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68 Cards in this Set
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ESRD Nursing Diagnosis: Non-adherence
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* Management = coping strategies
- allow control and independence - choice of clothing or food - counseling and support groups - keep open channels of communication * These people can commit suicide very easily. Only need to drink too much OJ |
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ESRD Nursing Diagnosis: Alteration in family process
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* Management
- teaching and patience - support groups and community resources - anticipatory guidance - treat the depression (suicide) - return to work and/or school |
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ESRD Nursing Diagnosis: Fluid Volume Excess
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* Assessment
- dry weight vs weight gain - peripheral edema, CHF, pulmonary edema * Management - Na (2g) restriction - H2O (500 cc and UOP) restriction - treat thirst: ice chips, oral care, lip balm - IF IV: place on pump at KVO rate |
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Information concerning dry weight
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- normal body weight without any fluid
- 1 lb = 500 cc |
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How is the goal of dialysis met?
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- Dry weight gives a goal for the dialysis procedure
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How is the fluid restriction amount determined?
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500 cc plus the UOP from the day before
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What is KVO
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- Keep vein open
- 20-30 cc/hr |
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When are diuretics often not used?
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In Stage 5 ESRD
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Fluid Volume Excess assessement
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- BP: might be giving BP meds with ESRD
- Daily weights - Strict I&O - Monitor serum Na |
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Dilutional Hyponatremia
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Na elevation in relation to water: equal Na in equal water. The pt may have too much Na, but if they also have too much water, it will measure as normal
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ESRD nursing diagnosis: decreased cardiac output
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* r/t rhythm disturbances of hyperkalemia
* Management: - limit K in diet (no salt substitutes) - Avoid or treat early catabolic states - No K in IV - Limit fat in the diet |
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Hyperkalemia can result from:
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- increased K in the diet
- acidosis - cellular catabolism or trauma - K containing meications |
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Decreased Cardiac Output leads to:
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- MI, CHF, LVF, pulmonary edema and cardiac arrest
- EKG will have TALL T WAVES |
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What causes pericarditis?
What is it? |
- Azotemia causes pericarditis
- A condition where fluid is able to enter between the heart and the sack of the hear. This causes a friction rub sound. This sound will diminish the more fluid enters the sac. It will sound as though the problem is being resolved, when really the problem is only getting worse. The heart will be compressed by the fluid and will not be able to pump blood effectively. |
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What is a side effect of Kayexalate?
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Increased levels of Na
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What protects the heart form high levels of potassium?
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- Calcium gluconate
- This is given from K that is greater than 7.0 mEq |
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ESRD nursing diagnosis: potential for injury (bleeding)
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* Azotemia causes bone marrow suppression
* Management: - assess sites often and apply needed pressure for > 3 min - Limit blood drawing - Use smallest guage needle for IM - Guaiac stools and vomitus - Use soft toothbrush, electric razor, avoid contact sports, stress safety - NO ASA |
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ESRD nursing diagnosis: infection
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* Azotemia causes bone marrow suppression
* Management: - monitor lab work and C&S - asepsis: handwashing and sterile technique - diet: Vitamin C, do not increase protein - limit invasive lines |
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Considering the fact ESRD pts heal very slowly...
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you would usually increase a person's protein intake to promote wound healing. Cannot do this for a ESRD pt b/c it will increase their azotemia. Therefore, Vit C is better to increase to promote wound healing.
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Normal protein level
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6-8 g/dL
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Normal albumin level
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3.5-4.5 mg/dL
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ESRD nursing diagnosis: alteration in thought process
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* r/t
- cerebral edema and azotemia - hypoxia and anemia - depressions of brain activity and acidosis - brain calcifications * Management: - seizure precautions - avoid sedatives - frequent orientation |
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What affect to brain calcifications have in ESRD?
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- Phos likes to bind with Ca which causes crystallizations
- These move throughout the entire body - As they enter the brain, they alter normal cerebral function |
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When is the best time to perform teaching for a person with ESRD?
