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116 Cards in this Set
- Front
- Back
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What is acute renal failure characterized by?
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Rapid deterioration of renal function associated with azotemia (accumulation of nitrogenous wastes in the blood and increasing levels of serum creatinine)
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ARF is associated with....
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oliguria: however there may be normal or increased urinary output
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When does ARF usually develop?
it commonly follows what? good prognosis? |
over hours or days with average 2-4 week duration
severe hypotension, hypovolemia, or exposure to a nephrotoxic agent good! |
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What is PreRenal ARF due to?
accounts for ____% of all ARF? |
external factors to the kidneys that reduce blood flow
55-60% |
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Examples of PreRenal ARF include?
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volume depletion/hypovolemia (hemorrhage, diuretics, GI losses), impaired cardiac efficiency l/t decreased cardiac output ( MI, CHF, dysrhythmias), decreased peripheral resistance or vasodilation (sepsis, anaphylaxis, antiHTN meds)
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What is InraRenal ARF due to?
accounts for ____% of all ARF? |
due to conditions that cause direct damage to the renal tissue resulting in impaired nephron function. Due to prolonged lack of blood supply or ischemia, nephrotoxins, myogloblin from dead muscle cells, or Hgb released from hemolytic RBCs.
35-50% |
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What are some common nephrotoxins that we expose hospital pts to?
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aminoglycosides ABx (neomycin, tobramycin, gentamicin), NSAIDs (ibprofen excedrin), and contrast medium
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Examples of IntraRenal ARF include?
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prolonged ischemia >2hr (surgery, severe hypovolemia, sepsis, trauma, burns), nephrotoxins, myoglobin (muscle trauma, infection), hemoglobin (tranfusion reactions), Acute Tubular Necrosis from ischemia and neprotoxins
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What is PostRenal due to?
accounts for ____% of all ARF? |
-involves mechanical obstruction of urinary outflow. As the flow of urine is obstructed, urine rfefluxes into the renal pelvis impairing kidney function.
<5% |
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Examples of PostRenal ARF include?
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Prostate cancer, BPH, urinary tract calculi, and extrarenal tumors.
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In the Oliguric phase what occurs?
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It's the 1st phase: starts with time of insult to s/s appear: caused by reduction of GFR with signs of oliguria. Duration of phase is 10-14 days. It's the most dangerous phase.
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What occurs in the oliguric phase?
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there is salt/water retenton (FVE): which can lead to CHF. There is metabolic acidosis: b/c kidneys cannot synthesize ammonia; pt develops Kussmauls resp. Serum K+ increases: may lead to cardiac arrest
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CRF: what is evident?
UA____ Specific gravity____ BUN_____ Creatinine_____ Creatinine clearance_____ K+_____ Na+_____ Phosphates_____ Ca+_____ Bicarb_____ Magnesium_____ |
excess protein, RBC, & casts
fixed @ 1.010 high as 200 mg/dl > than 4 falls below 5-10mL/min K+ is elevated Na+ is decreased Phosphates are Increased Calcium is decreased Bicarb is decreased Magnesium is increased |
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What is evident with CRF in a CBC?
RBC____ platelet____ Hct & Hgb_____ |
decreased RBC d/t hematuria, decreased RBC lifespan, inability of kidney to secrete erythropoitin.
platelets, Hgb, Hct are also reduced |
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Normal phosphate levels?
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3.0-4.5mg/dl
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Normal magnesium levels?
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1.5-2.5mEq/L
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Normal serum creatinine levels?
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0.6-1.2mg/dl
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If a pt dies from ESRD, what is the likely cause of death?
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congestive heart failure
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What is the dx of renal insufficiency?
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A pt who is not in ESRD but has a glomerular filtrate rate GFR that is 20-50% of normal, whose BUN and creatinine are elevated and who is showing some clinical signs of fluid alterations such as edema & oliguria with azotemia
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What is the last stage of CRF?
characteristics? |
ESRD End stage renal disease
kidney failure where at least 90% of functioning nephrons are lost and the GFR falls to below 5% of normal or below 15ml/min. Pt presents with uremia and renal replacement is necessary |
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In order place the highest causes of CRF
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1. DM 32%
2. HTN 28% 3. Glomerulonephritits |
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What does the MD order if a client is oliguric or anuric?
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Orders a fluid challenge
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What is a fluid challenge test?
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A way to determine if there is adequate intravascular volume to ensure adequte perfusion to the kidneys
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What does a fluid challenge entail?
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The pt is prescribed a 500cc bag of NS to be given IV over 4 hrs or less.
