Week 7; Acute Care Kidney Injury & Sexual Dysfunction Flashcards
AKI
Rapid reduction in kidney function; failure to maintain fluid and electrolyte balance and acid–base balance with accumulation of nitrogenous waste products in the blood. Evidenced by increased creatinine and BUN. Occurs over a few hours or days, causes systemic effects and complications, can result in death.
Glomerular filtration
First step in urine formation. Normal GFR averages 125 mL/min totaling 180 L day – this is included in reabsorption. Otherwise severe dehydration and death. Only about 1-3 L is excreted each day as urine.
GFR is controlled by BP and blood flow.
Kidneys self-regulate their own blood pressure and blood flow which keeps GFR constant
GFR decreases with age.
By age 65 the GFR is about 65mL/min (half of rate of a young adult) which increases risk of fluid overload.
Diabetes, HTN, or heart failure causes an even faster decline
The combination of reduced kidney mass, reduced blood flow, and a greater risk for drug reactions and kidney damage from drugs and contrast media in older adults.
AKI etiology
More likely in hospitalized adults with advanced age or pre-existing conditions, burns, third spacing depletes kidney of fluid, reduced cardiac output and fluid loss
3 Categories of Causes of AKI:
- Prerenal Causes – perfusion reduction, hypovolemia, low cardiac output
- Intrarenal Causes - Kidney damage, acute tubular necrosis, injury
- Postrenal Causes – Urine Flow Obstruction (Ureteral or Urethral)
Postrenal AKI causes
Ureteral obstruction from cancer, calculi, external obstruction, prostate enlargement, calculi, cancer, stricture, blood clot
Nursing priority with AKI
Preventing volume depletion and providing early intervention when volume depletion occurs are nursing PRIORITIES
Reduced perfusion is common cause of AKI
Reduced perfusion is a common cause of AKI; assess for:
Low urine output – oliguria begins within 1 day after a hypotensive event and can last 1-3 weeks
Decreasing BP
Decreasing pulse pressure
Orthostatic hypotension
Hypovolemic shock review
Abnormally decreased volume of circulating fluid causing peripheral circulatory failure
Endangers vital organs
Brain, heart, kidneys are particularly vulnerable
Tachycardia is an early sign of compensation for excessive blood loss
Tachycardia, tachypnea, BP normal initially, decrease or narrowing in pulse pressure (difference between systolic and diastolic)
elevated BP can occur initially until compensatory mechanisms fail
Acidosis with vasodilation and decreased BP, increased bleeding, decreased circulating volume, and subsequent organ death
Health promotion in the patient with AKI
Avoid dehydration by drinking 2 to 3 L of water daily, be aware of urine characteristic changes, such as sediment, hematuria (smoky or red color), foul odor, or any other worrisome changes, avoid nephrotoxic substances such as NSAIDS, antibiotics, organic solvents, chemicals like pesticides, heavy metals
Assessment of the patient with AKI
Urine characteristic changes or obstructive problems
Recent surgery or trauma
Drug history
Coexisting conditions
Acute illnesses (immunity-mediated AKI)
Anticipate AKI after hypotension or shock
Oliguria output-
<400 ml/24 hours
Anuria output-
<50 ml/day
Labs in pts with AKI
Creatinine, BUN
GFR (normal 90ml/min or higher)
Electrolyte values (K+, phosphorus, sodium)
Renal phosphate increases and calcium binds – so hyperphosphatemia with hypocalcemia
24 hour creatinine clearance
Treatment of AKI
Avoid hypotension, maintain fluid balance
Reduce exposure to nephrotoxic agents
Frequently monitor laboratory values
Closely watch I/O
Drug therapy – including diuretics to rid body of retained fluid, waste products (Lasix (furosemide), Mannitol)
Nutrition therapy
Kidney replacement therapy (intermittent versus continuous)
Why is nutrition therapy needed in AKI?
Patients with AKI often have high rate of catabolism (protein breakdown). Rate of protein breakdown correlates with the severity of uremia and azotemia (increase presence of nitrogenous wastes in blood). Parenteral nutrition may be indicated because patient is too ill.
