1. Glomerulonephritis
    What is it?
    Whats the main cause?
    What happens to vitals?
    What is happening?
    *Acute can lead to chronic

    Inflammation of the glomerulous. Antibodies from an immune response can get lodged and cause scarring and decrease filtering.

    Main cause is Strep (which also can damage kidney's and heart valves)

    • S/S involve:
    • Sore throat
    • malaise and HA
    • Increase in BUN and creatinine
    • Sediment/protein/blood in urine
    • Flank pain

    • BP increases
    • Urinary output goes down while specific gravity goes up. 

    Pt is going into fluid volume excess
  2. Treatment for Glomerulonephritis
    When will diuresis begin?
    • Get rid of strep
    • Balance activity with rest

    • I&O and daily weights (dealing with imbalance of fluids!!)
    • Monitor BP
    • Replace fluids:
    • Fluid replacement = 24 hr fluid loss + 500 mL

    Dietary needs: Limit protein and sodium (FVE) and increase Carbs (for energy)

    • May need dialysis - their retaining fluids and toxins
    • Diuresis begins in 1 - 3 wks after onset

    Educate s/s of renal failure: malaise, HA, N/V, decreased output and weight gain
  3. Nephrotic syndrome - patho
    • Inflammatory response in glomerulous where big holes form which results in proteinuria.
    • Client is now hypoalbuminemic.  Without albumin you can't hold fluid in vascular space
    • Therefore, fluid in vascular space is leaking into the tissues causing client to develop edema
    • Since fluid is going into tissues, circulating blood volume is going down. 
    • The poor kidneys sense this and want to help so they produce aldostrone which causes pt to retain sodium and water.
    • The problem is that there is no albumin (protein) to keep the fluid in the vascular space.
    • More and more fluid building in vascular space.
    • Results in anasarca
  4. What is anasarca?
    Total body edema
  5. Problems with protein loss
    Blood clots - losing proteins that normally prevent clots. 

    High cholesterol and triglycerides - liver compensates protein loss by making more albumin which causes an increase release of cholesterol and triglycerides.
  6. Nephrotic syndrome:
    • Usually idiopathic (spontaneous or unknown)but has been related to inflammatory:
    • Bacteria or viral infections
    • NSAIDs
    • Cancer/genetic predisposition
    • Systemic diseases (lupus or diabetes)
    • Strep

    • S/S include:
    • Proteinuria
    • Hypoalbuminemia
    • Edema (anasarca)
    • Hyperlipidemia
  7. Treatment for nephrotic syndrome:
    • Diuretics
    • Ace inhibitors to block aldosterone
    • Prednisone to decrease inflammation. (will shrink holes to protein can't get out. They will be immunosuppressed)
    • Lipid lowering drugs

    Decrease sodium and Increase protein

    • Anticoagulation therapy for up to 6 months
    • Dialysis
  8. Whats the rule with kidney problems Where nephrotic syndrome is the exception?
    • Limit protein with kidney problems 
    • EXCEPT
    • with Nephrotic Syndrome
  9. Renal failure:
    What is involved
    Requires bilateral failure

    • Causes:
    • Pre-renal Failure 
    • Intra-renal failure
    • Post-Renal failure
  10. Pre-Renal failure
    • Blood can't get to kidney's:
    • Hypotension
    • Decreased HR (arrhythmia) 
    • Hypovolemic
    • Any form of Shock
  11. Intra-renal failure
    • Damage has occurred inside the kidney:
    • Glomerulonephritis
    • Nephrotic Syndrome
    • Dyes used in tests such as heart cath and CT scan
    • Drugs (Aminoglycosides are nephrotoxic)
    • Malignant hypertension (uncontrolled HTN) and DM causes severe vascular damage
  12. Post Renal Failure
    • Urine can't get out of kidneys:
    • Enlarged prostate
    • Kidney stone
    • Tumors
    • Ureteral obstruction
    • Edematous stoma (ileal conduit - drains bladder)
  13. S/S of renal failure:
    • Increase creatinine and BUN
    • Specific gravity: initially concentrated
    • Anemia - not enough erythropoietin (low RBC)
    • HTN and HF = retaining fluid

    Anorexia, N/V = retaining toxins

    Itching frost (Uremic frost)  - urea comes out on skin. Need to have good skin care

    • Acid-base/fluid and electrolyte imbalances: 
    • Hyperkalemia = possible arrhythmia's
    • Metabolic Acidosis
    • Retain phosphorous = low serum calcium = calcium gets pulled from the bones
  14. Two phases of acute renal failure
    Kidneys have been damaged by one of the causes - this leads to the oliguric phase

