Renal lecture

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Renal lecture
2012-11-19 20:56:42
renal lecture

Sheri's renal lecture
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  1. who is the star of the show for the renal lecture
    nephron and glomerulus
  2. components of Bowman's capsule
    glomerulus and tubules
  3. best indicator for kidney function
  4. define BUN
    end product of protein metabolism
  5. normal BUN
    • adult:  5-25mg/dl
    • elderly:  May be slightly higher
  6. define creatinine
    • breakdown of skeletal muscle
    • good measure of GFR
    • more sensitive indicator of kidney disease
  7. normal creatinine
    • adult:  0.5-1.5 mg/dL
    • elderly:  decreased due to muscle loss
  8. define creatinine clearance
    24 hour urine collection to check GFR
  9. considerations when collecting a 24 hour creatinine clearance
    • obtain physician order
    • keep on ice
    • discard the first void of the morning, then start the collection
    • if miss a voiding, must start over
    • midway through will have a serum creatinine drawn
  10. normal creatinine clearance
    urine clearance:  1-2g/24 hours
  11. define GFR
    how fast kidneys filter wastes and fluids
  12. normal GFR
    125 mL/min to 200 mL/min
  13. what is acute renal failure?
    • sudden, reversible kidney function loss
    • may be almost complete
    • occurs in hours or days
    • can resolve itself or go into chronic renal failure
  14. S/S of acute renal failure
    • dyspnea
    • tachycardia
    • neck vein distention
    • moist crackles in lungs
    • generalized edema
    • appear acutely ill
    • lethargic
    • dry mm
    • HA
    • seizures
    • twitching
    • decreased UOP
  15. what is the leading cause of ARF?
  16. what is the 2nd leading cause of ARF?
  17. what is prerenal failure and what can cause it?
    caused by volume depletion

    ex:  hemorrhage, GI bleed, HF, sepsis, vasodilation, MI
  18. what is intrarenal failure and what can cause it?
    due to some sort of ischemia or necrosis

    ex:  drugs, dyes,
  19. what is postrenal failure and what can cause it?
    due to obstruction

    ex:  BPH, tumors, stones, blood clots, strictures
  20. What are the 4 phases of ARF?
    • initiation
    • oliguria
    • diuressis
    • recovery
  21. what is the initiation phase?
    from time of insult to when oliguria occurs
  22. what is oliguria?
    <400-500 mL/day
  23. what happens in the olguria phase?
    • lab values increase
    • decreased renal function
    • lasts about 10-20 days
  24. what is anuria
    < 50mL in 24 hours
  25. what happens in the diuresis phase?
    • gradual ^ in UOP
    • lab values stop increasing

    kidneys start to work again
  26. what happens in the recovery phase?
    • lab values return to normal
    • GFR is 1-3% reduced and not really noticeable to pt
    • lasts about 3-12 months
  27. medical management of ARF
    • restore fluid balance
    • provide nutritional therapy
    • medication regimen
  28. how can fluid balance be restored in ARF?
    • lab monitoring
    • accurate I/O
    • restrictions
    • dialysis may be needed
  29. how can nutrition be supported in ARF?
    • provide ^ carbohydrate diet
    • limit Na+ and K+
  30. what is included in the medication regimen for ARF?
    • temporary management (Insulin, Ca+ gluconate)
    • diuretics
    • cardiac medications
  31. how does Ca+ gluconate help someone in ARF?
    protects the heart
  32. how does Kayexalate help in ARF?
    • helps lower K+ via the "gut"
    • can cause diarrhea
  33. dietary concerns for burn pt in ARF or ARF pt w/ bed sores
    high biological protein diet

    ex:  eggs, meat
  34. dietary concern for renal pt
    low protein, high carb diet
  35. signs of hyperkalemia on ECG
    • decreased PR
    • widened QRS
    • peaked T
  36. nursing management/interventions for ARF
    daily treatments:  I/O, daily wt, assessment, monitor labs, ASEPSIS!!!, complication prevention

    prevention and support

    education:  dietary (fluid restrictions), fluid imbalance
  37. 500mL of fluid = ________lbs
  38. what is chronic renal failure (CRF) or chronic renal disease (CRD)?
    progressive, nonreversible