Signs of uremia-
n/v, anorexia, headache, dizziness, coma, death
Nutrition needs in pts with AKI
Several kidney specific supplements that are lower in sodium, potassium and phosphorus but high in calories. Lower protein, carbs increased. Goal is to provide sufficient nutrients to maintain or improve nutrition status, preserve lean body mass, restore or maintain fluid balance and preserve kidney function
Azotemia –
build up of nitrogen based wastes
Uremia –
azotemia with symptoms
Key features of uremia
Metallic taste in mouth
Anorexia
N/V
Muscle cramps
Uremic “frost” on skin
Itching – caused by uremic frost, and excess phosphorus
Fatigue and lethargy
Hiccups
Edema
Dyspnea
Paresthesias
Albumin in the urine is a marker of __ __, whereas GFR reflects __ __.
kidney damage, kidney function
Teach patients with mild CKD:
carefully managing fluid volume, blood pressure, electrolytes, and other kidney damaging diseases by following prescribed drug and nutrition therapies can slow progression to end-stage kidney disease.
Stage 1 CKD
Patient may have normal GFR >90 but have abnormal urine findings, structural abnormalities or genetic traits that point to kidney disease
Patient is at increase risk for kidney damage from infection, pregnancy, dehydration, and hypotension
Careful management of conditions such as diabetes, hypertension, and hear failure can slow onset and progression
Stage 2 CKD
GFR reduced ranging between 60-89
Albuminuria may be present
Kidney nephron damage has occurred.
There may be slight elevations in BUN, serum creatinine, uric acid, and phosphorus
Stage 3 CKD
GFR reduction continue and ranges between 30-59
Albuminuria usually present
Nephron damage greater and azotemia reflecting poor waste elimination is present
Stage 4 CKD
Waste elimination poor
GFR 15-29
Manage complication
Educate about options for renal replacement therapy
Stage 5 CKD
End stage kidney disease (ESKD)
GFR <15
Kidneys cannot maintain homeostasis
Waste elimination poor and without kidney replacement therapy death will result
Systemic changes associated with CKD:
Metabolic changes
Electrolyte changes
Early stages hyponatremia, later stages hypernatremia
Hyperkalemia – late stage during diuresis - hypokalemia
As more nephrons are lost – METABOLIC ACIDOSIS
KUSSMAUL respirations – increases with worsening kidney disease
Respiratory system tries to adjust or compensate for increased blood hydrogen, acidosis or decreased pH by increasing rate and depth of breathing causing further acidosis, particularly severe in DKA
Systemic changes associated with CKD: cardiac changes
Hypertension
Hyperlipidemia (increased triglyceride, total cholesterol, and LDL)
Heart failure
Pericarditis
Hematologic/immunity changes
GI changes
Cognitive and functional changes
CKD incidence
African-Americans are nearly 3X as likely to develop kidney diseases than white populations. Kidney disease linked to HTN.
Health promotion and maintenance in pts with CKD
Control diseases that lead to CKD, dietary adjustments, weight maintenance, smoking cessation, exercise, limitation of alcohol
CKD teaching
Teach adults treated for an infection anywhere in the kidney/urinary system to take all antibiotics as prescribed. Urge adults to drink at least 2 L of water daily unless a health problem requires fluid restriction. Caution adults who use NSAIDs to use the lowest dose for the briefest time period because these drugs interfere with blood flow to the kidney. High-dose and long-term NSAID use reduces kidney function.
