Med Surg Chapter 44-Renal

Front 1

Define chronic kidney disease

Back 1

kidney damage or decrease in GFR for 3 or more months

Front 2

What is the most accurate indicator of fluid loss or gain?

Back 2

the patients WEIGHT

Front 3

What does fluid vol deficit look like?

Back 3

weight loss >5%, dec skin turgor, dry mucus membranes, oliguria/anuria, inc hematocrit, BUN inc out of proportion to creatinine level, hypothermia
inc HR, dec BP, inc urine specific gravity

Front 4

What do you do for fluid volume deficit?

Back 4

fluid replacement, orally or patenterally

Front 5

What does fluid volume excess look like?

Back 5

weight gain >5%, edema, crackles, shortness of breath, dec BUN, dec hematocrit, distended neck veins

Front 6

What do you do for fluid volume excess?

Back 6

fluid and sodium restrictions, diuretics, dialysis

Front 7

What does sodium deficit look like?

Back 7

Nausea, malaise, lethargy, headache, adbdominal pain, cramps, apprehension, sz
<135

Front 8

What do you do for sodium deficit?

Back 8

diet, normal saline, or hypertonic saline solutions

Front 9

what does sodium excess look like?

Back 9

dry sticky mucous membraines, thirst, rough dry tough, fever, restlessness, weakness, disorientation
>145

Front 10

What do you do for sodium excess?

Back 10

fluids, diuretics, dietary restrictions

Front 11

What does potassium deficit look like?

Back 11

anorexia, abdominal distention, paralytic ileua, muscle weakness, ECG changes, dysrhythmias
<3.5

Front 12

What do you do for potassium deficit?

Back 12

diet, oral or parenteral potassium replacement

Front 13

What does potassium excess look like?

Back 13

diarrhea, colic, nausea, irritability, muscle weakness, ECG changes
>5.0

Front 14

What do you do for potassium excess?

Back 14

dietary restrictions, diuretics, IV glucose, insulin, and sodium bicarb, cation exchange resin, calcium gluconate, dialysis

Front 15

What does calcium deficit look like?

Back 15

abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek's or Trousseau's, tingling of fingers or around mouth, ECG changes
<8.6

Front 16

What do you do for calcium deficit?

Back 16

diet, oral or patenteral calcium salt replacement

Front 17

What does calcium excess look like?

Back 17

deep bone pain, flank pain, muscle weakness, depressed deep tendon reflex, constipation, N/V, confusion, impaired memory, polyuria, polydispsia, ECG changes
>10.2

Front 18

what does bicarbonate deficit look like?

Back 18

headache, confusion, drowsiness, inc resp rate and depth, N/V, warm flushed skin

Front 19

What do you do for bicarbonate deficit?

Back 19

bicarbonate dialysis, dialysis

Front 20

What does bicarbonate excess look like?

Back 20

depressed resp, muscle hypertonicity, dizziness, tingling of fingers and toes

Front 21

What do you do for bicarbonate excess?

Back 21

fluid replacement if vol is depleted, ensure adequate chloride

Front 22

What does protein deficit look like?

Back 22

weight loss, emotional depression, pallor, fatigue, flabby muscles

Front 23

what do you do for protein deficit?

Back 23

diet, dietary supp, hyperalimentation, albumin

Front 24

What does magnesium deficit look like?

Back 24

dysphagia, muscle cramps, hyperactive reflexes, tetany, pos Chvostek's or Trousseau's, tingling of fingers, dysrhthymia, vertigo

Front 25

What do you do for magnesium deficit?

Back 25

diet, oral or parenteral magnesium replacement

Front 26

What does magnesium excess look like?

Back 26

facial flushing, N/V, warm sensation, drowsiness, depressed tendon weakness, resp dep, cardiac arrest

Front 27

What do you do for magnesium excess?

Back 27

calcium gluconate, meachanical ventilation, dialysis

Front 28

What does phosphorous deficit look like?

Back 28

deep bone pain, flank pain, muscle weakness and pain, paresthesia, apprehension, confusion, SZ

Front 29

What do you do for phosphorus deficit?

Back 29

diet, oral or parenteral phosphorus supplemental therapy

Front 30

What does phosphorus excess look like?

Back 30

tetany, tingling of fingers, muscle spasm, calcification of soft tissue

Front 31

What do you do for phosphorous excess?

Back 31

diet restriction, phoshphate binders, NS, IV D5W, insulin

Front 32

What geratric considerations are there for renal fx?