    body fails to maintain the fluid and electrolyte balance
  39. CRF  cardiac assessment findings
    • edema
    • engorged neck veins
    • HTN
    • HF
  40. CRF dermatological assessment findings
    • pruritis
    • uremic frost
    • thin hair
    • brittle nails
  41. CRF GI assessment findings
    • hiccups
    • constipation
    • diarrhea
    • anorexia
    • metallic taste
  42. CRF neurological assessment findings
    • weakness
    • inability to concentrate
    • msucle twitching
    • seizures
    • asterixis
  43. what is asterixis?
    flapping of hands
  44. patient teaching considerations in CRF
    • give information in writing
    • repeat teaching
    • teach in small increments due to inability to concentrate
    • make sure family present
  45. CRF pulmonary assessment findings
    • crackles
    • SOB
    • thick tenacious sputum
  46. CRF musculoskeletal assessment findings
    • muscle cramps
    • muscle loss
    • bone pain
    • foot drop
  47. CRF emotional assessment findings
    • body changes
    • grieving stages (anger, depressed)
  48. stages of CRF
    • stage 1
    • stage 2
    • stage 3
    • stage 4
    • stage 5
  49. stage 1 of CRF
    • no symptoms
    • *GFR > or = to 90 mL/min
    • higher than normal levels of creatinine or urea in the blood
    • blood or protein in urine
    • evidence of kidney damage in an MRI, CT, US, contrast XR
  50. stage 2 of CRF
    • no symtoms
    • *GFR is = to 60-89 mL/min
    • care is viligant o reduce risk factors for kidney disease
  51. stage 3 of CRF
    • *GFR is 30-59 mL/min
    • moderate, chronic kidney disease
    • care is focused to slow progression of disease through diet and increased vigilance to avoid hypoperfusion, toxins, and other risk factors
    • *start having s/s
    • *should start seeing nephrologist
  52. stage 4 of CRF
    • *GFR is 15-29 mL/min
    • likely to develop complications of kidney disease such as HTN, anemia, bone disease, heart disease, and other CV diseases
    • *s/s:  nausea, taste changes, uremic breath, loss of appetite, difficulty in concentrating, nerve problems
    • *will probably begin thinking about dialysis, probably get dialysis access so it has time to heal
  53. dialysis and kidney transplants
    treatment, NOT A CURE!
  54. stage 5 of CRF
    • *<15 mL/min
    • s/s:  loss of appetite, N/V, HA, being tired, being unable to concentrate, itching, making little or no urine, swelling (especially around the eyes and ankles), muscle cramps, tingling in hands or feet, changes in skin colo, increased skin pigmentation
    • *have to intervene or pt will die

    FYI:  may be referred to as ESRD
  55. ARF vs CRF
    • ARF
    • reversible
    • survival is fluid electrolyte monitoring
    • may be caused by meds, trauma, MI, HF, renal obstruction

    • CRF
    • nonreversible
    • survivial means lifetime dialysis or transplant
    • may be caused by
  56. what is calciphylaxis?
    • progressive cutaneous necrosis that often occurs in about 1% of CKD/ESRD
    • happens distally in toes, fingers, glans penis, abd, trunk, buttocks
    • calcium deposits line the vessels (like having rocks in the blood)
    • rare, often fatal (80%)
    • ?
  57. medical management of CRF
    • goal:  maintain kidney function for as long as possible by treating underlying conditions
    • pharmacological
    • nutrition
    • dialysis  *treatment, NOT A CURE!
    • kidney transplant *treatment, NOT A CURE!
  58. what meds might a renal pt take to increase calcium level?
  59. what med might a renal pt take to increase red blood cell production?
    • epogen
    • procrit

