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Kidneys maintain homeostasis by?
maintaining constant chemical and fluid balance
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How much of the total blood suppy enters the kidney with each heart beat?
one fourth
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The functional unit of the kidney is called?
Nephron
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What part of the nephron is similiar to the hollow fiber membrane of the dialyzer?
Glomerulus - both have walls that are semipermeable
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Name the 7 functions of the kidney.
*A Wet Bed*
- 1. acid/base balance(pH)
- 2. water removal
- 3. electrolyte balance
- 4. toxin(waste)removal
- 5. blood pressure regulation
- 6. erythopoietin-stimulates RBC's
- 7. vitamin D production
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Define: CKD
Chronic Kidney Disease
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Define: ESRD
End Stage Renal Disease
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Define: ARF
- Acute Renal Disease
- -usually reversible, lasting 2-4 wks
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Uremia is used to describe signs and symptoms that accompany CKD. The signs/symptoms include:
edema, hypertension, anorexia, restlessness, dyspnea, fatigue, weakness
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Excess fluid in blood causes?
hypertension - High BP
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Excess electrolytes causes
potassium levels rise lead to cardiac rhthm problems
phosphorus levels lead to bone disease and calcification of blood vessels
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Waste products such as creatinine and BUN cause
- nausea, vomiting
- decreased appetite
- fatigue
- headaches
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Hyperkalemia - Potassium level greater than 5.5
caused by diet, infection, hyperglycemia and homolysis
symptoms: muscle weakness, abnormal heart rhythm, bradycardia, cardiac arrest
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Hypernatremia - sodium level greater than 146mEq/L
caused by excessive water loss
symptoms: restlessness, fever, dry mucos membranes, muscle weakness, difficult respiration, headaches, hypertension, crenation(shriveling of RBC's)
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Hyponatremia - sodium level less than 135mEq/L
caused by excessive intake or retension of fluid
symptoms: anxiety, headache, tachycardia, nausea, vomiting, clammy skin, hypotension, muscle cramps, hemolysis
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Hypercalcemia - calcium greater than 10.5 mg/dL
caused by hyperparathyroidism, diet, medication or dialysate
symptoms: lethargy, headache, irritablility, muscle weakness, cardiac arrest
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Hypocalcemia - calcium level less than 8.4 mg/dL
caused by infections, parathyroidectomy, diet, medication, too low calcium in dialysate
symptoms: numbness, tingling, muscle spasms, convulsions, cardiac sysrthythmias, bleeding
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Normal body pH is?
7.35 - 7.45
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Hypotention occurs when?
vascular space is depleted, and fluid shift from intercellular has not occurred as rapidly as fluid removal from vascular space
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Cramping:
caused from sodium and fluid pulled to rapidly, causing muscle spasms
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Hypertension:
cause by fluid/volume overload; can also be associated with renin secretion
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Interdialytic weight gain
pre weight - last post weight
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UFR
amount of fluid removed each hour of tx
(goal/hours of tx = UFR)
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Osmosis
fluid moves from a lower solute concentration to a higher solute concentration - attempts to move fluid to have an equal concentration on both sides of semipermeable membrane
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Diffusion
solutes move from a higher solute concentration to a lower solute concentration - attempts to equalize the solutes on both sides of semipermeable membrane
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Creatinine, phosphorus, and urea ______ _____ of the patients blood, into the dialysate and down the drain.
move out
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Bicarbonate, calcium, glucose, and potassium can cross the semipermeable membrane in __________ ___________ (diffusion: will move frome area of higher concentration to area of lower concentration)
either direction
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Bacteria is too __________ to cross an intact semipermeable membrane that may be present in dialysate.
large
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Normal Sodium serum level:
135-146mEq/L
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Normal Potassium serum level:
3.5 - 5.5 mEq/L
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Normal Calcium serum level:
8.5 - 10.5 mg/dL
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Normal Magnesium serum level:
1.7 - 2.5 mEq/L
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Normal Chloride serum level:
98 - 106 mEq/L
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Bicarbonate consists of 3 elements:
- *acid concentrate
- *bicarbonate concentrate
- *dialysis quality water
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The acid concentrate contains the _____________.
electrolytes
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Range of sodium in dialysate:
135 - 145 mEq/L
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Range of potassium in dialysate:
0 - 4 mEq/L
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Range of calcium in dialysate:
2.5 - 3.5 mEq/L
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Range of magnesium in dialysate:
.5 - 1.0 mEq/L
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Range of chloride in dialysate:
100 - 124 mEq/L
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Range of bicarbonate in dialysate:
32 - 40 mEq/L
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Range of glucose in dialysate:
0 - 250 mg/dL
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Over mixing of bicarbonate concentration must be acoided because
may cause carbon dioxide loss and an increase in pH which will result in the formation of precipitate!