CKD assessment
Weight and height
Daily weights, use same scale, same time of day
Medical history, especially of kidney or urologic origin
Drug use
Dietary habits
GI and GU problems
Energy level
Physical assessment/signs and symptoms in CKD
Neurological and sensory changes
Fluid overload
Tachypnea and hyperpnea
Anemia, abnormal bleeding
Foul breath, mouth inflammation or ulceration
Osteodystrophy
Protein, sediment, or blood in urine
Skin discoloration or uremic frost
CKD assessment
Laboratory assessment
Various blood and urine tests
GFR estimated from serum creatinine, age, gender, race, and body size
Imaging assessment
x-ray findings
Kidney or CT scan
Patients with CKD are at risk for;
fluid overload, decreased cardiac function, and weight loss due to inability to ingest, digest, or absorb food and nutrients as a result of physiologic factors, potential for infection, injury, fatigue, anxiety, depression
Erthropoietin
EPO and reduced RBC production decreased. Risk for anemia
Patient may be prescribed Erythropoietin-Stimulating Agents such as:
Epoetin Alfa (Epogen or Procrit) injection
Signals bone marrow to make more RBCs
Monitor Hgb levels – do not give if over 13g/dL
Common drugs used in CKD
Loop Diuretics – Lasix
Vitamins and minerals
Combo bicarb, insulin, glucose if K+ rises too high
Folic acid, iron supplements
Erythropoietin Stimulating Agents – Epogen (anemia), decreases need for blood transfusion
Managing acidosis
Sodium bicarb or calcium carbonate to correct mild acidosis
Oral phosphorus binding agents to lower serum phosphate levels such as calcium carbonate or calcium acetate)
Aluminum hydroxide for acute hyperphosphatemia
Vit D supplements to improve calcium absorption
Kidney replacement therapy
Used for patients with loss of kidney function and inadequate waste elimination. Indications: uremia, persistent or rapidly rising high potassium levels (greater than 6.5), severe metabolic acidosis (ph less than 7.1), or fluid overload that inhibits tissue perfusion. If AKI occurs with drug or alcohol intoxication, KRT can also remove toxins
Hemodialysis
Most commonly done on intermittent basis. Can be done on inpatient, mostly done on outpatient in a dialysis center. Often done 2-3 times per week – takes approx. 4 hours. Most commonly, patient has a fistula for access. A dialysate and blood flow in opposite directions. The dialysate contains a balanced mix of electrolytes and water resembling human serum. Circulating process continues removing wastes. Blood clotting can occur during the procedure and anticoagulation, usually heparin is delivered into the blood circuit via a pump
Vascular access for dialysis
Temporary catheter is placed in a central vein, most often internal jugular. Long term dialysis catheter may be placed by interventional radiology
Intermittent done at bedside. Most units are portable and a dialysis machine is brought to the unit
Continuous Kidney Replacement (hemofiltration)
is an alternative method for removing wastes ad restoring acid-base balance and fluid and electrolyte balance. Continuous Kidney Replacement is done over 12-24 hours. Hospitalized patients are too unstable to tolerate changes and may be in ICU
Dialysis disequilibrium syndrome –
headache, N/V. changes in LOC – thought to be caused by rapid reduction in electrolytes
Assessment of the pt receiving hemodialysis
Weight, VS, orthostatic hypotension, vascular access device, LOC, headache, N/V, labs, dialysis disequilibrium syndrome, cardiac symptoms, signs of infection
Peritoneal Dialysis (PD) route
Siliconized rubber catheter placed into abdominal cavity for infusion of dialysate. Types of PD (selection depends on patient’s ability and lifestyle)
Continuous ambulatory
Multiple-bag continuous ambulatory
Automated
Intermittent
Continuous-cycle
Peritoneal Dialysis (PD)
Usually infused by gravity into peritoneal space over a 10-20 minute period according to patient’s tolerance. Fluid stays in the cavity for a specified time prescribed individually for each patient by the nephrologist. Then fluid flows out of the body (drains) by gravity into a drainage bag. Peritoneal dialysis occurs through diffusion and osmosis across the semipermeable peritoneal membrane and capillaries. There are also machines that can perform peritoneal dialysis including at home machines.
Automated Peritoneal Dialysis
Permits in-home dialysis during sleep, allowing the patient to be dialysis free during waking hours. The incidence of peritonitis is reduced with APD because fewer connections and disconnections areneeded. Also, APD can be used to deliver larger volumes of dialysis solution for patients who need higher clearances.
