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63 Cards in this Set

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Describe the stages of CRF and identify the criteria for End Stage Renal Disease (ESRD).
There are 5 stages of CRF and they are defined based on the level of kidney function. Stage 1 is described as kidney damage with a GFR ≥90. Stage 2 is described as kidney damage with a GRF of 60-89. Stage 3 is described as a moderate ↓ in GFR (30-50). Stage 4 is described as a severe ↓ in GFR (15-29). And finally stage 5 is described as kidney failure with a GFR <15.
The criteria for ESRD is a GFR of less than 15ml per minute.
How does the uremia of CRF affect the following systems and processes
Uremia is a term applied to the manifestations of organ dysfunction seen in stages 3 and 4 as outlined above. Literally, uremia means urine in the blood. Azotemia, the accumulation of nitrogenous waste products, chiefly urea, in the blood is the hall mark of renal failure. It is a clinical syndrome resulting from retention of certain substances which are normally excreted into the urine and thus accumulate causing toxicity
at clinical manifestations does it cause in the following systems; urinary, metabolic, hematological, CV, respiratory, GI, neurological, musculoskeletal, integumentary, reproductive, endocrine, psychological functioning.
Urinary system: polyuria then oliguria

Metabolic: nausea, vomiting, lethargy, fatigue, impaired thought processed, headaches, hyperglycemia, hyperinsulinemia, and abnormal glucose tolerance.

Hematologic: anemia, GI bleeding

CV: hypertension, peripheral edema, CHF, pulmonary edema, cardiac arrhythmias, uremic pericarditis, pericardial effusion, cardiac tamponade

Respiratory: Kussmaul respiration, dyspnea from fluid overload, pulmonary edema, uremic pleuritis (pleurisy), pleural effusion, and uremic pneumonitis

GI: mucosal ulcerations, stomatitis, a metallic taste in the mouth, uremic fetor ( a uruinous odor of the breath), anorexia, nausea, vomiting, weight loss, malnutrition, diarrhea, constipation

Neurological: lethargy, apathy, decreased ability to concentrate, fatigue, irritability, altered mental ability, seizures, coma, peripheral neuropathy, muscular weakness, atrophy, loss of deep tendon reflexes, muscle twitching, jerking, asterixis, leg cramps

Musculoskeletal: uremic red eye, gangrene

Integumentary: yellow-gray discoloration of the skin, also pale skin due to anemia, dry and scaly skin, decreased perspiration, pruritus, itching, “uremic frost”, brittle hair, thin, brittle and ridged nails, petechiae and ecchymoses

Reproductive: infertility, decreased libido, anovulation, amenorrhea, impotence, anorgasmy

