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What are the functions of the renal system?
- Filters waste
- Regulates BP via RAAS system
- Acid/Base balance
- Regulates RBC's
- Regulates fluids
- Regulates electrolytes
- Vitamin D
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What labs show whether the body is filtering nitrogenous wastes?
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If a patient is in renal failure, what happens with the regulation of RBC's?
anemia because kidneys don’t send hormone to release erythropoietin
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When there is a problem regulating phosphates what other electrolyte do we need to look at?
calcium
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Hypertension is both ? ? of renal failure
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What are the top two causes of renal failure?
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Name risk factors that may lead to renal failure:
- contrast dye
- dehydration
- NSAID’s (nephrotoxic drug class)
- Elderly
- creatinine greater than 1.5 increases the risk
- Metformin (hold for 48 hours after contrast medium – can lead to lactic acidosis / hold before and after – to be safe on NCLEX)
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When a patient has a renal biopsy what is done post-procedure?
patient on back for 6 hours to prevent bleeding
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What is polycystic kidney disease?
- Cysts within the kidneys – hinder the good working cells of the kidneys
- Less good functioning nephrons
- Congenital disorder (autosomal dominant – genetic counseling)
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Key features of Polycystic Kidney Disease
- Abd or flank pain
- HTN
- Nocturia/Hematuria
- Increased abd girth
- constipation
- kidney stones
- sodium wasting and inability to concentrate urine in early stage
- progression to kidney failure with anuria
- Development of aneurysms (berry aneurysms)
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Patient and family education for Polycystic Kidney Disease?
- take and record BP daily, notify PCP if changes
- take temp and if fever, notify PCP
- weigh daily, notify if sudden gain
- limit intake of salt
- notify PCP if foul urine or hematuria
- notify PCP if HA that does not resolve or visual disturbances
- monitor bowel movements to prevent constipation
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What is the priority care with Polycystic kidney disease?
- control HTN
- helping with pain
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What is the third leading cause of end-stage kidney disease?
Polycystic kidney disease
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To prevent worsening of renal issues what do we advise regarding fluid intake?
at least 2L daily
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If one of parents has the disease, a child has 50% chance of getting the disease, what is this known as?
autosomal dominant
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This is Inflammation of glomerulous capillaries – develops after a strep (group A hemolytic strep) infection
Acute Glomerulonephritis
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What is the GFR?
amount of urine kidneys filter from the blood
-
What are risk factors for Acute glomerulonephritis?
- DM I
- Lupus
- strep (group A hemolytic strep) infection
- HTN and vascular issues
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What are S/S of Acute glomerulonephritis?
- Periorbital edema (fluid overload)
- Reddish brown (cola colored) urine
- Proteinuria
- Decreased urine output
-
What are labs we check for patient with Acute glomerulonephritis?
- ESR
- ASO titer – tells if antibodies to strep A
- Throat culture
- BUN / creatinine
- UA
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Treatment for Acute glomerulonephritis?
- Antibiotics
- Vasodilators
- Diuretics
- Steroids
- Plasmaphoresis
- I&O’s
- Daily weights
- Potential fluid and sodium restrictions
- Alert MD of sudden increase in weight or BP
-
protein is going out of the blood vessels into the extracellular space
- Proteinuria
- Balancing protein is difficult – will give some protein back and if GFR drops may back off
-
Key features of Nephrotic Syndrome? Sudden onset of...
- massive proteinuria
- hypoalbuminemia
- edema (especially facial and periorbital)
- lipiduria
- hyperlipidemia
- increased coagulation
- reduced kidney function
-
What is the hallmark of Nephrotic Syndrome?
lose a TON of protein in urine
Permeability of the glomerulous membrane – large molecules move across, like proteins
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What is the priority for Nephrotic Syndrome?
Up the protein
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What are the risks/causes of Nephrotic Syndrome?
- Lupus
- HTN
- Genetics
- Immune
- Inflammation that causes damage
- Severe proteinuria
- Severe peripheral edema
- Low protein (albumin)
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Treatment for Nephrotic Syndrome?
- HTN – ACE inhibitors
- Follow labs
- Statins
- Protein if GFR is okay
- Sodium restrictions
- Diuretics
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What is the onset of Acute Kidney Injury?
hours to days
-
what is the % of Nephron involvement of Acute Kidney Injury?
50-95%
-
What is the prognosis for Acute Kidney Injury?
- can be really bad and progress to chronic kidney disease
- OR
- really bad and NOT progress to chronic kidney disease
-
In Acute Kidney Injury we see decreased ?
- decrease in urine output (sometimes phases of diuresis phase)
- decrease in GFR
- decrease in creatinine
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PRERENAL causes of Acute Kidney Injury
- Dehydration
- Trauma with blood loss
- Hypotension
- Septic shock
- Decrease vascular volume secondary to liver disease
- MI or heart failure (low cardiac output)
- NSAID’s / ASA (decrease blood flow)
- Burns (loss of intravascular volume)
- Anaphylaxis bronchioles constrict but the rest of vessels vasodilate
- Renal artery stenosis
- Artherosclerosis
-
The prerenal phase of Acute Kidney Injury is a result of ?
not enough profusion to the kidneys
-
The INTRARENAL phase of Acute Kidney Injury is a result of ?
Things that have an Affect on the tissues of the kidneys
-
INTRARENAL causes of Acute Kidney Injury ?
- Thrombi – clot in kidney
- Systemic infection
- Vasculitis
- Contrast dye
- Rhabdomyolosis
- Lupus
- Antibiotics (aminoglycosides)
- NSAID’s
- Alcohol
- Heavy Metals
- Cocaine
-
The POSTRENAL phase of Acute Kidney Injury is a result of ?