Back 32

high incidence of atherosclerosis, HYN, HF, DM, cancer, poly pharmacy, kidneys are less able to respond to acute chances, atypical signs of fluid and electrolyte imbalance

Front 33

What are the clinical manifestations of glomerulus injury?

Back 33

proteinuria, hematuria, dec GFR, Na+ excretion alterations

Front 34

What is acute glomerulonephritis?
And what can cause it?

Back 34

inflammation of the glomerular capillaries
impetigo, strep, viral infections, etc

Front 35

What are the s/s of acute glomerulonephritis?

Back 35

hematuria (cola colored urine b/c of rbc), edema, azotemia (urea and nitrogenous wastes in the blood), proteinuria, HYN, anemia, headache, dyspnea, malaise, flank pain, FVE

Front 36

How do they diagnose glomerulonephritis?

Back 36

kidney biopsy

Front 37

What are complications of acute glomerulonephritis?

Back 37

Chronic glomerulonephritis, ESRD, HF, hypertensive encephalophathy, pulmonary edema

Front 38

How is acute glomerulonephritis managed?

Back 38

treatment of symptoms, kidney fx preservation, corticosteroids, restricted protein and sodium, high carb, lab tests monitored, fluid restrictions

Front 39

What causes chronic glomerulonephritis?

Back 39

repeated bouts of acute glom., hypertensive nephrosclerosis, hyperlipidemia, chronic tubulointerstitual injury, glomerular sclerosis, SLE, DM glomerulosclerosis, amyloidosis

Front 40

What are the s/s of chronic glomerulonephritis?

Back 40

renal failure, retinal hemorrhage, yellow-gray pigmentation, peripheral neuropathy, cardiomegaly, etc

Front 41

What will the urinalysis reveal?

Back 41

specific gravity at 1.010, proteinuria, urinary casts, electrolyte imbalances, hypoalbuminemia

Front 42

What happens when GFR <50%?

Back 42

hyperkalemia (dec excretion of potassium), metabolic acidisos (dec excretion), anemia (dec in erythropoiesis), hypoalbuminemia with edema (protein loss), inc serum phosphorous (dec excretion), dec serum Ca+, mental status change, impaired nerve conduction, cardiac enlargement, pulmonary edema

Front 43

What does the ECG display with hyperkalemia?

Back 43

tall, tented T waves

Front 44

How is chronic glomerulonephritis managed?

Back 44

antihypertensives, dialysis, prompt treatment of UTI, high cal/protein diet, strict i/o, daily weight, F/E imbalance watched, cardiac monitored, follow up labs often

Front 45

What is nephrotic syndrome?

Back 45

any condition that damages the golmerular membrane and results in increased permeability of plasma proteins
a cluster of clinical findings of:
proteinuria (>3.5 g/day)
hypoalbuminemia
edema
hyperlipidemia

Front 46

What causes nephrotic syndrome?

Back 46

chronic glomerulonephritis, DM with glomerulosclerosis, amyloidosis, SLE, multiple myeloma, renal vein thrombosis

Front 47

What are s/s of nephrotic syndrome?

Back 47

pitting edema (eyes, extremities, abdomen), headache, irritability, malaise

Front 48

What are complications of nephrotic syndrome?

Back 48

infection, thromboembolism, pulmonary emboli (renal vein), ARF (hypovolemia), atherosclerosis(hyperlipidemia)

Front 49

How does one diagnose and manage nephrotic syndrome?

Back 49

renal biopsy, labs, diuretics, corticosteroids, cyclosporine, low sodium protein and chol diet

Front 50

What is nephrosclerosis?

Back 50

decreased blood flow to renal arteries due to diabetes, HYN, atherosclerosis and cause ESRD

Front 51

What are two main types of nephrosclerosis?

Back 51

Malignant- assoc with malignant HYN (180/130)
Benign- assoc with atherosclerosis and HYN

Front 52

How do you treat nephrosclerosis?

Back 52

malignant- dialysis
benign- aggressive antihypertensive therapy

Front 53

What is acute renal failure?

Back 53

reversible clinical syndrome where there is a sudden loss of kidney fx (dec GFR)
Kidneys cannot remove wastes and perform regulatory fx

Front 54

What are the s/s of ARF?

Back 54

inc serum creatinine and BUN, could be a change in urine vol

Front 55

What are the risk factors for ARF?

Back 55

hypovolemia, hypotension, dec CO and HF, obstruction of the kidney or lower UTI, bilateral obstruction of renal arteries or veins

Front 56

What is meant by prerenal failure and what can cause it?