Endocrine: hypothyroidism

Psychologic: personality and behavioral changes, emotional lability, withdrawal, depression, fatigue, lethargy
What are the goals of conservative care and discuss the rationale and precautions necessary for the drugs used in CRF?
The goals of conservative therapy are to preserve existing renal function, treat the clinical manifestations, prevent complications, and provide for the patient’s comfort.
Medications for hyperkalemia
include Kayexalate. This medication exchanges sodium ions for potassium ions in order to lower the potassium level. The patient should be observed for sodium and water retention and some diarrhea is normal.
Medications for hypertension
include diuretics, B-adrenergic blockers, calcium channel blockers, and ACE inhibitors. Diuretics lower the volume of blood the heart has to pump thereby lowering BP, B-adrenergic blockers lower CO and HR, calcium channel blockers relaxes and prevents coronary artery spasm and reduces myocardial oxygen utilization and supply, and ACE inhibitors inhibit the release of angiotensin-converting enzyme.
Precautions include measuring BP periodically in different positions.
Medications for osteodystrophy
include Calcium-based phosphate binders and calcium acetate. These meds are used to bind phosphate, which is then excreted in the stool. Another med used is Sevelamer which also binds phosphate but does not contain calcium or aluminum and has the added benefit of lowering cholesterol and LDL’s. Precautions include possible constipation.
Medications for anemia include
Epogen, Aranesp, and Procrit which work by stimulating RBC production. Some adverse effects are the development or acceleration of hypertension, and the development of iron deficiency. Supplemental folic acid should be given because it is needed for RBC production.
Drug toxicity
Drug toxicity is a major problem with CRF because of the delayed or decreased elimination of medications. Drug doses may be altered depending on kidney function. Also some medicines are nephrotoxic and can speed up the kidney damage.
Describe and give the rationale for the dietary modifications necessary in the treatment of CRF.
Protein restriction is needed so as not to add to the waste product of protein (BUN) in the body.
Water restriction is dependent upon the patients daily urine output. The fluid restriction is calculated by adding 600ml to the previous days urine output.
Sodium and potassium restriction depends on the degree of edema and hypertension but usually ranges from 2-4g.
Phosphate restriction is required because by reducing the intake of phosphate, calcium has less to bind with and creates less metastatic calcifications deposited around the body.
Develop a teaching plan for the patient with CRF.
1. Explain dietary and fluid restrictions.
2. Encourage discussion of difficulties in modifying diet and fluid intake.
3. Explain signs and symptoms of electrolyte imbalance, especially high potassium.
4. Teach alternative ways of reducing thirst, such as sucking on ice cubes, lemon, or hard candy.
5. Explain the rationale for prescribed drugs and common side effects. Examples: phosphate binders should be taken with meals and Iron supplements should be taken between meals.
. Explain the importance of reporting any of the following:
Weight gain >4lb.
Increasing BP
Shortness of breath
Edema
Increasing fatigue or weakness
Confusion or lethargy
is the common vascular access sites used for HD?
The common vascular access sites used are arteriovenous fistulas (AVFs), and grafts (AVGs), temporary and semipermanent catheters, subcutaneous ports, and shunts.
The patient with cardiomyopathy, pulmonary edema, and severe dyspnea is placed on dobutamine, which of the following assessment indicates improvement?
) Increase activity tolerance
What condition is linked to more than 50% of patients with abdominal aortic aneurysms?
Hypertension
Which condition most commonly causes cardiogenic shock
Acute myocardial infarction (MI)
After a myocardial infarction, there is an increase in serum glucose levels and free fatty acid production. What type of physiologic changes are these?
Metabolic
After undergoing a cardiac catheterization, the patient has a large puddle of blood under his buttocks. Which steps should the nurse take first?
Apply gloves and assess the groin site
Which group of symptoms indicates a ruptured abdominal aortic aneurysm?
Decreased blood pressure, decreased RBC count, increase WBC count, and severe lower back pain,
When assessing a patient for an abdominal aortic aneurysm, which area of the abdomen is most palpated?
Middle lower abdomen to the left of the midline
What condition is most commonly responsible for myocardial infarction (MI
Coronary artery thrombosis
Which class of medication increases ventricular contractility and maximizes cardiac performance in patients with heart failure ?
notropic agents
Which types of angina is most closely associated with an impending myocardial infarction (MI)?
 
Unstable angina
For the patient with unstable angina who receives topical nitroglycerin, the nurse is a aware that the next dose should be held if the patient has:
Systolic blood pressure less than 90
What is the most common cause of an abdominal aortic aneurysm?
Atherosclerosis
Which artery primarily feeds the anterior wall of the heart?
Left anterior descending artery
Which invasive procedure is necessary for treating cardiomyopathy after medical treatment has failed?
Heart transplantation
Which blood vessel layer could be damaged in a patient with an aneurysm
Media
Which condition most commonly results in coronary artery disease (CAD)?
Diabetes mellitus
Septal involvement occurs in which type of cardiomyopathy?
Hypertrophic
Toxicity from which medication may cause a patient to see a green halo around lights?
Digoxin
The fourth heart sound indicates which of the following cardiac conditions?
Failure of the ventricle to eject all the blood during systole
A patient with right-sided heart failure might exhibit which of the following symptoms?
Oliguria
Which class of drug is most commonly used for treating cardiomyopathy?
eta-adrenergic blockers
Which complication can be indicated by a third heart sound?
Ventricular dilation
What is the primary reason for administering morphine to a patient with a myocardial infarction?
To decrease oxygen demand on the patients heart
The nurse is aware that an intra-aortic balloon pump (IABP) is working properly when it inflates,when the :
) Aortic valve is closed
Which test is used most often to diagnose angina?
2-lead electrocardiogram (ECG)
A nurse is providing discharge instructions to a client undergoing a renal biopsy. Which of the following statements made by the client indicates a need for further teaching?
"I will probably experience pain in my shoulder or back."

