Kidneys

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tiffanydawnn
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136439
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Kidneys
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2012-02-20 06:32:43
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Kidneys
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Kidneys
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  1. function of kidneys
    • form urine - glomerular filtration, reabsorption, excretion
    • erythropoietin - increase RBC to increase O2 carrying capacity (in response to tissue hypoxia)
    • regulate BP - RAA - renin secreted by afferent arterioles in response to decreased BP
    • electrolyte balance
    • H2O balance - ADH
    • pH balance - H+/HCO3- secretion/reabsorption if too acidi/alkaline
    • activate vitamin D - stimulated by PTH in response to low blood calcium > calciferol (absorbs Ca/PO4 from small intestine)
  2. glomerular filtration
    • BP forces plasma, small proteins out of glomeruli into Bowman's capsule > renal filtrate
    • GFR: amount of fluid filtered/filtrate formed per minute - 100-125mL/min
    • increased BP in glomeruli (60 mmHg)
  3. tubular reabsorption
    recovery and return of useful materials from filtrate to circulation via peritubular capillaries
  4. tubular secretion
    • waste products actively secreted into filtrate
    • ammonia, creatinine, medications
    • H+ secreted/reabsorbed to maintain blood pH
    • excess potassium secreted
  5. elimination
    ureters > bladder > urethra
  6. urine
    • 1-2L per 24 hours
    • straw or amber colored
    • clear vs cloudy
    • ***specific gravity: 1.010-1.025***
    • --<1.010: DI, overhydration, renal disease, potassium deficit (dilute)
    • -->1.025: dehydration, fever, DM, vomiting, DHR (concentrated)
    • pH: 4.6-8.0 - influenced by diet, meds (chemo is acidic > bladder hemorrhage > CBI to neutralize)
    • 95% H2O, 5% nitrogenous waste (urea, creatinine, uric acid)
  7. urinary system - aging
    • decreased nephrons
    • decreased GFR r/t decreased renal blood flow s/t arteriosclerosis
    • decreased bladder size
    • decreased detrusor muscle tone > increased frequency, PVR (s/b < 150, >150/250 = straight cath)
    • increased UTIs
    • decreased ability to concentrate urine
    • increased r/f dehydration r/t decreased ability to compensate for salt intake
    • decreased potassium excretion r/t decreased aldosterone levels
    • fluid/electrolyte imbalances
    • decreased drug clearance
  8. kidney disorders
    • congenital malformation
    • polycystic kidney disease
    • glomerular disorders (nephrotic syndrome)
    • renal failure
  9. polycystic kidney disease
    • formation of fluid filled cysts, massive kidney enlargement
    • hereditary
    • two forms: autosomal dominant and autosomal recessive
    • autosomal dominant - adults
    • autosomal recessive - children
  10. PKD patho
    • renal cysts affect nephron
    • fill, enlarge, multiply
    • affect medulla and cortex
    • cause fibrosis and scarring
  11. PKD manifestations
    • slow progression
    • flank pain
    • kidney concentration problems:
    • --hematuria - microscopic or gross
    • --proteinuria
    • --polyuria
    • --nocturia
    • UTIs, renal calculi - cysts block normal drainage
    • HTN - RAA
    • enlarged, palpable kidneys
    • renal insufficiency > CKD > ESRD
  12. PKD dx
    • renal ultrasound
    • CT scan
    • genetic testing
  13. PKD tx
    • supportive management
    • avoid nephrotoxins - mycins, oral antidiabetics
    • manage/avoid HTN
    • avoid UTIs, lithiasis - fluid intake 2000 - 2500 mL
    • hemodialysis > renal transplant
  14. PKD nursing dx
    • excess fluid volume r/t impaired renal function