Urinary obstruction - flow
-
POSTRENAL causes of Acute Kidney Injury ?
- Bladder cancer
- Prostate cancer
- BPH – enlargement of the prostate
- Kidney stones
- Nephrolithiasis
- Urolethiasis
- Blood clots in urinary system
-
Timely interventions to remove the cause of Acute Kidney Injury may prevent?
- ESKD (end-stage kidney disease)
- lifelong renal replacement therapy
- renal transplant
-
In an acute care setting how can we prevent acute kidney injury?
- recognize manifestations of volume depletion (low urine output, low BP...)
- intervene early with oral fluids or request increase to IV rate
-
What OTC meds have a direct effect on the renal system?
-
Decreased urine output?
Oliguria
-
Urine output of about 400 ml /day?
Anuria
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What does the BP do in Acute Kidney Injury (AKI)?
Hypotension
-
What does the BP do in Chronic Kidney Disease (CKD)?
HTN
-
What is the normal range for MAP (mean arterial pressure)?
70-110 mm Hg for healthy adults
-
What is the recommended MAP (mean arterial pressure) to maintain kidney profusion?
65 mm Hg
-
What is the MAP (mean arterial pressure) calculation?
MAP = (SBP + [2 x DBP]) / 3
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If kidney function is poor what will BUN/creat look like?
They will rise
-
When the kidneys cannot filter and there is a build up of nitrogenous waste?
-
What are the key features of Uremia?
- metallic taste in the mouth
- anorexia
- N/V
- muscle cramps
- uremic frost
- ITCHING
- fatigue and lethargy
- hiccups
- edema
- dyspnea
- paresthesias
-
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What do we do for Stage 1 kidney function?
Screen for risk factors and manage care to reduce risk
-
GFR 60-89 mL/min
- Stage 2
- Mild chronic kidney disease
- Reduced kidney function
-
What do we do for Stage 2 kidney function?
Focus on reduction of risk factors
-
-
What do we do for Stage 3 kidney function?
Implement strategies to slow disease progression
-
-
What do we do for Stage 4 kidney function?
- Manage complications
- Discuss patient preferences and values
- Educate about options and prepare for renal replacement therapy
-
GFR <15 mL/min
- Stage 5
- End-stage kidney disease (ESKD)
-
What do we do for Stage 5 kidney function?
- Implement renal replacement therapy
- Kidney transplantation
-
What do we teach patients with mild CKD?
- manage fluid volume, BP, electrolytes, other kidney-damaging diseases
- following prescribed drug and nutrition therapies
- prevents and slow progression
-
As CKD progresses what happens to potassium?
K+ goes up
-
What is done if K+ is 5.5?
Cut K+ out of diet
-
What is done if K+ is 6.0?
kayexalate to bind K+ and poop out
-
What is done if K+ is 7.0?
- must act immediately to reduce quickly
- give insulin with glucose to push K+ into cell
- prepare for dialysis
-
In metabolic acidosis fast and deep breathing to blow off PCO2 is called?
Kussmaul breathing
-
What is given to correct hyperphosphatemia?
- Aluminum hydroxide – phosphate binders
- hyperphosphatemia = hypocalcemia
-
This is both a cause and result of CKD
HTN
-
When ACE inhibitors are started for CKD what do we do?
- When first started – can drop GFR – test 2 weeks later
- Confusing because can cause worsening GFR or can help the kidneys so we will evaluate labs
-
Key features of end-stage kidney disease
- Neurologic
- Cardiovascular
- Respiratory (halitosis, stomatitis)
- Hematologic
- GI
- Urinary
- Integumentary
- MSK
- Reproductive
-
What do we need to check and maintain for Hemodialysis?
Vascular access – AV fistula, graft (bruit and thrill, good peripheral pulses, never compromise, no BP, venipuncture…)
-
Key features to remember for hemodialysis
- Vascular access – AV fistula, graft (bruit and thrill, good peripheral pulses, never compromise, no BP, venipuncture…)
- 3 x week at least 4 hours
- Clinic
- Daily weights
- Heparin
-
Key features to remember for peritoneal dialysis
- Intact peritoneum
- Daily – all day
- More flexibility but takes longer
- Home
- Increased risk of infection (sterile technique)
- Any cloudy effulent – specimen for C/S – or see provider
- Need more protein in diet, less dietary restrictions because daily
- Daily weights
- Flow issues – constipation from enlargement of bowels pressing against
-
Best practice for patient safety and quality care for hemodialysis
- weigh before and after
- know the patients dry weight
- discuss whether any of the meds should be held
- be aware of events that occurred during previous dialysis
- get V/S
- assess for orthostatic hypotension
- assess the vascular access site
- observe for bleeding
- assess LOC
- asses for HA, N/V
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Caring for Arteriovenous Fistula or Arteriovenous Graft
- No BP on that extremity
- no venipuncture or IV on that extremity
- palpate for thrills and auscultate for bruits Q4H
- assess distal pulses and circulation
- elevate extremity post op
- encourage ROM
- check for bleeding
- assess for infection
- no heavy objects
- don't sleep with body weight on extremity
-
Manifestations of peritonitis?
- cloudy dialysate
- fever
- abd tenderness
- malaise
- N/V
-
Caring for pt with a peritoneal dialysis catheter
- mask patient and self, wash hands
- don sterile gloves, remove old dressing, remove contaminated gloves
- assess for signs of infection
- use aseptic technique (set up sterile field)
- don sterile gloves
- clean around site with swabs soaked in providine-iodine
- apply precut gauze pads over catheter site and tape edges
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