Signs and symptoms of hemorrhage following a renal biopsy include flank or back pain, shoulder pain, pallor, and lightheadedness. The client is instructed to report these manifestations to the physician immediately. The other responses demonstrate an understanding of teaching for care following a renal biopsy.
. A client with nephrotic syndrome is being admitted to the unit. The nurse includes which of the following in planning the care for this client?
Interventions for client with generalized edema

Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema. The client is generally hypertensive and has fluid volume excess. Microscopic hematuria is noted, but frank blood loss is not expected.
A male client presents to the emergency department with complaints of fatigue, anorexia, nausea, and vomiting, and states that his urine is coffee-colored. The nurse notes periorbital edema, and the blood pressure is elevated. The nurse suspects the client is experiencing
. acute glomerulonephritis

Acute glomerulonephritis is manifested by hematuria, cocoa or coffee-colored urine; salt and water retention; periorbital, facial, and possibly dependent edema; hypertension; azotemia; anorexia; nausea; vomiting; and headache. Infection of the pharynx or skin with Group A beta-hemolytic streptococcus is the common precipitating factor of this disorder.
. A nurse, developing a plan of care for a client diagnosed with polycystic kidney disease, would not plan to include
luid restriction.

Clients with polycystic kidney disease are encouraged to maintain a fluid intake of at least 2500 mL per day
What are the lab tests most commonly followed on dialysis patients? What is normal, and what is a typical value for hemodialysis patient
1. Creatinine (usually high) (8.0-20.0 mg/dl)
2. Blood Urea Nitrogen (high) (60-110 mg/dl)—BUN of 20-50=mild azotemia; levels greater than 100 mg/dL indicate severe renal impairment
3. Potassium (3.5-5 mEq/L)-usually below 6.5 mEq/L
4. Chloride
5. Sodium (135-145 mEq/L)
6. Calcium (60-100 mg/dl) (usually decreased in dialysis pt)
7. Phosphorus (high usually in dialysis pts) 2.3-4.7 mg/dl
8. Alkaline Phosphatase (25-100 units/L
9. Albumin and total protein (3.8-5.5 gm/dl)
10. Glucose (fasting) (60-100), Less than 140
11. Hematocrit (usually low) (33%-36%)
12. Hemoglobin 11-12
What Meds are common for the hemodialysis patient? What medications are held prior to hemodialysis
eplace vitamins lost during dialysis and add vitamins you may not be getting with the special renal diet. Water soluble multi-vitamins are held and given after dialysis because the vitamins would be taken out with the extra fluid
2. Phosphate binders: control your phosphorous level and help prevent bone disease
3. Calcium supplements are used if your body needs calcium and for phosphate binding
4. Other common meds: iron, high blood pressure meds, heart stimulants, and stool softeners
5. Synthetic Erythropoietin: a drug to prevent anemia

Blood pressure meds and sedatives are held and given after dialysis
.Identify common complications of dialysis
Vascular access problems are the most common reason for hospitalization among people on hemodialysis. Common problems include infection, blockage from clotting, and poor blood flow. These problems can keep your treatments from working. You may need to undergo repeated surgeries in order to get a properly functioning access.
Other problems can be caused by rapid changes in your body's water and chemical balance during treatment. Muscle cramps and hypotension—a sudden drop in blood pressure—are two common side effects. Hypotension can make you feel weak, dizzy, or sick to your stomach.
You'll probably need a few months to adjust to hemodialysis. Side effects can often be treated quickly and easily, so you should always report them to your doctor and dialysis staff. You can avoid many side effects if you follow a proper diet, limit your liquid intake, and take your medicines as directed.