Back 56

impaired blood flow that leads to hypoperfusion of kidney and dec in GFR
vol depletion, dec CO, vasodilation
Many have <20 of Na+ in urine

Front 57

What is intrarenal failure and what causes it?

Back 57

actual damage to the glomeruli or kidney tubules
acute tubular necrosis (prolonged ischemia, nephrotogic agents, infectious process)
May have >40 Na+ plus casts and cellular debris

Front 58

What is postrenal failure and what causes it?

Back 58

pressure rises in kidney tubules and GFR eventually decreases
obstruction somewhere distal to kidneys

Front 59

Describe the four phases of ARF

Back 59

initiation
oliguria- could lead to hyperkalemia
duiresis
recovery- 3-12 months

Front 60

What are the s/s of ARF?

Back 60

dehydration, lethargy, CNS changes, drowsiness, headache, muscle twitching, sz

Front 61

What are the abnormal findings of ARF?

Back 61

low specific gravity of urine, abnormal sodium levels, inc BUN/creatinine ratio, hyperkalemia, metabolic acidosis, inc phosphorous, and low Ca+ (elevated ph causes a decrease in Ca), anemia (dec erythropoeitin)

Front 62

How does one manage ARF?

Back 62

avoid fluid excess, dialysis, watch for hyperkalemia, med dosage must be reduced, high carb/no potassium or phosphorous diet, dec metabolic rate, promote pulm fx, no foley, meticulous skin care.

Front 63

What are the s/s of fluid excess?

Back 63

dyspnea, tachycardia, distended neck veins, crackles

Front 64

What can you do if patient is hyperkalemic?

Back 64

(>5.5, tall tented T wave)
Kayexalate- exchanges sodium ions for potassium ions (causes explosive diarrhea that stains)
IV D50%, insulin, Ca+ replacement, albuterol, dialysis

Front 65

What is chronic Renal failure or ESRD?

Back 65

progressive, irreversible, deterioration of renal fx
inability to maintaine metabolic and F/E balance resulting in uremia or azotemia

Front 66

What causes ESRD?

Back 66

DM, HYN, chronic glomerulonephritis, pyelonephritis, obstruction of UT, lesions, vascular d/o, infections, meds and toxic agents

Front 67

What is the path of ESRD?

Back 67

end product of protein metabolism cannot be excreted and builds up in the blood
Uremia develops

Front 68

What are the s/s of ESRD?

Back 68

CV- HYN, HF, pulmonary edema, pericarditis, general edema, hyperkalemia, hyperlipidemia
Integ- pruritus, uremic frost
GI -N/V, anorexia, hiccups, ammonia breath
Neuro- confusion, muscle twitching, peripheral neuropathy, restless leg, sz
Pulm- crackels, shortness of breath, tachypnea, kussmaul resp
MS- muscle cramps, dec muscle strength, bone pain, foot drop
Neuro-

Front 69

Explain GFR

Back 69

amount of plasma filtered through the glomerul/unit of time
creatinine clearance: serum vs urine is compared to to calculate ability to clear
GFR dec-creatinine clearance dec

Front 70

What is the more sensitive indicator of renal fuction?

Back 70

SERUM CREATININE

Front 71

What is normal GFR?

Back 71

GFR 125 ml/min/1.73 m2

Front 72

What is stage 1 ESRD?

Back 72

GFR >90 ml/min/1.73 m2

Front 73

What is stage 2 ESRD?

Back 73

GFR = 60-89 ml/min/1.73 m2

Front 74

What is stage 3 ESRD?

Back 74

GFR = 30-59 ml/min/1.73 m2

Front 75

What is stage 4 ESRD?

Back 75

GFR = 15-29 ml/min/1.73 m2

Front 76

What is stage 5 ESRD?

Back 76

GFR < 15 ml/min/1.73 m2

Front 77

What risks are associated with ESRD?

Back 77

sodium and H2O retention (edema, HF, HYN), loss of Na+ (hypotension, hypovolemia), metabolic acidosis (unable to excrete NH3- and reabsorb HCO3-), anemia (inadequate erlythropoietin), increase phosphate and decrease in calcium leading to calcium leaving the bones (calcification of blood vessels), decrease in active Vit D

Front 78

What is uremic bone disease?

Back 78

renal osteodystrophy- calcification of blood vessels from complex changes in calcium, phosphate and parathyroid hormone

Front 79

What are the complications of ESRD?

Back 79

hyperkalemia, pericarditis, pericardial effusion, pericardial tamponade, HYN, anemia, bone disease, vascular calcification

Front 80

How does one manage ESRD?

