatotoxic
Nursing considerations: Monitor BG (hypoglycemia), Monitor ALT and AST, Do not use in eGFR under 30
STATINs - treatment for chronic kidney disease
Antihyperlipidemia, HMG-CoA reductase inhibitor
Action – treat dyslypidemia
Side effects – headache, dizziness, insomnia, GI upset, muscle pain
Caution – hepatotoxic (monitor ALT and AST)
Nursing considerations:
- Lipid labs (require fasting) o HDL, LDL
Dialysis Assessment
Monitor vitals, respiratory, and cardiac function (hypovolemia)
Monitor fluid balance & weight (shows efficacy)
Measure weight pre-dialysis and compare with weight following last treatment
Monitor labs ofen
Peritoneal Dialysis
Run by gravity or continuous cycle
Treatment occurs overnight
Nursing actions:
- Warm hypertonic solution before administration
- Infection prevention: Wash hands, Wear mask
- Monitor for peritonitis: Febrile, cloudy drainage, tachycardia
hemodialysis
Diffusion of dissolved solutes from one fluid compartment to another
Fistula care (vascular access point) and assessment
Avoid BP on dialysis arm
Perform neurovascular assessments
Do not touch the site without proper care
Hold medications
Transplant
Healthy kidney replacement
Most effective treatment for stage 5 CKD
Afer transplants, recipients MUST be on immunosuppressants for life
80% survival rate 5 years post-transplant