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What does increased output mean after a fluid challenge is started?
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The pt is oliguric or anuric because of dehydration.
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What does no increase or change in output suggest?
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May suggest further workup but not until a second bag of IV is infused. Also, a diuretic is prescribed.
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When is Continuous Renal Replacement therapy an option?
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For those is ARF but are hemodynamically unstable. The procedure entails continuous but slow removal of excess fluid and waste products.
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In ARF, what fluid intake is allowed?
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It must be closely monitored. Fluid restrictions to 500 or 600ml plus the previous 24hr urinary output.
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Daily caloric intake is maintained to about ____ to prevent catabolism and further waste accumulation.
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30-35kcal/kg
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What is the most serious complication of ARF?
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Infection, which affects about 30-70% of pts with ARF
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How should one help protect infection?
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Nurse should monitor the pts WBC and temp, provide meticulous skin care including IV care site, provide good pulmonary hygiene, handwashing, avoind unnecessary punctures and caths.
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Who is at high risk for developing ARF?
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those with prolonged hypotension or hypovolemia; those on nephrotoxic drugs, contrast materials, surg pts, elderly, those with calculi/prostate problems
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1lb of weight gain is equal to _____ ml of fluid gained
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500ml
1lb=500ml |
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To control HTN in CRF, which is the drug of choice??
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ACE Inhibitors ie. "prils"...Lisinopril, Catopril, Accupril
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How is metabolic acidosis managed? and why?
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to prevent CV effects such as weak cardiac contractions; lungs try to blow off excess CO2 by Kussmaul's resp; TX by giving sodium bicarbonate or calcium carbonate, or if severe by dialysis
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How is hyperkalemia treated?
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Life-threatening!
A level > than 7 or 8 can lead to fatal cardiac arrythmias: Give KAYEXALATE; mouth or enema. Other: admin of dextrose with regular insulin temp allow excess K+ to go back into the cells, dialysis, low K+ diet |
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What are some examples of potassium rich foods?
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Salt substitutes, baked potato with skin, cantaloupe, bananas, and OJ.
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How much should phosphorus be limited to?
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Less than 1000mg/day
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What are some examples of Phosphorus foods?
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meat, eggs, and dairy products
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What drugs can help lower
phosphate levels? Lowering the phosphate will increase what? |
Phosphate binders such as PhosLo, Tums, and Renagel will bind when taken with meals and they are excreted in the stool.
Calcium levels |
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What improve calcium levels?
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Vitamin D supplements
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How does one help with hypermagnesemia?
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Avoid magnesium -containing antacids & laxatives such as MOM.
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Management for excess BUN/creatinine levels
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Restrict proteins, choose high biological proteins (meats), increase carb intake (prevents gluconeogenesis: a compensatory process in the liver that will generate more proteins, and REST: decreases metabolism by decreasing waste product accumulation
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How is anemia treated?
Name 2 erythropoietin drugs that can increase RBC and provide more energy? |
Folic acid which is necessary for RBC production and iron supplements.
Procrit and Epogen |
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Excess Fluid Volume r/t....
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inability of the kidneys to excrete fluid
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Risk for Injury r/t.....
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fractures AEB alterations in Calcium and Phosphorus metabolism
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Activity Intolerance r/t....
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bedrest and decreased energy secondary to decreased RBC
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Imbalanced Nutrition < than body requirements r/t......
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dietary restrictions
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Anticipatory grieving r/t......
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prognosis
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Risk for Infection r/t......
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decreased immune function
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Risk for peripheral neuropathy r/t ......
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the effects of uremic toxins and loss of Vitamin B from dialysis
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When is dialysis indicated?
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the need to correct f/e imbalances and to remove waste products in renal failure:
Need to correct Fluid Volume Overload, uncontrolled HTN, pericarditis, and hyperkalemia. |
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What is in dialysate?
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sodium chloride, sodium acetate, calcium chloride, and water.
There is no urea or creatinine |
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In order to remove extra fluid from the pt with ESRD, the dialysate is prepared how??
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hypertonic: high concentration
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When is an AV fistula availble to use once implanted?
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6-8 weeks
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What is the preferred access site for dialysis? why?
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AV Fistula; because it is least prone to clot and have infection
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What are AV Grafts comprised of? any issues?
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Synthetic materials that form a brifge b/w an artery and vein. It is under the skin and accessed using 2 14-15 gauge needles.
They become easily infected 7 have tendency to clot. |
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What advantage does the AV graft have over the AV Fistula?