The most common problem with peritoneal dialysis is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contamination occurs as the catheter is connected or disconnected from the bags. Peritonitis requires antibiotic treatment by your doctor.
To avoid peritonitis, you must be careful to follow procedures exactly and learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor immediately so that peritonitis can be treated quickly to avoid serious problems.
Identify areas of teaching for the new patients on hemodialysis
Hemodialysis cleans and filters your blood using a machine to temporarily rid your body of harmful wastes, extra salt, and extra water. Hemodialysis helps control blood pressure and helps your body keep the proper balance of important chemicals such as potassium, sodium, calcium, and bicarbonate.

How It Works
Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to clean your blood. During treatment, your blood travels through tubes into the dialyzer, which filters out wastes and extra water. Then the cleaned blood flows through another set of tubes back into your body. The dialyzer is connected to a machine that monitors blood flow and removes wastes from the blood.

Hemodialysis.
Hemodialysis is usually needed three times a week. Each treatment lasts from 3 to 5 or more hours. During treatment, you can read, write, sleep, talk, or watch TV.

Who Performs It
Hemodialysis is usually done in a dialysis center by nurses and trained technicians. In some parts of the country, it can be done at home with the help of a partner, usually a family member or friend. If you decide to do home dialysis, you and your partner will receive special training.

Diet for Hemodialysis
Hemodialysis and a proper diet help reduce the wastes that build up in your blood. A dietitian is available at all dialysis centers to help you plan meals according to your doctor's orders. When choosing foods, remember to:
Describe polycystic kidney disease and its pathology.
Polycystic kidney disease is a hereditary disease characterized by cyst formation and massive kidney enlargement, affects both children and adults.
The autosomal dominant form affects adults, the autosomal recessive form is present at birth.
Renal cysts are fluid-filled sacs affecting the nephron, the functional unit of the kidneys. They develop in the tubular epithelium of the nephron, filling with straw-colored glomerular filtrate. The cysts may range in size from microscopic to several centimeters in diameter and affect the renal cortex and medulla of both kidneys. As the cysts fill, enlarge, and multiply, the kidneys also enlarge. Renal blood vessels and nephrons are compressed and obstructed and functional tissue destroyed. The renal parenchyma atrophies and becomes fibrotic and scarred.
Manifestations: Slowly progressive. Symptoms develop by age 40-50. Flank pain, microscopic or gross hematuria, proteinuria, and polyuria and nocturia as the concentrating ability of the kidneys is impaired.
Symptoms of early renal failure
Symptoms:

Greatly reduced urine output, swelling of the abdomen and legs, nausea and vomiting
headache, itching, back pain, recent surgery or serious trauma

2
Body Area Abdomen
General Symptom Swelling and Distention - With Swollen Legs
Box # 2
Symptoms

chronic decrease in urine output, numbness of hands or feet, generalized swelling, bad breath, itching, shortness of breath with exercise, history of diabetes, history of glomerulonephritis, Fluid and electrolyte imbalances, Little or no urine output

Body Area Abdomen
3
Body Area Abdomen
General Symptom Swelling and Distention - With Swollen Legs
Box # 5
Symptoms
severe headache, blood in urine, blurred vision, nausea and vomiting,itching, generalized swelling, loss of appetite, weight gain, history of hypertension