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- The days between dialysis
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ESRD nursing diagnosis: alteration in nutrition
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* Management:
- increase activity as tolerated - rest before meals; limit socialization - frequent mouth care (hard candy or gum) - Antacid (Ca) - high calories (35-45/kg/day) - protein controll (0.8-1.5g/kg) - limit fat - small frequent meals with bland food - vitamin supplements` |
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What kind of antacids should be given to a ESRD pt
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Antacids with Ca. Those with Mg should be avoided
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ESRD nursing diagnosis: constipation
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* r/t:
- phosphate-binding and/or iron meds - decreased intake of fluids - decreased activity and decreased peristalsis with fatigue and anemia * management: - bran for fiber - stool softener or metamucil each day - increase activity (walking) - enema (sorbital) |
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What kind of enema should be given to an ESRD pt?
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- Sorbitol enema
- no tap water b/c too much water will be absorbed - no saline b/c too much Na and water will be absorbed. - no phos b/c too much phos and water will be absorbed - sorbitol is a sugary like enema |
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ESRD nursing diagnosis: alteration in skin integrity
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* r/t:
- urea deposits and azotemia - Ca/Phosphate crystal deposits - edema * management (pruritis) - baths qod (avoid soap) - use lotions and oils - avoid scratching - turn q2hrs or increase mobility - elevate legs - cool temps - Benadryl and antipruitic meds |
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uremic frost
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the look of frost on an ESRD pt's body due to deposits on their skin
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ESRD nursing diagnosis: activity intolerance
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* r/t:
- fatigue and anemia - muscle wasting and metabolic acidosis * management: - correct anemia and acidosis - keep in an anabolic state (treat fever) - high calories - use energy conservation techniques - keep as active as possible (promote independent ADLs) |
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When should vitals be taken in relation to activity?
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before activity and 5 minutes after activity
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ESRD nursing diagnosis: impaired physical activity
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* r/t:
- joint pain and stiffness (Ca & Phos crystals) - Bone fractures * Management: - safety/fall precautions - decrease phosphates in the diet - weight bearing activities |
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Normal Ca level
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8.0 - 10.5 mg/dL
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Normal Phos level
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2.5 - 4.5 mg/dL
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How does hypocalcemia occur in ESRD?
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- Phos is in almost all foods
- In ESRD, the kidneys are not able to excrete it properly. - Phos then binds with Ca that it deactivates the Ca and causes hypocalcemia - Decreases in Vit D also causes Ca - The parathyroid hormone will then activate in an attempt to increase the Ca levels in the blood (osteoclastic activity) - Phos will then bind to the Ca. - This vicious cycle leads to crystals and bone demineralization |
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How is hypocalcmia treated in ESRD?
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- treat the Phos first and then the Ca
- The first response might be to increase the Ca in the diet, but this may cause seizures or other medical emergencies |
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In ESRD, what should be given with meals and why?
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- Phos binding meds should be given with food in an attempt to decrease the amount of Phos that can bind with Ca
- Activated Vit D (calcipherol) along with Ca to aid with Ca absorption |
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ESRD nursing diagnosis: alteration in body image
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* r/t:
- appearance (shunt, scarring, short stature) - lack of secondary sex changes and fertility - loss of sexuality * Management: - transplant and growth hormone |
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Why is there a loss of sexuality in ESRD?
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- decreased growth hormone
- lack of tissue response to GH - feel bad - decreased libido |
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Goal of dialysis
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- restore fluid balance
- balance electrolytes - control acid/base - remove waste products |
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When to pts usually feel best after dialysis?
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most pts think they will feel better after dialysis. Most feel their best the day between the dialysis treatments
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What does dialysis NOT do?
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- does not activate Vit D
- does nothing for Erythropoetin - does not deal with drug toxicity on a daily basis |
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Concepts of Dialysis
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- osmosis: water ultrafiltration
- diffusion: electrolytes - semipermeable membrane |
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ESRD Vascular Access - AV graft/fistula
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* clotting:
- check bruit/thrill q8hrs - call MD immediately - Gentle handling of exremity - No compression, IV, blood or BP * infection: - skin care and antibiotics * Pain: - 14-16 guage needles |
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Complications of Hemodialysis
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- air embolism
- thromboembolism - hemolsis - exsanguination - electrical hazards |
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Complications of Hemodialysis (Post Tx): Fluid volume deficit
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* fluid volume deficit
- plasma or blood loss - hypoalbuminemia/third spacing * Assessment - hypotension, tachycardia, restless, cool, moist skin, vomiting, low BP * Management - NO MEDS pre treatment - orthostatic hypotension prevention |
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Complications of Hemodialysis (Post Tx): bleeding
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* bleeding
- anticoagulation * Assessment: - bright red bleeding or oozing * Management: - protamine sufalte administered post procedure - pressure or pressure dressing - avoid injections or surgery post Tx |
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ESRD and anticoagulants
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- give anticoagulants so that blood doesn't clot while in the machine being dialyzed.
