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List medications that can cause nephrotixicity
- Antibiotics ("mycins")
- Aspirins
- Cephalosporins
- Cyclosporins
- Ibuprofen
- Rifampin
- Sulfonamides
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Specific drugs of concern that cause nephrotoxicity
- Digoxin
- metformin/glyburide
- Gentamicin
- Vancomycin
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Top 3 ways a person develops chronic renal failure
- #1 Diabetes
- #2 Hypertension
- #3 Glomerulonephritis
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Why does diabetes cause CRF?
when you have diabetes for awhile the glomeruli will be under a lot of pressure and will become sclerotic and thick causing a decrease in GFR
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How does a person get Glomerulonephritis? and how does it cause CRF?
it happens from strep throat
which causes an immunologic response triggering inflammation and proliferative changes to the glomerulus resulting in scarring and a decrease in the ability of the glomerulus to filter blood
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What's pyelonephritis? What can it cause?
upper UTI problem....CRF
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What is polycystic kidney disease? What can it cause? Mainly in who?
grapelike cluster of cysts that destroys renal tissues by compressing it
genetically transmitted....seen in kids
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What is nephrosclerosis? What can it cause?
it is a thickening (hypertrophy) of the renal arteries, arterioles and glomerulus caused by elevated BP
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What meds cause CRF?
- Contrast Media
- Aminoglycosides
- NSAIDS
- Crack
- Heroine
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What's the goal ofcollaborative management for clinical manifestations experienced by a patient with CRF?
- to preserve the existing kidney function
- treatment of cardiovascular disease
- prevention of complications
- provide comfort for the patient
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Why does a person get dialysis?(2)
Indicators that it is needed?(2)
- for correction of fluid and electrolyte imbalances
- removal of waste products for a person in kidney failure
- removal of uremia
- GFR is <15
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What is peritoneal dialysis?
the peritoneum is used as the semi permeable membrane
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What is hemodialysis?
it is an exchange of fluid and electrolytes and toxins from blood to a bath that circulates through an artificial kidney and returned to the venous circulation
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What is important to remember when you are caring for a patient with a fistula/graft for dialysis?
- No BP on that arm
- No blood draws from that extremity
- No injections in that extremity
- No IV's in that extremity
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When a person has a AVF or AVG (Arterial Venous Fistula/Graft) what do you want to listen for?
bruit and thrill.....we want a bruit
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Pre Dialysis checks....
- PA
- Assess access site
- Compare post and pre dialysis weights
- Labs and MD Dialysis order
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How often do you check VS on a person who is getting dialysis?
every 30-60 minutes.....watching for changes in a persons BP
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Post Dialysis checks
- observe for fluid volume deficit
- VS-watching temperature
- assess for bleeding at AVF/AVG
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Home daily care for the patient with a Peritoneal catheter
- wash site with soap and water
- change dressing (daily)
- check site for infection
- showers are best
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Daily care for a patient with a peritoneal catheter when they are in the hospital
- AESEPTIC dressing change with masks for patient and me
- check site for infection
- check VS
- check WBC count
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General Care for the patient with a peritoneal catheter for dialysis
- blood draw prior to treatment
- PA of VS, temp, breath sounds
- Weigh
- Check I&O's
- Any patient teaching?
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Labs I am looking at when a person has a peritoneal catheter for dialysis
- BUN
- Creatinine
- Sodium
- K
- phosphate
- **Look at before treatment
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Advantages of PD
- Less complicated
- Fewer dietary restrictions
- Less cardiovascular stress
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Which type of dialysis is preferred for a patient with Diabetes?
PD
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Which dialysis can you do at home?
BOTH
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Disadvantages of PD
- Bacterial or chemical peritonitis
- Infections
- Hyperglycemia is common
- Surgically inserted
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Who's contraindicated to have a PD?
a person who has had multiple abdominal surgeries, trauma or has an unrepaired hernia
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Advantages of Hemodialysis
- Rapid fluid, urea and creatinine removal
- Effective K removal
- Less protein loss
- Lowers serum triglycerides
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Disadvantages of Hemodialysis
- Vascular access problems
- Dietary and fluid restrictions
- Heparinization may be necessary
- Surgery is required to place devise
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What are two complications that can occur with hemodialysis?
Hypotension and added blood loss causing anemia
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If you are looking to slow the progression of kidney failure what should you be on top of?