4 Body Area Abdomen
General Symptom Nausea and Vomiting
Box # 9
Symptoms
Greatly Reduced Urine Output, Generalized Swelling, Headaches, Nausea, Vomiting, Weight Gain, Itching, Recent Severe Illn
Describe the Nursing Care that you would provide for patients who are in Chronic renal failure
luid Volume Excess-Intake 500cc+cc of output the previous day, assess weight gain, edema, lung sounds, ascites
Altered Nutrition: Less than Body Requirements
Risk for Infection-Risk of Hepatitis B, C, and HIV (Testing done on all new admits), strict aseptic technique,
Body Image Disturbance- Lack of independence
Knowledge Deficit- What to do in a snowstorm and can't get to dialysis- Disease process, diet, meds, symptoms to report, access care, lab values, financial assistance, trip planning and scheduling
What does the procedure for peritoneal dialysis entail?
dialysis entail? • Procedure -
1. Weigh
2. Gather supplies with dialysate appropriate for fluid removal
3. Mask during exchanges
4. Outflow by drainage bag low
5. Meticulous cleansing of the catheter and sterile technique for spiking a new bag
6. Inflow and fold and leave bag connected 7. Four exchanges per day
haracteristics of peritoneal dialysis
Characteristics - Outflow may be bloody during first few exchanges, should be clear and colorless to light yellow thereafter. A brown outflow indicates bowel perforation. Cloudy outflow indicates peritonitis.
Complications from Peritoneal dialysis
• Complications -Peritonitis - Meticulous sterile technique when hooking up or clamping off bags, and catheter site care- monitor for fever, cloudy outflow, and rebound tenderness., culture outflow if suspect, and antibiotics. Abdominal pain -Pain during inflow is common for 1-2 weeks, cold temperature of dialysate aggravates but to be warmed only with special warmer pad, place heating pad on abdomen during inflow. Insufficient outflow Reposition by MD if cath migration out of peritoneal area, full colon, maintain drainage bag below the client's abdomen, change client's outflow position by turning or ambulating, check for kinks in the tubing, encourage high fiber diet, stool softeners as prescribed
Implementation-What meds do you hold before dialysis
Implementation - hold antihypertensives and sedatives prior to the procedure (attempt to prevent dramatic drop in BP after fluid removal). Client may eat prior to or during the procedure (unless past history of vomiting).
• Hold water soluble vitamins because they dialyze off.
Hemodialysis
Internal A V Graft-type
explain
Internal A V Graft Artificial graft made of GoreTex or a bovine(cow) carotid artery is used to create and artificial vein for blood flow between and artery and a vein. Maturity takes about 1-2 weeks and is required before fistula can be used. Less danger of clotting and bleeding and decreased incidence of infection. Needle insertions required for dialysis. Aneurysm formation and hematomas with infiltration are problems. Arterial steal syndrome and CHF are considerations.
Nursing Care Acute Renal Failure
Fluid Volume Excess --Increased weight, edema, CHF, Pulmonary edema, (Note changes in
(note changes in rhabdomyolysis)

Altered Nutrition Less than body requirements - Diet -Decrease-- Protein, Decrease--Na+, Decrease--K + given in frequent small meals to give adequate calorie for protein-sparing action
Renal Failure-Acute
Treatment
Dopamine – Increases renal perfusion
Loop or osmotic diuretic
ACE inhibitor
NSAIDS stopped
Antacids & H2 receptor antagonists- Increased risk of GI bleed Calcium chloride or calcium gluconate
Kayexalate (sorbital) Rectally to hold 30-60 min in bowel or given PO
Dialysis
Aluminum hydroxide gels for Increased Phos+ levels -Promote excretion of Phos through the bowel
Drug dosages decreased
Fluid Restriction 500 cc/day + output in last 24 hours
Protein Restricted Diet to decrease azotemia (After on dialysis when creatinine and BUN decrease, then high protein to replace protein lost with dialysis - either peritoneal or hemo)
Avoid nephrotoxic meds or dyes
Continuous renal replacement therapy
Continuous- slow but steady.
Either condition improves or to chronic dialy
A 28-year-old male presents to the emergency department with multiple trauma after falling off a roof while working. Which of the following signs or symptoms indicates to the nurse the possibility of retroperitoneal bleeding from the kidney?
. Bluish discoloration of the flank

Bluish discoloration of the flank (Turner's sign) is evidence of retroperitoneal bleeding from the kidney. Tachycardia, tachypnea, and cool, pale skin are signs of shock, and may be present with retroperitoneal bleeding, but may be related to other trauma.
A client, newly diagnosed with chronic renal failure, has recently begun hemodialysis. The nurse, establishing the client's plan of care, includes monitoring the client for disequilibrium syndrome. Which of the following symptoms will the nurse assess the client for?
. Headache, nausea and vomiting, altered level of consciousness, and hypertension
A client is admitted for emergency dialysis for newly diagnosed chronic renal failure. The nurse recognizes that which of the following laboratory values poses the greatest risk to the client?
Potassium 7.0 mEq/L
Volume Expanders
Albumin
Albumin

Indications
Fluid volume deficit, shock, hemorrhage, burns, portal hypertension, endstage liver disease.