    can take 3 wks - 1 mth to start working
  60. what med might help a renal and/or diabetic pt w/ gastric emptying?
  61. what meds might be held when a pt is going to hemodialysis?
    blood pressure meds
  62. nutritional management of CRF
    • low in K+
    • low in Ph
    • low in Na+
    • encourage positive foods
    • avoid saying "don't eat this or that..."
  63. food low in K+
    rice, spaghetti, oatmeal, cream of wheat, peach, grape, apple, lemons, helly, unsalted pretzels, soaked potatoes, mushroom
  64. foods low in Phosphorus
    grapes, apples, pineapple, cranberry, strawberry, pasta, broths, soy milk, lettuce, cabbage, green beans
  65. food low in Na+
    some lean meats, applesauce, figs, pears, plum, tea, coffee, alcohol, lamb, veal, turkey, lollipops, caramel
  66. nursing management of CRn
    • assess, assess, assess to prevent complications
    • teach, teach, teach to increase independence
    • promote, promote, promote responsible f/u and self-care
    • support, support, support self-esteem, self-care, independence
  67. reminders in elderly kidney function
    • normal kidney function decreases w/ age
    • glomerular filtration decreases altering lab values
    • watch for dehydration
    • mental assessment is difficult due to already changes/atrophy
    • dx, tx may be delayed due to masking symptoms
    • conservative measure may be used
  68. what are the 2 types of dialysis?
    • HD (hemodialysis)
    • PD  (peritoneal dialysis)
  69. hemodialysis
    • vascular access
    • running circuit
    • dialyzer and dialysate
    • blood flow rate
    • continuous renal replacement therapy (CRRT)
    • pre-lab and dry wt
    • diet
    • schedules
  70. peritoneal dialysis
    • Tenckhoff access
    • continuous ambulatory peritoneal dialysis (CAPD)
    • continuous cyclic peritoneal dialysis (CCPD)
    • diet
    • activites/schedules
  71. pt who is hemodynamically unstable and cannot tolerate regular dialysis may be put on _________ instead.
    • CRRT
    • continuous renal replacement therapy
  72. _______ dialysis is the closest to mimicking the natural action of the kidneys.
  73. types of hemodialysis access
    • catheters
    • temporary access
    • subclavian, jugular, femoral
    • can be used immediately
    • high infection rates
    • high clotting rates
    • severeal months use
    • tessio catheter
    • upper chest near collar bone
    • SC device
  74. AV fistula
    • direct connection between pt's artery and vein
    • goal is an AV fistula
    • last the longest
    • less prone to infection
    • placed in non-dominant FA
    • allowed 14 days to mature and can be used in a few months
  75. graft
    • indirect conncetion of vein and artery though an artificial synthetic tube
    • usually placed in upper FA
    • can be placed in upper arm and thigh
    • clots and easier to become infected (foreign body)
    • artegraft access in 10 days
  76. steal syndrome
    • blood does not flow to hand
    • hand becomes cold, pale
    • decreased pulse distal to fistula or graft
    • painful distal to fistula or graft
  77. bruit vs thrill
    feel the thrill, hear a bruit
  78. which is more common to clot, graft or fistula?
  79. CRRT
    • used in ARF and CRF in pt not stable for hemodialysis
    • need a double lumen venous access
    • "this tx tries to emulate the normal function of the kidneys.  It is slow and continuous."
  80. peritoneal dialysis
    • need surgical permanent access (Tenckhoff)
    • 2-3 wks to heal
    • prevent trauma and infection
  81. peritoneal exchange concept
    • peritoneum is very vascular
    • osmosis for removing water and fluid
    • diffusion for removing particles
    • CAPD: long dwells, daytime, QID
    • CCPD: short dwells, night, 8 hrs, cycler required
  82. disequilibrium
    • results from cerebral fluid shift
    • H/a, n/v, restlessness, decrease loc, seizures
  83. why transplantation?
    • avoid dialysis
    • improve well-being by not having to have to go to dialysis or have accesses taht clot or need to be changed
    • more freedom
    • able to lead more of a normal life
    • cost
  84. altruistic donor
    • someone w/ 2 healthy kidneys gives up a kidney to help anyone
    • can be anonymous if chosen by donor
  85. kidney chain donor
    wanting to give a kidney to someone who is noncompatable so find someone who is a match