Intermittent peritoneal dialysis (IPD)
combines osmotic pressure gradients with true dialysis. The patient usually requires exchanges of 2 L of dialysate at 30- to 60-minute intervals, allowing 15 to 20 minutes of drain time. For most patients, 30 to 40 exchanges of 2 L three times weekly are needed. IPD treatments can be automated or manual.
PD complications
Peritonitis
Pain
Tunnel infections
Poor dialysate flow
Fibrin clot formation
Dialysate leakage
Other complications
Caring for the patient receiving PD
Before treatment: Evaluate baseline vital signs, weight, laboratory tests
Continually monitor patient for respiratory distress, pain, discomfort
Monitor prescribed dwell time, initiate outflow
Observe outflow amount and pattern of fluid
Kidney transplant
Candidate selection criteria
Free of problems that might raise procedural risk
Certain conditions preclude kidney transplant
Donors
Available kidneys matched based on tissue similarity between donor and recipient
Organs from LRDs have highest rates of kidney graft survival
Physical criteria must be met
Kidney transplant pre-op care
Immunologic studies
Dialysis 24 hours before surgery
Kidney transplant complications
Many complications possible after kidney transplantation. Early detection and intervention improve the chances for graft survival.
Rejectionis the most serious complication of transplantation and is the leading cause of graft loss. A reaction occurs between the tissues of the transplanted kidney and the antibodies and cytotoxic T-cells in the recipient’s blood.
These substances treat the new kidney as a foreign invader and cause tissue destruction, thrombosis, and eventual kidney necrosis.
Lifetime anti-rejection medication.
Post op care of kidney transplant
Urologic management
Assessment of hourly urine output × 48 hours
Complications
Rejection
Thrombosis
Renal artery stenosis
Other complications
Immunosuppressive drug therapy
Goals for pt with CKD
Achieve and maintain appropriate fluid and electrolyte balance
Maintain an adequate nutrition status
Avoid infection at the vascular access site
Use effective coping strategies
Prevent or slow systemic complications of CKD, including osteodystrophy
Report an absence of physical signs of anxiety or depression
Urolithiasis
Is the presence of calculi or stones in the urinary tract. Stones often do not cause symptoms until they pass into the lower urinary tract causing severe pain. Stones are particles in the urine that occur in amounts too high to stay dissolved in the urine. Particles precipitate and form calculi
Nephrolithiasis
is formation of stones in the kidney
Ureterolithiasis
Is formation of stones in the ureter.
Stones can cause:
Pain associated with ureteral spasm is excruciating and may cause the patient to go into shock form stimulating nearby nerves
Hematuria may result from damage to the urothelial lining
If obstruction in not removed, urinary stasis can lead to infection and impair kidney function to side of the blockage
As blockage persist, hydronephrosis can result
hydronephrosis
Enlargement of kidney and possibly permanent damage
Stone formation r/t
Dehydration
Obesity
Diabetes
Gout
Calcium, vitamin D and high dose Vitamin C
Prevention of stone formation:
high intake of fluids, fruit vegetables, low consumption of protein and a balanced intake of fats and carbs
Renal Colic –
Severe pain related to stones. Sometimes sudden, unbearable pain, causes N/V, pallor, diaphoresis.