Actions
Mobilize fluid from extravascular tissues back into intravascular space

S.E. PULMONARY EDEMA, FVO

NR implications
Monitor VS, CVP, I/O. If feer-Stop infusion and call the Dr. Assess for vascular overload, bleeding (no clot factors in albumin, solution clear, no sediment or discoloration.

Pt. teaching
Report s/s of hypersensitivity rx.
Classification/Sub Class
Hypokalemics

Sodium polystyrene (sulfonate) (Kayexalate c sorbitol)
pokalemics
Sodium polystyrene (sulfonate) (Kayexalate c sorbitol)

Indications/
route Oral, rectal, for hyperkalemia

Actions Stimulates Production of RBCs, Ion exchange resin that releases sodium ions in exchange primarily for potassium ions. Removes potassium in the intestine before the resin is passed from the body. Reduces potassium levels

Side Effects
Diarrhea?, anorexia, nausea, vomiting, constipation, fecal impaction, hypocalcemia, hypokalemia

Nursing Implications Monitor K+ level frequently and stop med when K+ normal, assess EKG. Monitor magnesium, calcium levels. Monitor daily bowel activity, stool consistency, fecal impaction can occur on high doses. Monitor for fluid overload.

Patient Teaching
Stop meds call dr. if tinnitus, drink plenty of fluids

Expected Outcomes Lowers serum potassium
Aluminum hydroxide AlternaGel, Amphojel, Nephrox
Aluminum hydroxide AlternaGel, Amphojel, Nephrox

Indications
For pts with increased phosphorus and decreased calcium in their system-(pts in renal failure)

Actions
Binds phosphates in GI tract to be excreted in feces

Side Effects
Constipation

Nursing Implications
Give with meals or times of phosphorus intake. Laxatives to treat constipation should be without Mg+
Assess location, duration, character, and precipitating factors of gastric pain

Patient Teaching
Take antacids at least 2 hours before other oral medications. Antacids directly affect the acidity of the stomach and may interfere with drug absorption-so don’t take within 1-2 hours of other meds
Note number and consistency of stools, since antacids may alter bowel activity
Medication may make stools appear white. Shake liquid preparations before dispensing

Expected Outcomes Normal phosphorus, Normal calcium
poetin alfa
Epogen, EprexJ,
poetin alfa
Epogen, EprexJ, Procrit

Actions
Stimulates division, differentiation of erythroid progenitor cells in bone marrow. Therapeutic Effect: Induces erythropoiesis, releases reticulocytes from marrow. Stimulates production of RBC (erythropoiesis). Treatment of anemia with associated chronic renal failure, management of anemica w/ AZT therapy in HIV, chemotherapy

Side Effects
CHRONIC RENAL FAILURE PTS:
Hypertension, headache, nausea, arthralgia.
Fatigue, edema, diarrhea, vomiting, chest pain, skin reactions at administration site, asthenia (loss of strength, energy), dizziness.

Nursing Implications BASELINE ASSESSMENT
Assess B/P prior to drug initiation (80% of pts with chronic renal failure have history of hypertension). B/P often rises during early therapy in pts with history of hypertension. Consider that all pts eventually need supplemental iron therapy. Assess serum iron (should be greater than 20%) and serum ferritin (should be greater than 100 ng/ml) prior to and during therapy. Establish baseline CBC (esp. note Hct). Monitor aggressively for increased B/P (25% of pts on medication require antihypertensive therapy, dietary restrictions).

INTERVENTION/EVALUATION
Monitor Hct level diligently (if level increases greater than 4 points in 2 wks, dosage should be reduced); assess CBC routinely. Monitor temperature, esp. in cancer pts on chemotherapy and zidovudine-treated HIV pts. Monitor BUN, serum uric acid, creatinine, phosphorus, potassium, esp. in chronic renal failure pts.

Patient Teaching Frequent blood tests needed to determine correct dosage. Inform physician if severe headache develops. Avoid potentially hazardous activity during first 90 days of therapy (increased risk of seizures in renal pts during first 90 days). Diet: increase iron (liver, pork, green veg. strawberries) decrease K+