- early detection of heart problems
- dehydration
- infections
- nephrotoxins
- urinary tract obstructions
- glomerulonephritis
- renal artery stenosis
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If you treat this.....you will slow the progression of kidney disease
cardiovascular disease....HTN
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Name the risk factors for developing CKD
- Diabetic
- HTN
- >60
- Cardiovascular Disease
- Family History
- Exposure to Nephrotoxic Drugs
- African American/Native American
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Name the 4 hormones that are counter-regulatory to insulin
- Cortisol
- Epinephrine
- Glucagon
- Growth Hormone
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Why doesn't management of diabetes in the older adult require as tight of glucose control as in a young diabetic?
cuz it takes 10-20 years for long term effects to occur
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When do you take Prandin and Starlix to avoid hypoglycemia?
30 minutes prior to eating
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If GFR is 60 what is Creatinine Clearance?
60....they are equal
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What is your next step if you find protein in a persons urine?
Get a 24 hr. creatinine clearance test ordered
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When I do any diagnostic procedure with contrast what do I need to watch for?
nephrotoxicity....hard on kidneys. Check the patients BUN and Creatinine before and after
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Which diagnostic procedures use contrast media?
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What does a renal biopsy determine?
reason for the renal dysfunction....tumor?
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What's a Renal Arteriogram?
its an evaluation of renal blood flow by putting dye in to the renal arteries
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What is a cystoscopy used for?
it removes stones or tumors.....goes up the urethra
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3 main functions of the kidneys
- erythropoetin
- renin
- prostaglandins
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Major functioning unit of the kidneys....
Nephron
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What will kill a persons Nephron?
artherosclerosis
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How often is HD done and how much is pulled out each time?
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How often is PD done?
7x week...and it is more effective
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Which is better....AVF or AVG?
When can each be accessed after placement surgery?
AVF is better cuz it lasts longer and is from our own tissues
Access AVF 4-6 weeks after placement....but better to wait 3 months
Access AVG 2-4 weeks after placement.
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What gauge needle is used for AVF and AVG?
14-16 gauge
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Bruits you......
Thrill you....
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What meds will you hold prior to administering dialysis
- BP
- water soluable vitamins
- diaretics
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Priority nursing care for a person with a stone
- hydration
- treat for pain
- find out what kind of stone it is
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If you have an Incontinent Urinary Diversion procedure done you will....
have a visible stoma and a bag
Simplest form of diversion
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What is Continent Urinary Diversion?
when the ureters are attached to the bowels
will self cath every 4-6 hours....so now bag
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Describe Orthotopic Bladder Substitution
a segment of the bowel is reshaped to become a neobladder with ureters and a urethra is surgicacally attached
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Positives and negatives for Orthotopic Bladder Substitution
Pt. can naturally micturate
But may need to self cath some times
May have problems with incontinence....especially women cuz short urethra
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Pre Op Care for a person getting a urinary diversion done
- address fears about body image
- address concerns about sex
- arrange a visit by ostomate or ET nurse when getting Incontinent Urinary Diversion
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What will kidney transplant rejection look like?
- Person will have an increase in fluids and electrolytes (similar to levels prior to surgery)
- HTN/Increased BP
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Describe Acute Kidney Transplant Rejection
How do you treat it.
- happens 1 week to 2 years after the transplant from T cell immune response and will see:
- Anuria
- low grade fever
- tender kidney
- lethargy
- fluid retention
- Rise in serum creatinine
- Oliguria
- Azotemia
- Increase immunosuppressive drugsMethylprednisolone
- OKT3 Monoclonal antibody
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Describe Chronic Kidney Transplant Rejection
Can happen months to years post transplant and it involves both humoral and cellular immune response
- Will see progressive azotemia
- Proteinuria
- HTN
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What are some other kidney transplant complications besides rejection?
- Infection
- Cardiovascular
- Malignancies/Tumors
- Reoccurrence of original Renal Disease
- Corticosteroid related complications
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What cancer do you see oftenly in a person who has had a kidney transplant?
Lymphoma
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What are corticosteroid complications?
- bone/joint problems
- osteoperosis
- peptic ulcers
- cataracts
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What is very important to tell a person who is on nephrotoxic meds?
STAY HYDRATED
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When does a hyper-acute infection occur after a transplant? What are the S/S? How will you treat this?
within 48 hrs of the surgery
- fever
- HTN
- Pain at transplant site
Remove kidney stat....back on dialysis and list
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Azotemia
very high levels of nitrogen, urea and creatinine
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What is the most common problem after a kidney transplant?
How do you prevent it?
Infection
- Promote hand hygiene
- Monitor for signs of local and systemic infection (pneumonia/sepsis)
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Nephrolithiasis
stones in the kidneys
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Urolithiasis
stones in the urinary tract outside the kidneys
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Who's most likely to get kidney stones?
White man
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What causes kidney stones?
- increase in urine levels of calcium and acids
- warm climates (dehydration)
- diet
- family history
- sedentary life style
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What disorders increase your risk for kidney stones?
- Gout
- cystinuria
- Renal acidosis
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What should you keep in mind with your diet if you get kidney stones?