    Other is diuretic phase
  15. Oliguric phase
    • Urinary output is decreased
    • between 100 to 400 mL/24 hr
    • Pt is in fluid volume excess
    • Potassium increases
  16. Diuretic phase
    • Sudden onset where urinary output increases
    • Client is in a fluid volume deficit (SHOCK!)
    • Potassium decreases
  17. Types of Dialysis
    • Hemodialysis
    • Peritoneal Dialysis
    • Continuous Renal replacement therapy (CRRT)
  18. What about hemodialysis:
    What happens with blood?
    How often?
    What is continually monitored?
    Machine is the glomerulus (filter). Blood is removed, cleaned, and returned at a rate of 300 to 800 mL/min.

    Done 3-4 times a week, so client has to watch what they eat and drink btwn tx

    • Will be given an anticoagulant during dialysis to prevent clot formation. 
    • Usually Heparin - so initiate bleeding precautions. Stays in body 4-6 hrs after dialysis

    Electrolytes and BP are continually monitored

    Depression can lead to suicide.

    not all pt's can tolerate hemodialysis
  19. Types of vascular access:
    AVF - arteriovenous fistula with anastomosis between an artery and a vein.

    AVG - arteriovenous graft with a synthetic graft to join vessels. 

    Both require surgery and takes weeks to mature and be ready for repeated venipunctures
  20. What is important to assess with fistula?
    Make sure access is patent!!

    • check by:
    • Thrill - cat purring sensation (palpate)
    • Bruit - turbulent blood flow (auscultate)

    Fell the thrill...Hear the bruit!
  21. What is peritoneal dialysis:
    What is it?
    How does it work?
    What instrument is used to infuse?
    What should drainage look like?
    Who gets it?
    What is all the fluid doesn't come out?
    Use the peritoneal membrane as a filter.

    Dialysate is warmed (cold fluid would cause constriction) and infused into peritoneal cavity by gravity via a Tenckhoff catheter

    The fluid (2000-2500 mLs) fills the peritoneal cavity (takes about 10 mins) and remains there for prescribed amount of time (called the dwell time)

    Bag is then lowered and fluid, along with toxins, drains by gravity. (called exchange)

    Drainage should look clear, straw-colored. If it's cloudy = infection!!

    People who can't tolerate hemodyalisis gets peritoneal.  also, some people prefer it. 

    If all the fluid doesn't come out, turn them from side to side.
  22. Two types of peritoneal dialysis:
    Whats involved with each
    How often
    Any contraindictions?
    • CAPD (Continuous Ambulatory Peritoneal Dialysis)
    • Must have pt that has energy and desire to be active in their treatment and also able to learn and follow directions. 
    • Done 4 times a day, 7 days a week.
    • Fluid causes pressure on back so pt with disc disease or arthritis can't do it. 
    • Client with colostomy can't either as theres a high risk for infection.

    • CCPD (Continuous Cycle Peritoneal Dialysis)
    • These pts connect their peritoneal dialysis catheter to cycler at night and exchange is done automatically while they sleep. Disconnected in AM. Client has more freedom.
  23. Complications of Peritoneal Dialysis
    • Major complication is peritonitis (cloudy effluent 1st sign)
    • Constant sweet taste
    • May get hernia
    • Altered body image/sexuality
    • Anorexia
    • Low Back pain

    • Dietary needs:
    • Increase fiber = will have decreased peristalsis due to abd fluid
    • Increase Protein = will have big holes in peritoneum and lose protein with each exchange
  24. Continuous Renal Replacement Therapy
    • CRRT
    • Typically done in ICU setting and is continuous so pt doesn't have drastic fluid shifts
    • Never more than 80 mLs of blood out of body at a time
    • Performed on pt with fragile cardiovascular status and acute renal failure
  25. Kidney stones:
    • urolithiasis = stone lodged in ureter
    • renal calculi = stone in kidney

    • S/S include:
    • Pain
    • N/V
    • WBC in urine
    • hematuria

    anytime you suspect kidney stone, get urine specimen ASAP and check for RBC & WBC

    If kidney stones is present, pain meds will be given immediatly
  26. Treatment for Kidney Stones
    • ondansetron (Zofran) and NSAIDs or opioids
    • Increase fluids
    • Maybe surgery
    • Strain Urine
    • Extracorporeal shock wave lithotripsy (ESWL)
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