    "you pat my back and i'll pat yours"
  86. preoperative kidney transplant management
    • compatibility testing
    • diagnostic testing
    • dental exam and cleaning
    • psychological evaluation
    • hemodialysis the day before if already been on dialysis
    • must be free from infection
    • permits
    • nursing must do peroperative teaching to include NPO, TCDB, pain control
  87. are the nonfunctioning kidneys removed when a kidney transplant occurs?
  88. postoperative kidney transplant care
    • goal:  maintain homeostasis until new kidney is functioning
    • recognize signs of rejection
    • prevent infections
    • mointor urinary function
    • address psychological concerns
    • prevent complications
    • early ambulation
    • watch for side effects of immunosuppressant therapy
  89. why do post kidney transplant pt's get placed on antibiotics?
    immunosuppresant therapy lowers immune system and increases risk of infection
  90. List some common immunosuppresant drugs.
    • immuran?
    • antibiotics
    • cellcept?
  91. rejection detection
    rejection and failure can occur from within 24 hours (hyperacute), within 3-14 days (acute), or after years (chronic)
  92. signs & symptoms of rejection
    • oliguria
    • edema
    • fever
    • increased B/P
    • wt gain
    • swelling or tenderness over surgical site
  93. signs & symptoms of postop transplant infection
    • shaking
    • chills
    • fever
    • tachycardia
    • tachypnea
  94. home care post transplant
    • teach LIFE TIME f/u is necessary
    • teach drug regimen
    • review s/s of infection and rejection
    • avoid contact sports
    • teach to inform all healthcare teams of transplant (ex:  dentist)
  95. What does potassium have to do with the kidneys?
    90% of potassium is excreted by the kidneys
  96. What are the normal lab values for K+?
  97. What are some s/s of hyperkalemia?
    • abominal cramps
    • twitching
    • tingling
    • slow pulse
    • peak T and Wide QRS and disappearing P wave
    • cardiac arrrest
  98. What are some s/s of hypokalemia?
    • dizziness
    • hypotension
    • n/v/d
    • muscle weakness
    • leg crampts
    • decreased perastalsis
    • polyuria
    • depressed ST flat or inverted T wave
  99. What is the purpose of Na?
    • maintains body fluids
    • conduction of neurmuscular activity
    • regulates acid/base balance
  100. What are the normal lab values of Na+?
    135-145 meq/L
  101. What are some s/s of hypernatremia?
    • restless
    • flushed
    • sticky membranes
    • rough dry tounge
    • fast pulse
    • thirsty
    • htn
  102. What are some s/s of hyponatremia?
    • apprehension
    • anxiety
    • muscular twitching
    • weakness
    • h/a
    • confusion tachycardia
    • hypotension
  103. What is chloride for?
    maintains body fluid balance and acid base balance
  104. what are the normal lab values for chloride?
    95-105 mEq/l
  105. What are some s/s of hyperchloremia?
    • weakness
    • deep rapid breathing
    • lethargy
  106. What are some s/s of hypochloremia?
    • slow shallow breathing
    • hyperactivity of the nervous system
    • hypotension
  107. What is the normal value of ketones?
  108. What is the normal pH urine value?
    4.5-8.0 with an avg of 6
  109. What are some s/s of the presence of ketones?
    • restlessness
    • confusion
    • sweet smelling breath
  110. What are the normal values of protein in the urine?
    normally not present
  111. What are the normal specific gravity urine values?
  112. What is the purpos for urine osmolarity?
    determines urine concentration
  113. what are the normal values for urine osmolarity?
    • 50-1200 mOsm/kg/H2O
    • avg is 200-800
  114. What is BUN?
    the end product of protein metabolism
  115. what are the normal lab values for BUN?
    • 5-25mg/dl
    • (elderly may be slightly higher)
  116. what are some s/s of elevated BUN?
    • decreased urine output
    • fast pulse
    • decreased BP
    • increased resp
    • high protein diet
  117. What are some s/s of low BUN?
    • low protein diet
    • high carb
    • continuous dextrose infusion
  118. What is creatinine?
    • breakdown of skeletal muscle
    • good measure of GFR
    • more sensitive indicator of kidney disease
  119. what are the normal lab values of creatinine?
    • 0.5-1.5mg/dl