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Level of bacteria in equipment/dialysate is:
less than 200 CFU/mL
action level of 50 CFU/mL
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Level of endotoxin level in equipment/dialysate is:
less than 2 EU/mL
action level of 1 EU/mL
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Conductiviity is defined as a substances ablility to conduct and electrical current.
acceptable range: 13.0 - 15.5 mMhos
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pH refers to the acidity of a solution
acceptable range: 7.0-7.4
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Dialysate temperature
35 - 39degrees Celcius
keeping this range helps avoid hemolysis or crenation of RBC's
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Healthy person is exposed to 14L of drinking water per week. CKD patient is exposed to 360L of water per week.
Healthy kidneys remove contaminents in drinking water; CKD patients do not have this protection. This is why water must pass through a treatment system.
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AAMI
Association for the Advancement of Medical Instrumentation
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Inorganic Chemical Contaminants are monitored on a
annual basis
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Microbial matter (bacteria and endotoxins) is monitored on a
monthly basis
Endotoxins can cause pyrogenic reactions
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Total Chlorine monitored prior to first pt tx and every 4 hours after. Too high chlorine levels can
cause hemolysis or pt death
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Hard water tested at the end of the day can cause
scaling of the membranes, with potential damage to RO membranes.
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Backflow Preventor:
required by municipalities; tested annually
Prevents treated water and disinfectants from backing up into the city water supply.
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Blend valve: allows the membrane to function at the most efficient temperature
77 degrees
too hot a temp can damage the RO membrane
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Booster Pump
controls pressure so there is adequate pressure to run RO and to push water around loop. Eliminates wide pressure fluctuations.
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Multimedia Filter filters out silt and sand
water enters the top of the tank and flows to the bottom coming in contact with progressively smaller filtering particles
Backwashing nightly to remove trapped particles
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Water softener removes calcium and magnesium via ion transfer.
Soften water keeps the RO running smoothly with no damage to membrane.
works with the brine tank to exchange sodium for calcium and magnesium.
Regenerates nightly, flushing Ca and Mg from system and replacing with Na.
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Carbon Tanks essential for the removal of chlorine/chloramines.
there is primary tank(s) and secondary tank(s) in a series. They are backwashed nightly. They have to be replaced or rebedded when they no longer absorb chlorine/chloramines.
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Chlorine is checked ?
prior to first pt tx, and every 4 hours after
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If chlorine levels are above .1mg/L then what??
recheck post primary tank, if still above limit of .1 then check post secondary tank. If secondary tank is clear, then secondary tank must be checked every 30 min. If secondary tank does NOT pass, stop tx immediately!!
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RO prefilter removes fine carbon particles; placed after the carbon tanks and before the RO unit.
must be replaced after water treatment systemdisinfection or per manufacture recommendations.
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Purification requires water to pass through RO membranes followed by an ultrafilter.
Deionization followed by Ultrafilter may be present in the event the primary RO source is not working.
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RO (reverse osmosis) provides the system with dialysis quality water.
It removes bacteria, viruses, endotoxins,salts, particles, andsome dissolved organic substances. It's the primary device of the water system. It uses a semipermeable membrane and pressure produced by a pump, the pressure forces water thru the membrane.
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DI tanks or deionization exhanges unwanted ions for water. They essentially collect contaminants and exchanges them for H2O.
AAMI requires that DI tanks be followed by ultrafilters to capture any bacteria or endotoxins.
DI tanks have resin beads that hold on to all ions. When they are exhausted, they have to be replaced!! Measured by resistance - alarm at 5meg, at 1 meg tx must stop!
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DI tanks can be used for backup for water purification
DI tanks can be used to "polish" the RO
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Ultrafilters: or pyrogen or endotoxin filter is placed at the end of the water system. Is it capable of removing all viruses, bacteria and most endotoxins.
Filters are replaced annually or according to manufacturers recommendation.
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Distribution loop is the transport systemt to bring purified water to the patients.
Minimum flow of velocty is 3ft/sec to prevent the buildup of biofilm (slime made by microorganisms)
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Low venous pressure alarms if:separation of blood tubing from the venous fistula needle or catheter - needles came out of arm???? An occlusion in the blood tubing, or a clotted dialyzer.