Back 80

dialysis, phosphate binding agents (avoidance of antacids- magnesium toxicity), antihypertensive agents, fluid restrictions (500 ml> then yesterday urine output), low sodium, potassium and protein diet, diuretics, Epogen (erythropoeitin), ionotrops, sz meds, iron

Front 81

What is suggested preventative care for renal patients

Back 81

vacinnations: flu, pneumo, Hep A, Hep B
TB screen
LDL monitored (<100 or <70 for DM, CVD)
screen for malignancy
glycated hemoglobin A1C (blood sugar over 3 months) < 7%
good skin care
asepsis techni for central line

Front 82

When is acute dialysis used?

Back 82

high levels of serum potassium, fluid overload, pulmonary edema, increasing acidosis, pericarditis, severe confusion, to remove toxins or meds

Front 83

When is chronic or maintainence diaylsis used?

Back 83

presence of uremic signs and overall body systems (N/V/lethargy, confusion, anorexia), hyperkalemia, fluid overload not responsive to diuretics, lack of well-being

Front 84

What is the objective of hemodialysis?

Back 84

extract toxic nitrogenous substances from the blood and to remove excess water

Front 85

How are toxins and wastes removed from the blood?

Back 85

By diffusion- they move from an area of higher concentration in the blood to an area of lower concentration or the dialysate
The semipermeable membrane impedes diffusion of large molecules like RBC and proteins

Front 86

How is excess water removed from the blood?

Back 86

osmosis- water moves from an area of higher solute concentration (blood) to an area of lower solute concentration (dialysate bath)

Front 87

What does ultrafiltration do?

Back 87

moves water under high pressure to an area of lower pressure through negative pressure or suctioning force to the dialysis membrane
usually necessary to achieve fluid balance

Front 88

How is the body's buffer system maintained?

Back 88

dialysate bath is made up of bicarbonate or acetate which metabolizes into bicarbonate
heparin is also added to keep blood from clotting

Front 89

What are the advantages of ultrafiltrate dialyzers?

Back 89

reduced neuropathy, increased efficiency (shortened treatment time), reduced need for heparin

Front 90

What is the optimal rate of dialysis?

Back 90

300-550 mL/min

Front 91

What vascular access is used temporarily?

Back 91

subclavian, internal jugular, femoral vein
no longer then 3 weeks

Front 92

What access sites are used long term?

Back 92

double lumen into internal jugular vein, av fistula, av graft

Front 93

How many days does it take for the av fistula to heal? What is the patient encouraged to do?

Back 93

14 days
exercises to increase size of vessel to accomodate large-bore needle

Front 94

When is an av graft used and what are the complications of them?

Back 94

when patients have compromised vascular systems, usually in arm, leg, or chest
infection and thrombosis are common

Front 95

What is the highest priority?

Back 95

protection of the access line
do not use arm to draw blood or BP

Front 96

What are complications of hemodialysis?

Back 96

atherosclerosis CVD (HF, CHD, angina, stroke, PVD), lipid metabolism disturbances, GI ulcers, calcium disturbances (fx), fluid overload, malnutrition, infection, neuropathy, pruritis, sleeping disturbances, hypotension, painful muscle cramping, blood loss if lines seperate, dysrhythmias, air embolism, dialysis disequilibrium (fluid shift)

Front 97

What are s/s of hypotension?

Back 97

N/V, diaphoresis, tachycardia, dizziness

Front 98

what is exsanguination?

Back 98

drain of blood (occurs if line separeate or dialysis needle dislodges

Front 99

What is dialysis disequilibrium?

Back 99

cerebral fluid shifts
s/s-headache, N/V, restlessness, dec LOC, SZ

Front 100

List nursing management for dialysis patient

Back 100

weight, strict I/O, s/s of uremic syndrome, electrolyte imbalance, cardiac & resp status, BP, with hold BP meds, avoid meds with potassium and magnesium, asepsis, good skin care, nutrition

Front 101

What is proper nutrition for dialysis patient?

Back 101

dec protein intake, fluid restriction, sodium restriction, potassium restriction

Front 102

What is CRRT?

Back 102

continous renal replacement therapy, use of hemofilter
used for thoses too clinically unstable for traditional hemodialysis

Front 103

What is CVVH?

Back 103

continuous venovenous hemofiltration, continuous slow fluid removal without arterial access

Front 104

What is CVVHD?

Back 104

continuous venvenous hemodialysis, use of hemofilter and ultrafiltration without arterial access

Front 105

What is the goal of peritoneal dialysis?

