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
What labs show whether the body is filtering nitrogenous wastes?
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
When there is a problem regulating phosphates what other electrolyte do we need to look at?
Hypertension is both ? ? of renal failure
What are the top two causes of renal failure?
Name risk factors that may lead to renal failure:
- contrast dye
- NSAID’s (nephrotoxic drug class)
- 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)
When a patient has a renal biopsy what is done post-procedure?
patient on back for 6 hours to prevent bleeding
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)
Key features of Polycystic Kidney Disease
- Abd or flank pain
- Increased abd girth
- kidney stones
- sodium wasting and inability to concentrate urine in early stage
- progression to kidney failure with anuria
- Development of aneurysms (berry aneurysms)
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
What is the priority care with Polycystic kidney disease?
- control HTN
- helping with pain
What is the third leading cause of end-stage kidney disease?
Polycystic kidney disease
To prevent worsening of renal issues what do we advise regarding fluid intake?
at least 2L daily
If one of parents has the disease, a child has 50% chance of getting the disease, what is this known as?
This is Inflammation of glomerulous capillaries – develops after a strep (group A hemolytic strep) infection
What is the GFR?
amount of urine kidneys filter from the blood
What are risk factors for Acute glomerulonephritis?
- DM I
- strep (group A hemolytic strep) infection
- HTN and vascular issues
What are S/S of Acute glomerulonephritis?
- Periorbital edema (fluid overload)
- Reddish brown (cola colored) urine
- Decreased urine output
What are labs we check for patient with Acute glomerulonephritis?
- ASO titer – tells if antibodies to strep A
- Throat culture
- BUN / creatinine
Treatment for Acute glomerulonephritis?
- 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
- 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
- edema (especially facial and periorbital)
- 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
What is the priority for Nephrotic Syndrome?
Up the protein
What are the risks/causes of Nephrotic Syndrome?
- Inflammation that causes damage
- Severe proteinuria
- Severe peripheral edema
- Low protein (albumin)
Treatment for Nephrotic Syndrome?
- HTN – ACE inhibitors
- Follow labs
- Protein if GFR is okay
- Sodium restrictions
What is the onset of Acute Kidney Injury?
hours to days
what is the % of Nephron involvement of Acute Kidney Injury?
What is the prognosis for Acute Kidney Injury?
- can be really bad and progress to chronic kidney disease
- 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
PRERENAL causes of Acute Kidney Injury
- Trauma with blood loss
- 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
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
- Contrast dye
- Antibiotics (aminoglycosides)
- Heavy Metals
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
- 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?
Urine output of about 400 ml /day?
What does the BP do in Acute Kidney Injury (AKI)?
What does the BP do in Chronic Kidney Disease (CKD)?
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
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
- muscle cramps
- uremic frost
- fatigue and lethargy
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?
What is given to correct hyperphosphatemia?
- Aluminum hydroxide – phosphate binders
- hyperphosphatemia = hypocalcemia
This is both a cause and result of CKD
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
- Respiratory (halitosis, stomatitis)
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
- Daily weights
Key features to remember for peritoneal dialysis
- Intact peritoneum
- Daily – all day
- More flexibility but takes longer
- 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
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
- abd tenderness
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