    • in elderly it is decreased due to muscle loss
  120. what are some s/s of high creatinine?
    • dehydration
    • hypovolemia
  121. what are some s/s of low creatinine levels?
    people with small muscle mass / amputations/ muscle disease usually have low creatinine levels
  122. what is a creatinine clearance test?
    24 hour urine collection to check GFR
  123. what are the normal values of a creatinine clearnace test?
    • 1-2g/24 hours
    • it is decreased in elderly and females
  124. what causes a high results in a creatinine clearance?
    strenuous exercise
  125. What does GFR measure?
    how fast kidneys filter wastes and fluid
  126. what are the normal serum values of GFR?
    125ml/min- 200ml/min
  127. what is the purpose of phosphate?
    • combines with calcium for bones/teeth strength
    • maintenance of acid base
    • promotion of nerve/muscle activity
  128. what are the normal lab falues of phosphate?
    • 2.5-4.5mg/dl
    • in elderly it is slightly lower
  129. what are some s/s of an elevated phosphate level?
    • tetany
    • decreased renal output
  130. what are some s/s of a low phosphate level?
    • anorexia
    • bone and muscle pain
  131. What is calcium and what is his purpose?
    • found in bones/teeth
    • necessary for nerve impulses and myocardial contration
    • strengthens capillary membranes
    • cuases blood to clot by converting prothrombin to thrombin
  132. what is the normal calcium level?
  133. what are some s/s of hypercalcemia?
    • lethargy
    • h/a
    • weakness
    • muscle flaccidity
    • heart blocks
    • anorexia
    • n/v
    • digitalis toxicity
    • thiazide diuretics
  134. what are some s/s of hypocalcemia?
    • tetany
    • twithcing
    • tremors
    • laryngeal spasms
    • numbness and tingling
    • prolonged ST and lengthened QT intervals
  135. what is the purpose of magnesium?
    used to transport Na and K across the cell membrane
  136. what are the normal lab values for magnesium?
  137. what are the s/s of an elevated magnesium lab value?
    • flushing
    • increased sweating
    • peak t wave and wide qrs
    • diminished reflexes
    • hypotesnive
    • sedation
    • muscle weakness
  138. what are some s/s of a low magnesium level?
    • tetany
    • neuromuscular irritability
    • muscle cramps
    • tingling
    • resless
    • confusion
    • inverted t wave
  139. what is the purpose of glucose?
    needed in cells for energy
  140. what are the normal glucose levels?
    • 70-110mg/dl
    • in elderly 70-120mg/dl
  141. what are some s/s of hyperglycemia?
    • excessive thirst
    • polyuria
    • excessive hunger w/ weight loss
    • rapid deep breathing
    • kussmauls
  142. what are some s/s of hypoglycemia?
    • nervousness
    • rapid pulse
    • diaphoresis
    • weakness
    • clammy/cold skin
    • confusion
  143. What is the difference between acute and chronic renal disease?
    • Acute
    •  Reversable   
    • Survival is fl and electrolyte   monitoring   
    • May be caused by medications,   trauma, MI, heart failure, renal obstruction 
    • chronic
    •  Progressive   
    • Survival means lifetime dialysis   or transplant  
    • May be caused by other systemic   diseases such as DM, HTN or can be from medications
  144. What are the stages of acute renal failure?
    • pre-renal
    • intra-renal
    • post-renal
  145. What occurs in the pre- renal stage of acute renal failure
    • volume depletion
    • fluid loss
  146. What occurs in the intra-renal stage of acute renal disease?
    kidneys start to die and ischemia occurs
  147. what occurs in the post-renal stage of acute renal failure?
    there is an obstruction
  148. what causes the pre-renal stage in AKD?
    • hemorrhage
    • gi bleed
    • HF
    • MI
    • vasodilation
  149. What causes the intra-renal stage in AKD?
    • nephrotoxic drugs
    • dyes and contrast
  150. What causes the post renal stage in AKD?
    • kidney stones
    • bph
    • tumors
    • blood clots
    • strictures
  151. What are the phases of AKD?
    • initiation phase
    • oliguria phase
    • diuresis phase
    • recovery phase
  152. when does the initiation phase take place in AKD?
    from the time of the insult to the oliguria phase occurs (UO less than 400-500ml/24hrs)
  153. What happens in the oliguria phase of AKD and how long does it last?