High venous pressure alarms if: occlusion or obstruction in blood tubing btw monitoring site and venous needle, bad positioning of needle, infiltration, poorly functioning catheter, clotting access
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Low arterial pressure d/t: occlusion of the arterial supply from vascular access, kink in blood tube, bad position or infiltration of arterial needle, blood pump set higher than access can provide, hypotension, vasoconstriction, poorly functioning access.
High arterial pressure d/t: (0 or positive number) blood line seperation, leak between patient and monitor, decrease in pump speed, infusion of saline or medication.
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To assess maturation of a new AV fistula:
(rule of 6's)
- .6 cm below skin
- 6-8 weeks for maturation
- access bfr greater than 600mL/min
- diameter greater than .6cm
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Advantages to AV fistula:
reduced clotting and infections, no allergic reactions, lasts a long time, no activity restrictions, buttonhole capability
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Disadvantages of AV fistula:
- time to mature
- requires pt to excercize
- may have inadequate blood flow rate
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Check for thrill and bruit
- thrill is what you feel,
- bruit is what you hear
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Advantage of AV graft:
- can be used sooner than fistula, generally 4-6 wks
- need to wait to cannulate til edema is gone, time for access to adhere to tissues
- blood flow not dependent on maturation
- no activity restrictions
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Disadvantages of AV Graft:
- clotting
- venous stenosis
- infections
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Catheter - CVC advantages:
- can be used immediately
- used when problems with clotting or infections
- used when extremity vessels are inadequate
- used when emergency tx is needed
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Disadvantages to CVC's:
clotting, infection, stenosis, recirculation, inadequate blood flow= inadequate dialysis, self image alterations, dislodgement, hemorrhage, air embolus
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Causes of hypertension pre-treatment
- fluid overload
- renin (vasoconstriction)
- street drug usage
- no adherence to prescribed medication schedule
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Causes of hypotension pre-treatment:
- hehydration
- antihypertensive meds
- nitroglycerin patches
- irregular heart rate
- underlying cardiac disease
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Decreasing the patients blood flow rate affects the rate of:
diffusion
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feed conductivityj minus product conductivity divided by 100 is the formula calculation of:
percent rejection
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A slow pulse rate of 54 beats per minute would indicate the patient has:
bradycardia
Normal heart rate is 60-100 beats per minute
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Asepsis:
the absense of disease producing organisms.
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Sepsis/Septic:
invasion of the body by pathogenic microorganisms or their toxins
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The National standard, based on the KDOQI guidelines, for the Urea Reduction Rate (URR) is a ratio greater then
65%
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The medication used to treat anemia is:
Epogen
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The medication used to improve calcium absorbsion is:
Zemplar
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Signs/symptoms of hypotension
- *gradual or sudden drop in bp
- *flushing
- *yawning
- *dizziness
- *ringing in the ears
- *tachycardia
- *anxious feeling
- *nausea, vomiting
- *cold, clammy skin
- *seizures
- *possible death
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Sodium Modeling: to assist in fluid removal, to reduce cramping, raise BP
sodium content in the dialysate is higher than the pt's blood, sodium will diffuse from dialysate into pt's blood stream. Now by osmosis, fluid will move from tissues into vessels then removed via ultrafiltration.
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Muscle cramps caused by rapid shifts in fluid, hypoatremia, hypocalcemia
intervention: saline bolus, reduce UFR, massage or apply opposing force
prevention: sodium modeling, assess and adjust EDW
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Disequilibrium Syndrome (DDS):
an acute increase in brain water.
causes: too rapid changes in serum electrolytes, pH, blood vs brain tissue osmolarity
Pt's at greatest risk: new pt's, pt's who have skipped tx
signs/symptoms: headache, hypertension, nausea, vomiting, restlessness, convulsions, decrease in consciousness, coma, death
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Sterilant Infusion
causes: no residual testing, inaccurate testing, rebound(can occur when sterilant trapped in potting compound is released during tx)
signs/symptoms: immediate pain/burning in access, nausea, shortness of breath, flushing, chest pain, hypotension, tingling around mouth, gasoline tates
Intervention: stop blood pump, DO NOT RETURN BLOOD!, assess vital signs, administer saline for low bp, oxygen, notify Dr., draw blood samples per Dr orders
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Hemolysis
causes: hypotonic dialysate, blood pump not calibrated correctly, temp too high, chlorine, failure of conductivity meter, exposure to disinfectant
signs/symptoms: blood appears "cranberry juice" color, anxiety, restlessness, pain in access arm, nausea, vomiting, abdominal cramping, chest tightness, seizures, dysrhythmias, anemia, possible death
interventions:stop blood pump, clamp lines, DO NOT RETURN BLOOD, give 02, notify Dr.
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