A large stationary stone may not cause pain because it is not moving, when stone reaches bladder, frequency and dysuria can occur
Urinary tract obstruction
is an emergency and must be treated immediately to preserve kidney function
Assessment of pt with calculi
Check for bladder distention
Assess pain – onset, location, description, intensity,
Pale, ashen, diaphoretic
UA – low pH is associated with uric acid and cysteine stones, high pH is associated with calcium phosphate and struvite stones
24 hour urine collection – determine whether supersaturation of common stone particles is present
Hematuria
WBC and bacteria may be present as a result of urine stasis
Serum WBC elevated
Current standard for confirmation – CT can
Assessment of pt with calculi
Check for bladder distention
Assess pain – onset, location, description, intensity,
Pale, ashen, diaphoretic
UA – low pH is associated with uric acid and cysteine stones, high pH is associated with calcium phosphate and struvite stones
24 hour urine collection – determine whether supersaturation of common stone particles is present
Hematuria
WBC and bacteria may be present as a result of urine stasis
Serum WBC elevated
Current standard for confirmation – CT can
Managing pt with calculi
Acute nursing interventions focus on promoting comfort and prevent infection and urinary obstruction
Most patient expel the stone without invasive procedures
The larger the stone and higher up in the urinary tract, the less likely to pass
When passed, should be capture if possible for lab analysis
Pain management for the pt with renal calculi
Opioids to control severe pain
NSAIDS such as ketorolac (Toradol) in acute phase may be effective
NSAIDS interfere with renal autoregulation and the risk for impairment is greater in patients with pre-existing kidney disease
Also NSAIDS increase risk for bleeding
Drug combo for stones
thiazide diuretic and allopurinol combined with high fluid intake. These increase urine volume and decree pH and help increase the excretion of the stones
Other interventions for stones
Lithotripsy – extracorporeal shock wave lithotripsy; use of sound, laser, or dry shock waves to break up the stone
Surgical management – using a stent to keep ureter open enlarging passage
Surgical removal
Preventing obstruction –
high intake of fluids and accurate I&O
Treat underlying cause –
lower calcium levels with thiazide diuretics or treat gout
Education for the pt being treated with calculi
Finish entire prescription of antibiotics
Resume usual activities
Balance regular exercise with work and rest
Return to work 2 days to 6 weeks after surgery depending on type of intervention, personal tolerance, and primary provider’s directives
Depending on type of stone – take medications
Drink at leas 3L of fluids per day to dilute potential stone-forming crystals, prevent dehydration and promote urine flow
Additional education for the pt with renal calculi
Monitor urine pH as directed, expect bruising after lithotripsy, urine may be bloody after surgery for several days, pain in the kidney or bladder region may signal beginning of an infection or formation of another stone. Report pain, fever, chills or difficulty with urination to pcp, keep follow up appointments as directed by primary care provider
Normal menses involves minor discomfort, such as:
Breast tenderness, cramping, low back pain, mood swings
Dysmenorrhea
Pain associated with menses, one of most common menstrual dysfunctions
Dysfunctional uterine bleeding (DUB)
Heavy uterine bleeding that is irregular, painless
Primary Dysmenorrhea
Hormonal, common in young women with normal menstrual function
Primary dysmenorrhea s/s
Pelvic pain that radiates to the groin
Low backache lasting 12–48 hours
Pain radiating to lower back, thighs
Diarrhea
Headache
Nausea, vomiting
Anorexia
Breast tenderness
Pain begins on first day of menses or 3–5 days before
Typically peaks 24 hours after menses begins, decreases in 2–3 days
Secondary dysmenorrhea
Related to pathology or diseases of uterus, pelvic area. More likely in women ages 30–50. Pain may occur at any time in menstrual cycle, can be severe. Dull lower abdominal pain radiating to back, down thighs. May begin early in menstrual cycle, last longer than primary dysmenorrhea pain
Endometriosis
Most common cause of secondary dysmenorrhea
Cells from endometrial tissue implant and grow outside uterus, responding to estrogen and progesterone. Mature, open, bleed each month, causing pain, fibrosis, adhesions. May occur anywhere in body, usually on organs in lower pelvis
Dysfunctional uterine bleeding (DUB)
Involves little or no pain. Profuse painless bleeding preceded by long stretches of amenorrhea. Most often associated with anovulatory cycles. Cycles produce thickened endometrial lining that begins irregular sloughing, prolonged heavy bleeding.
Primary dysmenorrhea etiology
Caused by release of prostaglandins → uterine contractions to expel menstrual fluid, tissue
Other inflammatory mediators may prolong contractions, decrease blood flow.
Pain from passage of menstrual tissue, lack of exercise, anxiety about menses
Pain may be associated with shape, position of reproductive organs
Secondary dysmenorrhea etiology
Caused by abnormalities or disease in the pelvic area, congenital malformations such as tumors, cysts, pelvic adhesions, pelvic inflammatory disease (PID), infections, cervical stenosis, uterine leiomyomas, adenomyosis, endometriosis.