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It can be used within 1-2 weeks
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What type of vascular access is used for a quickly needed site?
name examples? |
Temporary access sites: they are special catheters with 2-3 lumens that are inserted into the subclavian, jugular, or femoral vein.
Quinton and Tessio |
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Which needle is used to pull blood from the pt and send it to the dialyzer with the assistance of a blood pump?
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The needle closest to the Fistula or Graft
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What effect does Heparin have with dialysis?
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it is added to the blood as it flows into the dialyzer to prevent blood clots from forming. Once the blood enters the extracorporeal circuit, it is propelled through the dialyzer by a blood pump at a flow rate of 20-500ml/min while the dialysate which is warmed to body temp circulates in the opposite direction at a rate of 300-900ml/min
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Blood is returned from the dialyzer to the pt via the ______line through the ______ needle
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venous line; second
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What are common symptoms the pt feels after dialysis?
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HA, N/V, dizziness, muscle cramps, & feeling washed out
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What do the VS show after dialysis? weight?
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1. Slight increase in temp due to dialysate
2. Slight increased pulse rate 3. Low BP due to loss of fluid volume weight loss expected |
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What is disequilibrium syndrome?
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seen in those just starting HD; due to rapid decrease in ECF composition including BUN levels causing cerebral edema which leads to HA, N/V, restlessness, twitching and jerking, dec LOC, seizures, death
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What are manifestations of disequilibrium syndrome?
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HA, N/V, restlessness, twitching and jerking, dec LOC, seizures, death
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How to you treat disequilibrium syndrome if detected early?
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pt is given antiseizure meds or barbiturates but it is best prevented by doing low flow and short periods of HD for new pts.
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Why does hypotension occur in HD?
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from rapid fluid removal, decreaed cardiac output, and decreased vascular resistance.
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How to you prevent and treat hypotension in HD and what are the s/s?
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Light headedness, NV, seizures, and vision changes.
Prevent by decreasing the volume of fluid being removed and infusing 100-300ml of NS. Prevented by holding anti-HTN meds prior to HD |
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How do you increase vascular volume?
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Trendenlenburg position and NS infusion
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What is the treatment for bleeding from heparinization?
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Protamine sulfate
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How do you treat leg muscle cramps from the rapid removal of Na & H2o or neuromuscular hypersensitivity?
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Reduce the ultrafiltration rate and admin hypertonic or NS bolus and pt instructed to stretch legs
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Why use the peritoneum for PD? how is waste and fluid removed?
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it is rich in capillaries and has a large surface area
by osmosis and diffusion |
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Who is good candiates for PD?
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those with vascular access problems, who cannot tolerate heparinization, the elderly, and those who are hemodynamically unstable
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Is there a waiting period before the start of a new PD? any instructions?
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7-14 days; to ensure the proper sealing of the catheter and allow for tissue to grow into the cuffs.
daily care : antiseptic solution and a clean dressing |
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What are the 3 phases of PD?
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Fill (inflow)
Dwell (equilibrium) Drain |
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During inflow (Fill) how long is the prescribed dialysate solution infused for?
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10 minutes
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What is the dialysate bag contain in PD? can meds be added to the solution?
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a hypertonic solution wtih glucose used as the osmotic agent
yes, like heparin to prevent fibrin clots or those with peritonitis. ABx and insulin |
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What happens after the 10 min inflow phase?
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The clamp is closed and the dwell phase begins.
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What occurs during the Dwell phase? and how long does it last for?
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Electrolyte and fluid movement b/w the pts blood and the peritoneal cavity occur by osmosis and diffusion.
Lasts 20-30minutes for manual but can last up to 8 hrs depending on PD method used. |
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How long does the Drain period last for?
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It takes about 15-30 minutes and the outflow contains the dialysate plus excess wastes, electrolytes, and nitrogenous wastes from the pt. Then the cycle begins with another infusion of a dialysate solution.
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What is the most common type of PD technique?
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CAPD- Continuous Ambulatory Peritoneal Dialysis: where four 2L of exchanges are dones daily using no machine and the dialysate remains in the peritoneal cavity for 4-10 hours.
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Name an osmotic diuretic?
loop diuretic? |
Mannitol
Lasix |
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What should the dialysate look like after the equilibrium period?
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clear and light yellow
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What is the major complication of PD?
what are the s/s? treatment? |
Peritonitis: results from contamination of the dialysate or tubing, or bacteria.
cloudy effluent, fever, abd pain, malaise, N/V, hyperactive bowel sounds Tx: ABx |
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What causes abdominal pain in PD? alleviated how?