- drink 2-3 L/day
- watch intake of proteins
- watch intake of tea and fruit juices
- watch intake of calcium
- watch intake of oxalate
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What leads to lithiasis
- supersaturation (high concentration of insoluble salt in urine
- pH of urine
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How do stones get formed?
when crystals are in a supersaturated concentration they unite to form a stone
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If your urine is alkalitic (high pH) what will happen?
calcium and phosphate will be less soluble
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If your urine is acidic (low pH) what will happen?
uric acid and cysteine will be less soluble
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How do Struvite stones get made? Who gets them?
bacteria invades and causes the urine to become aklalitic and they form
Females....UTI's
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What's the problem with Staghorn stones?
They are large and cant come out on their own....so cause renal hydronephrosis
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A person who has an autosomal recessive disorder which causes an increase excretion of cystine has
Cystinuria
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Symptoms for a person with calculi affecting kidney calices/pelvis
few symptoms unless obstructing urine flow
dull, aching flank pain
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Symptoms for a person with calculi affecting the bladder
- Gross hematuria
- dull suprapubic pain with exercise or post voiding
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Symptoms for a person with calculi affecting the ureter
- Ureter spasm...SEVERE flank pain
- N/V
- Pallor
- Cool
- Clammy Skin
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How do you treat a person with a calcium oxalate stone?
- increase hydration
- *give cellulose phosphate
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How do you treat a person with Struvite stone?
- Admin antimicrobial (from UTI?)
- Surgically remove
- make urine acidic
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How do you treat a person with a Uric Acid stone?
reduce purines in diet
Sardines, mussels, venison....meats
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How do you treat a person with a Cystine stone?
- increase hydration
- give potassium citrate to maintain alkaline urine
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Spasmolytic med for stones
Ditropan
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Name some oxalates
- dark roughage
- spinach
- tomatoes
- beets
- nuts
- chocolate
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What kind of urine do you promote for clients with uric acid or cystine stones?
calcium or urinary tract infections?
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How large of a stone can we pass?
2mm
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Extracorporeal Shock Wave Lithotripsy
- ESWL
- sound waves/laser used to break the stone in to fragments to be excreted in the urine
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After a person has had an ESWL procedure make sure.....
- strain the urine
- increase fluids
- monitor VS
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Precutaneous Ultrasonic, Laser and Electrohydraulic Lithotripsy all will be done by...
poking a hole in the person.
Give prophylaxis antibiotics
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What is common after Lithotripsy procedures?
Hematuria
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Risk factors for Renal Cancer
- Smoker
- Men (2 xs often)
- Obesity
- HTN
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If you have acquired cystic disease of the kidney associated with ESRD....what else are you at risk for?
Renal Cancer
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Risk factors for Bladder Cancer
- 60-70 y/o
- Man
- Cigarette Smoker
- Women being treated for cervical cancer
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If you have chronic, recurrent renal calculi and chronic lower UTI's, you have an increased risk for.....
Bladder Cancer
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Who's at risk for prostate cancer?
- African American
- Male
- Over 65
- Family History of
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What system stages Renal Cancer
Robsons I-V
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When is a radical nephrectomy done and describe
- Stage I and II
- removal of kidney, adrenal gland, part of the ureter and draining lymph nodes
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When does a person with renal cancer have radiation?
when it is inoperable for palliative care
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Where does renal cancer met to?
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After a nephrectomy what should the patient know?
protect your only kidney that's left....watch the sports you play and may need to change your occupation
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After a nephrectomy what will a person have in place?
an NG tube to decompress
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Post care after Nephrectomy
- Urine output
- Respiratory
- Pain
- Abdominal Distention
- Kidney fxn
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Transurethral Resection with Fulgurtation for Bladder cancer
Best for superficial lesions and pt who are poor operative risk
Tumor is removed by a blade
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Laser Photocoagulation for bladder cancer
destroys the mass....but cant stage it then
Can be done multiple times if it comes back
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Open Loop Resection for Bladder Cancer with Fulguration
used for large superficial tumors
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Post op management for Bladder Cancer
- Drink lots of water for 1st week
- NO ETOH
- urine should be pink
- Analgesic admin
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What will happen 7-10 days after a bladder tumor resection or ablation?
the patient will see dark red or rust colored flecks in the urine (SCABS)
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Follow up with Dr. after bladder cancer surgery
Q3-6 months for 3 years
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Staging used for prostate cancer...and it is based on what?
Gleason
size and if it has spread
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Radical prostatectomy
removal of entire prostate gland, seminal cesivles and part of the bladder neck
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Primary therapeutic approach for prostate cancer
deprivation of androgens cuz it is an androgen dependent cancer
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