Endometriosis etiology
Thought to have genetic component or related to immune dysfunction
DUB etiology
Hormonal, similar to abnormal uterine bleeding caused by uterine tumors, endometrial or cervical cancer, polyps, ovarian cysts, bleeding disorders, complications of pregnancy. Causes of abnormal uterine bleeding must be ruled out before diagnosis of DUB can be made
Dysmenorrhea risk factors
Early age at menarche
Long or heavy menstrual periods
Smoking
Family history of dysmenorrhea
Endometriosis risk factors
Menarche before age 11
Cycle length <27 days
Heavy or prolonged menses
Sedentary lifestyle
Increased dietary fat
First-degree relative with endometriosis
DUB risk factors
Age
Teens, early 20s
Approaching menopause
Stress
Extreme weight changes
Obesity
Thyroid disease
Metabolic disorders
Use of hormone replacement therapy (HRT) or some types of hormonal contraceptives
Use of intrauterine contraception (IUC) device
Prevention
Lifestyle changes may benefit patients at risk for them:
Balanced diet, avoiding sugary and salty foods
Avoiding caffeine, alcohol, cigarettes
Regular exercise and stress-relieving activities
Healthy, gradual weight loss for overweight patients
Once diagnosis has been made, prevention of future episodes depends on
Long-term maintenance of prescribed treatment regimen
Even in absence of symptoms
Focuses of care
Identify underlying cause
Reestablish functional capacity
Manage pain
Focus of care of woman with DUB
Identify, treat underlying disease, hormonal disorder
Patient to keep diary of menstrual patterns to help diagnose cause
Pharmacologic therapy for dysmenorrhea
Combined oral contraceptives (COCs), Depo-Provera, danazol, or gonadotropin-releasing hormone (GnRH) agonists to suppress ovulation
COCs and progesterone injections to relieve cramping
Nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve cramping
Selective serotonin reuptake inhibitors (SSRIs) to manage mood, help patient cope with chronic pain
Diuretics to relieve bloating
To correct menstrual irregularities
COCs for anovulatory DUB
Depo-Provera to regulate uterine bleeding
Hormonal IUCs to control irregular bleeding
Conjugated estrogens and medroxyprogesterone for heavy bleeding
Oral iron supplements to replace iron lost through bleeding
ED s/s
– Inability of male to attain or maintain erection sufficient for sexual intercourse
– May involve total or inconsistent inability to achieve erection or ability to sustain
erection only briefly
– Penis may become semi-erect but lack sufficient rigidity for intercourse
ED characteristics
– Characterized as disorder of arousal
– May or may not be associated with loss of libido
– Occurs in men of all ages
– Can be chronic, intermittent, or episodic
ED dx:
Medical diagnosis: dysfunction present ≥3 months
Psychiatric diagnosis: dysfunction present ≥6 months
ED risks
Older men affected at higher rates
– Rates for chronic or complete ED lower than those for occasional ED
ED causes:
Vascular, neurologic, urologic, endocrine, respiratory, iatrogenic, lifestyle related, psychologic, aging process
Aging process r/t ED
Less elastic collagen in penis interferes with veno-occlusive mechanism
Declining ability of skin to sense vibrotactile stimulation
Hypogonadism → decreased testosterone
Likelihood of chronic conditions that are linked to ED
Prevention of ED
▪ Regular exercise
▪ Balanced diet
▪ Healthy body weight
▪ Abstaining from tobacco, alcohol
– Mitigation of risk factors specific to particular patients
▪ Men with diabetes: maintain appropriate blood glucose levels
▪ Men with depression: seek counseling
– Many medications used to treat problems related to ED can themselves produce
erectile problems as side effect
Medications for ED
–Oral, injection into penis, or insertion into urethra
–Oral medications: sildenafil citrate (Viagra), vardenafil hydrochloride
(Levitra), tadalafil (Cialis), avanafil (Stendra)
▪ Injectable medications for ED
–Alprostodil
–Difficult to administer, used for patients who cannot take oral drugs