- This anticoagulated blood is then put back into the body. Therefore, protamine sulfate is given to counteract the heparin - If too much protamine is given and it doesn't bind with heparin, it's also an anticoagulant, so it will also cause bleeding |
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Complications of hemodialysis (Post Tx): impaired thought process
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* impaired thought process
- dialysis disequilibrium syndrome - Too fast BUN removal causes cerebral swelling * Assessment: - headache, change in LOC, seizures, convulsions, speech changes * Management: - seizure precautions - keep BUN/Creatinine low between dialysis - low stimuli environment |
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If BUN is removed too quickly during dialysis, what happens?
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- Too fast BUN removal causes cerebral swelling
- The BUN in the body will be decreased faster than the BUN in the brain - The BUN in the brain sucks in water b/c or it's osmotic pull causing swelling in the brain - This is Dialysis Disequilibrium Syndrome |
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Peritoneal Dialysis
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* Types:
- manual or automated - continuous Cyclic PD - continuous ambulatory PD * Access: - catheter into peritoneum which then acts as the semipermable membrane (dwell time) * Complications: - hyperglycemia - respiration impaired - bowel perforation |
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Complication of Peritoneal Dialysis (Post Tx): Infection
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* Infection
- peritonitis or tunnel infection - dialysate glucose and contamination * Assessment: - elevated tempt and WBC, distended, hard abdomen, pain, rebound tenderness * Management: - asepsis (sterile) - assess outflow appearance - Surgery - tunnel catheter under skin - Decrease manipulation - Cleansing with soap and water |
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Why are glucose solutions used for P-dialysis
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Because it has osmotic pull
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Transplantation - donor issues
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71,000 people in US waiting for a kidney
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Histocompatibility testing
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* compatibility of tissue based on inheritance
- Blood type match - HLA match - 6th chromosome - WBC crossmatch - mixed lymphocyte crossmatch - the closer the match, the greater chance for success and longevity |
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Graft rejection - types
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* hyperacute: B lymphocytes
- occurs within minutes * acute: T lymphocytes - 2 to 4 weeks after * Chronic: combination of B and T |
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How to identify graft rejection
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- decreased UOP
- fever > 100 (can be masked by steroids) - pain, tenderness or swelling over graft - elevated BP, edema and weight gain - malaise - serum labs: elevated BUN and Cr - Anxiety |
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What is the major reason for organ failure in transplants?
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Graft rejection
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Because steroids can mask temp, what is the best way to see if there's trouble with the new kidney?
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Palpation
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Prednisone
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- immunosuppressant and anti-inflammatory
- inhibits T cell proliferation and lysis antigen-activated lymphocytes - synthetic hormone: adrenal corticosteroid |
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Prednisone teaching
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- administer with AM meals
- slowly taper off - must be taken for life of graft. - Will start off with a large dose and taper down to a lower dose |
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Side effects of prednisone
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- infections (wear a mask)
- weight gain and fat deposits - emotional changes - insomnia - salt and water retention (edema and HPT) - acne, bone problems, cataract, stomach ulcers and bleeding, diabetes, delayed wound healing and straie |
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Imuran - Azathioprine
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- interferes with DNA and protein synthesis
- depresses bone marrow and blocks antibody reproduction (very toxic) - affects B and T cell proliferation |
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Imuran side effects
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- infection
- leukpenia - hepatotoxicity - Thrombocytopenia - mouth ulcers - pancreatitis |
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Imuran medication
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Mycostatin mouth wash
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Cyclosporine and Tacrolimus
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Acts on helper T lymphocytes activity by suppressing interleukin-2 which suppresses cytotoxic T cells and cell-mediated B cells
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Cyclosporine and Tacrolimus side effects
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- infection
- hypertension - neurotoxic (tremors) - hepatotoxic - nephrotoxic |