    • grieving r/t loss of kidney function
    • readiness for enhanced knowledge
    • risk for ineffective coping
  15. glomerular disorders
    • affect structure and function of glomerulus
    • disrupts glomerular filtration
    • capillary membrane more permeable to plasma proteins, blood cells > hematuria, proteinuria, edema
    • decreased plasma proteins > increased filtrate > RAA stimulation > vasoconstriction, decreased GFR
    • decreased GFR > HTN, azotemia (increased waste products [urea] in blood), oliguria (< 400mL for 24 hours)
  16. glomerular manifestations
    • hematuria r/t permeable membranes
    • proteinuria r/t permeable membranes
    • Na, H2O retention r/t increased aldosterone s/t RAA
    • cola colored urine
    • ***periorbital edema, dependent edema***
    • HTN
    • fatigue
    • anorexia
    • N&V
  17. acute proliferative glomerulonephritis
    • inflammation of glomerular capillary membrane
    • caused by beta hemolytic strep infection
    • circulating immune complexes become trapped in glomerular membrane
    • tx: antibiotics, bed rest
  18. Goodpasture's syndrome
    • rare autoimmune disorder
    • formation of antibodies to glomerular basement membrane
    • tx: immunosuppression, plasmapheresis (remove antibody/antigen complex)
  19. nephrotic syndrome
    • group of clinical findings
    • s/t malignancy, HTN, infection
    • --proteinuria
    • --hypoalbuminemia r/t protein loss in urine
    • --hyperlipidemia r/t liver compensation for decreased proteins
    • --edema
    • risk for clotting, DVT, PE (decreased clotting factors)
    • tx: ACE inhibitors, low sodium diet (1 to 2 g daily), moderate, complete proteins
  20. chronic glomerulonephritis
    • diabetic neuropathy - 40% of DM patients, leading cause of CKD
    • lupus nephritis
  21. glomerular disorder dx
    • identify underlying disease process, preserve kidney function
    • throat/skin culture, ASO titer - strep
    • ESR - autoimmune
    • KUB - kidney, ureter, bladder xray - enlarged kidneys (acute), small kidneys (late chronic)
    • kidney scan - perfusion
    • **biopsy - most reliable to determine type, prognosis, tx
  22. glomerular disorder labs
    • BUN - increased r/t azotemia
    • serum creatinine - increased r/t decreased renal function (> 4 = serious)
    • creatinine clearance - amt cleared in one minute - decreased
    • serum albumin - decreased r/t proteinuria
    • serum electrolytes - hyper except calcium
    • RBC - decreased r/t decreased erythropoietin levels
    • urine creatinine - decreased
    • urine protein - increased
    • urine RBC - increased
    • GFR - decreased (normal > 60)
    • "elevated potassium, phosphorus, decreased protein, pee pee"
  23. glomerular disorder meds
    • antibiotics if infectious
    • immunosuppressive therapy if autoimmune
    • oral glucocorticoids if autoimmune
    • ACE inhibitors - renal protective, decrease BP
    • antihypertensives - limit kidney damage
  24. glomerular disorder nursing
    • goal: maintain renal function, prevent complications, promote healing
    • fluid volume excess - restrict fluids
    • fatigue
    • ineffective protection
    • ineffective role performance
    • pain
    • ineffective breathing patterns
    • anticipatory grieving
  25. chronic kidney disease
    • presence of kidney damage for 3+ months (GFR < 20)
    • diffuse bilateral kidney disease with progressive destruction and scarring of whole nephron
    • caused by
    • --diabetes
    • --HTN
    • --pre-existing glomerular nephritis
  26. CKD patho
    • depends on underlying disorder
    • gradual loss of entire nephron unit
    • hypertrophy of remaining nephrons > increased glomerular capillary flow and pressure
    • more solute particles filtered to compensate for lost renal mass
    • increased demand cause scarring on remaining nephrons