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from the low pH of the dialysate, peritonitis, intraperitoneal irritation, and catheter placement
-change cath position, ,decrease the infusion rate and warming of solution |
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Can pulmonary complications arise and why? prevent?
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Yes, atelectasism pneumoniam abd bronchitis from repeated upward displacement on diaphragm, resulting in decreased lung expansion....from longer the dwell time
freq repositioning and deep breathing, elevate HOB |
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What about protein loss in PD?
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Since the peritoneal membrane is permeable to protein, amino acids, and ploypeptides they can be lost in the dialysate fluids. Eat adequate protein...can lose up to 5-15 g/day!
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Is hyperglycemia common in PD?
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Yes, due to the use of glucose as the osmotic force in the dialysate. It can lead to increased insulin secretion which stimulates the production of triglycerides.
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What if the pts BG is elevated?
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Amino acid solution may be used in the dialysate or insulin is added
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What position is best for pt with a hernia repair using PD?
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Supine: also use small dialysate volumes!
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What can relieve an outflow problem from a kink with PD?
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a bowel evacuation
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What are the advantanges of PD over HD?
*note* |
-eliminates vascular access and heparinization
-avoids rapid fluctuation in ECF -diet/fluid intake is more liberal (since wastes are removed on a daily basis) -client more able to self-manage -training less complex However, HD is preferred for more immediate results! |
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What is the tx choice of ESRD?
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Renal transplant
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What is considered a perfect match in renal transplant?
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If they have 6 antigens in common, with HLA being the most important determinant of compatibility
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Who has more pain but less time in OR?
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donor
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When does acute rejection occur and what is it signified?
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takes place within 3 months
-oliguria or anuria, increase in temp and BP, enlarged and tender kidney, lethargy, increased BUN and creatinine levels and fluid retention |
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To prevent rejection, what is the pt placed on?
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Immunosuppressive drug therapy ie. Cytoxan, Sandimmune, and corticosteriods
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When does chronic rejection occur? tx?
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takes months to years and the pt slowly manifests signs caused by gradual occlusion of the renal vessels.
no tx: but can resume dialysis or another transplant |
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What can long-term use of Immunosuppressive drug therapy ie. Cytoxan, Sandimmune, and corticosteriods lead to?
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infection: teach to avoid crowds & see MD for early signs of fever, sore throat, or malaise
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What is chronic pyelonephritis usually a result from?
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A long standig UTIs with relapses and reinfections
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How many liters or gallons of blood does are kidneys process?
How much urine is excreted daily? |
180L or 47 gallons
1500ml/day |
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What are the functions of the kidneys?
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Main: to regulate the volume and composition of the ECF volume and excrete waste from the body
-control BP -produce erythropoietin -activate Vit D -regulate acid-base balance |
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What does Aldosterone do?
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it's a hormone that causes the tubules of the kidneys to retain sodium and water. This increases the volume of fluid in the body, and drives blood pressure up.
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Name a potassium sparring diuretic?
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Spironolactone: conserve potassium
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What color is the skin with a ESRD pt?
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yellowish gray to pale from anemia
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What area is percussed to determine possible glomerulonephritis or pyelonephritis?
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The CVA is percussed for pain
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What occurs in the elderly when the kidneys have less ability to concentrate urine?
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nocturia
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A low BUN level could indicate what?
and high? |
Fluid excess
high is dry-dehydration |
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What is a cystogram?
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a radiologic study where a contrast material (NOT nephrotixic) is instilled in the bladder via a cystoscope or a catheter: purpose to visualize the bladder and assess injury.
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What are the requirements if one is to have a percutaneous renal biopsy?
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must have 2 kidneys, shoud tolerate prone position for 30-45 minutes and suspend breathing
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What does one see in a pt with nephrotic syndrome ?
in a blood chemistry? |
Edema, massive proteinuria, HTN, hyperlipedemia, & hypoalbuminemia
Decreased serum albumin, decreaed serum protein (ascites and anasarca), and elevated cholesterol. |
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What 2 things can occur in nephrotic syndrome from proteinuria?
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Hypercoagulability and thromboembolism (renal vein esp) or PE
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How to treat nephrotic syndrome?
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Edema: ace inhibitor, NSAIDs, low sodium 2-3g, low/mod protein 0.5-0.6g/kg/day
hyperlipidemia: Colestid or Mevacor |
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What is a berry aneurysm?
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a vascular cyst that can rupture and cause sudden death with there is a severe HA
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What does PKD lead to?
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results in CRF
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