Back 105

to remove toxic substances and metabolic wastes and re-establish normal fluid and electrolyte balance

Front 106

How does peritoneal dialysis vary from hemodialysis?

Back 106

sterile dialysate fluid is introduced in intervals into peritoneal cavity via abdominal catheter
Urea, creatinine, and metabolic end products are removed by diffusion and osmosis from high conc to lower conc

Front 107

What is used as the filter for peritoneal dialysis?

Back 107

peritoneal membrane that covers abdominal cavity is the semipereable membrane

Front 108

What is the rate at which urea and creatinine are removed?
How does this differ from hemodialysis?

Back 108

ureas is cleared at 15-20 ml/min, creatinine is removed slower
takes 36-48 hour to achieve what hemodialysis can achieve in 6-8 hours

Front 109

Which patients are better candidates for peritoneal dialysis?

Back 109

those susceptible to rapid fluid, electrolyte and metabolic changes
DM, CVD, HF, pulmonary edema, severe HYN

Front 110

Before peritoneal dialysis?

Back 110

vitals signs, weight, serum electrolyte levels, empty bladdera and bowel, may give antibiotic and heparin and potassium chloride, insulin maybe needed, meds added before, diasylate warmed to body temp

Front 111

How does peritoneal dialysis work?

Back 111

dialysis infused by gravity (5-10 mins to infuse 2-3 L), drainage for 10-30 minutes, cycle is repeated

Front 112

What if excess water is needed to be removed?

Back 112

hypertonic dialysate is used with high dextrose concentration (1.5-4.25%)

Front 113

what are acute complications of peritoneal dialysis?

Back 113

-peritonitis (cloudy dialysate, abd pain, rebound tenderness, hypotension) treatment is antibiotics, catheter removal
-acute malnutrition, delayed healing (large loss of proteins)
-leakage
-bleeding

Front 114

What are long term complications of peritoneal dialysis?

Back 114

hypertriglyceridemia, incr BP, incr fluid volume, abd hernias, pain, anorexia

Front 115

When is acute intermittent peritoneal dialysis used?

Back 115

unstable patient with uremic signs, fluid overload, acidosis, hyperkalemia

Front 116

What are nursing considerations for intermittent peritoneal dialysis?

Back 116

aseptic techn, VS, weight, I/O, fluid balance, dialysate concentration, skin turgor, turning patient, comfort, resp, bleeding, peritonitis, leakage

Front 117

Things to consider for all dialysis patients

Back 117

protect vascular access, check site for clotting/infection, give IV therapy as slow as possible, strict I/O, corticosteroid or parental nutrition may inc toxic accumulation and require daily dialysis, continually check for fluid overload, HF, pulm edema, cardiac tamponade, electrolyte levels, good skin care, hypertension, low WBC counts

Front 118

State preoperative considerations for kidney surgery

Back 118

fluids are encouraged, if infection antibiotics, conagulation studies
Resp fx, VS, pain, urinary retention

Front 119

State postoperative considerations for kidney surgery

Back 119

hemorrhage and shock, fluid and blood replacement, abdominal distenstion and paralytic ileus, DVT, pneumonia

Front 120

What makes kidney transplants more successful

Back 120

if the kidney comes from a live donor, performed before dialysis is initiated

Front 121

What is the nursing management of a kidney transplant patient

Back 121

pulmonary hygiene, pain managment, early ambulation, immunosuppressive therapy, infection prevention, urinary output, vascular access clotting

Front 122

What are s/s of transplant rejection, infection or adverse effects of immunosuppressive regimen:

Back 122

dec urinary output, weight gain, malaise, fever, resp distress, tenderness, anxiety, depression, changes in BP, eating, drinking

Front 123

What do kidney patients have a higher risk for?

Back 123

CVD and cancer

Front 124

What are the clinical manifestations of renal tumors?

Back 124

painless hematuria, pain, mass in the flank, dull/colicky pains, unexplained weight loss, increasing weakness, anemia

Front 125

What are the risk factors for renal cancer?

Back 125

gender (men), tobacco use, occupational hazards, obesity, unopposed estrogen therapy, polycystic kidney disease

Front 126

What are the treatments for renal cancer?

Back 126

surgery: radical nephrectomy, laparoscopic nephrectomy, partial nephrectomy
Renal artery embolization
Radiation
Chemo

Front 127

What are the two types of renal trauma?

Back 127

blunt trauma 80%
penetrating trauma 10%

Front 128

What are clinical manifestations of renal trauma?

Back 128

pain, renal colic, hematuria, swelling, ecchymoses, hemorrage, oliguria, hemorrhagic shock