    • decreased renal reserve > renal insufficiency > renal failure > ESRD
  27. decreased renal reserve
    • GFR 50% of normal
    • normal BUN
    • slightly elevated creat
    • asymptomatic
  28. renal insufficiency
    • GFR 20-50%
    • mild azotemia
    • increased BUN
  29. renal failure
    • GFR < 20%
    • sharp increase in BUN/creat
  30. ESRD
    • GFR < 5%
    • renal replacement therapy
  31. uremia
    • "urine in the blood" - build up of waste - severe azotemia
    • nausea, apathy, weakness, fatigue, confusion
  32. fluid/electrolyte imbalances
    • impaired ability to regulate fluids, electrolytes, acid/base
    • early stage: Na/H2O not conserved > dehydration, polyuria, nocturia, dilute urine
    • late state: Na/H2O retained > FVE
    • hyperkalemia - muscle weakness, paresthesia, EKG changes (when GFR < 5)
    • hyperphosphatemia - excretion impaired
    • hypermagnesemia - avoid antacids
    • hypocalcemia - reduced calcium absorption r/t impaired vitamin D activation
    • H+ excretion, bicarb production impaired - metabolic acidosis - Kussmaul respirations
  33. cardiovascular effects
    • accelerated atherosclerosis
    • HTN r/t FVE, increase RAA, vascular resistance
    • HF r/t FVE
    • decreased contractility r/t acidosis
    • hyperlipidemia
  34. hematologic effects
    • anemia r/t decreased erythropoietin, decreased life span s/t toxins in blood
    • impaired platelet function
  35. immune effects
    • increased r/f infection - impaired inflammation and immune response r/t toxins
    • suppressed fever
  36. GI effects
    • anorexia
    • N&V
    • hiccups
    • uremic fetor - urine breath
  37. neuro effects
    • central and peripheral changes r/t uremia
    • AMS, fatigue, insomnia
    • restless legs, paresthesias r/t hypocalcemia
  38. musculoskeletal effects
    • hyperphosphatemia, hypocalcemia stimulate PTH > renal osteodystrophy (renal rickets) - softened bones, decreased bone mass
    • bone tenderness, pain, muscle weakness
    • Trousseau's, Chvostek's
  39. endocrine/metabolic effects
    • glucose intolerance
    • high triglycerides
  40. dermatologic effects
    • uremic frost - crystals on skin from urea
    • pallor r/t anemia
    • yellow hue r/t retained metabolites
  41. CKD dx
    • urinalysis - specific gravity (low d/t impaired tubular secretion, reabsorption, concentration)
    • urine culture - UTIs
    • BUN - 20-50 = mild azotemia, 100+ = severe azotemia, 200+ = uremic sx
    • serum creatinine > 4 = serious renal impairment
    • eGFR - stage disease
    • Na - normal to low d/t H2O retention
    • K - elevated
    • Phos - elevated
    • Ca - decreased
    • CBC - amemia, low platelets
    • renal US - kidney size decreaed as nephrons destroyed
    • kidney biopsy - determine underlying disease
  42. CKD meds
    • avoid nephrotoxic meds
    • increased half-life
    • avoid oral antidiabetics, NSAIDs
    • ACE/ARBs - slow progression of CKD, HTN
    • diuretics - reduce FV, edema, HTN, waste K
    • Na bicarb/Ca bicarb - correct acidosis
    • Phos-Lo - binds to phosporus to lower phosphate, normalize Ca
    • High K levels - bicarb + insulin + glucose (move K back into cells)
    • Kayexalate - excrete K
    • folic acid/iron/vitamin D
  43. CKD diet
    • reduced protein - 0.6gm/kg/day
    • increased carbs - 35cal/kg/day
    • decreased Na and H2O as disease progresses
    • decreased K - salt substitutes
    • decreased phos - eggs, dairy, meat
  44. CKD nursing dx
    • goals: prevent further damage, minimize toxic waste, maintain nutritional status
    • ineffective renal perfusion r/t nephron destruction
    • imbalanced nutrition - less r/t anorexia, N&V
    • risk for infection r/t altered immunity
    • disturbed body image

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