    • lasts about 10-20 days
    • lab values increase
    • decreased renal function
    • blood count decreases
  154. what occurs in the diuresis phase of AKD
    • there is a gradual increase in urine output
    • lab values stop increasing
  155. What occurs in the recovery phase of AKD and how long does it last?
    • lasts about 3-12 months
    • lab values return to normal
    • GFR is 1-3% reduced and not really noticed by patient
  156. What are the stages of CKD?
    • Stage 1- at risk for CKD
    • Stage 2- mild risk for CKD
    • Stage 3- moderate risk for CKD
    • Stage 4- severe CKD
    • Stage 5- ESRD
  157. What is the GFR in Stage 1 of CKD?
    > = 90
  158. What is the GFR value for stage 2 of CKD?
  159. What is the GFR lab value for Stage 3 of CKD?
  160. What is the GFR to Stage 4 of CKD?
  161. What is the GFR value in stage 5 of CKD?
    15 or <
  162. What are the s/s of Stage 3 CKD?
    • caused by waste product build uo
    • HTN
    • anemia
    • early bone dz
    • brittle nails
    • Fatigue
    • fl excess
    • urination changes
    • kidney pain
    • sleep problems
  163. What are the s/s of stage 4 CKD?
    • same as stage 3 plus
    • nausea
    • taste changes
    • uremic breath
    • loss of appetite
    • difficulty in concentrating
    • nerve problems
    • anemia
    • fluid buildup
    • numbness
    • tingling
  164. What are the s/s of stage 5 CKD?
    • kidney failure
    • Loss of appetite
    • n/v
    • HA
    • tired
    • unable to concentrate
    • itching
    • making little or no urine
    • swelling esp around eyes and ankles
    • muscle cramps
    • tingling in hands or feet
    • changing in skin color
    • increased skin pigmentation
    • anemia
    • resp problems
  165. What is care directed towards in Stage 2?
    reduce risk factors for kidney dz
  166. What is care directed towards in stage 3 CKD?
    • Try to Keep pt in stage 3
    • monitor q6months
    • Monitor labs
    • See a nephrologist
  167. What is care directred toward in stage 4 of CKD?
    teaching patient regarding dialysis and either put an access in or start considering it
  168. What is care directred toward in stage 5 of CKD?
  169. What is given to patient with kidney disease to increase their calcium levels?
    • tums
    • oscal
    • titrolac
  170. Why is epogen given to patients with renal disases?
    to prevent blood transfusions, stimulates bone marrow to produce cells
  171. Why may reglan be prescribed?
    problems with diabetic gastroporesis
  172. Why may phoslo be prescribed and when is the best time to give it?
    • to lower phosphate level
    • given with the first bite of food
  173. What kind of diet will be prescribed for patients with CKD?
    • high carb
    • low potassium
    • low sodium
    • low phosphorus
  174. what are some examples of foods low in K+?
    • rice
    • spaghetti
    • oatmeal
    • cream of wheat
    • peach
    • grape
    • apples
    • lemons
    • jelly
    • unsalted pretzels
    • soaked potatoes
    • mushroom
  175. What are some examples of foods low in phosphrus?
    • grapes
    • apples
    • pineapple
    • cranberry
    • strawberry
    • pasta
    • broths
    • soy milk
    • lettuce
    • cabbage
    • green beans
  176. What are some examples of foods low in sodium?
    • some lean meats
    • applesauce
    • figs
    • pear
    • plum
    • tea
    • coffee
    • alcohol
    • lamb
    • veal
    • turkey
    • lollipops
    • caramel
  177. What is CRRT?
    • used in ARF and CRF in pts not stable for hemodialysis
    • Need a double lumen enous access
    • tries to emulate the normal function of the kidneys
    • slow and continuous
    • Runs slow and continuous
    • for Unstable patients
  178. What is CAPD?
    • has to be done qid
    • patient does it during the day
    • long dwell times (when fluid is in the patient)
  179. What is a  fistula?
    • Direct connection of vein and artery
    • Goal is a AV fistula
    • Last the longest
    • Less prone to infection
    • Placed on non dominant forearm
    • Allowed 14 days to mature and can be used in a few months
  180. What is a graft?
    • Indirect connection of vein and artery through an artificial synthetic tube
    • Usually placed in forearm.
    • Can be placed in upper arm and thigh
  181. What is a tenchkoff catheter?
    • surgically placed
    • takes 2-3 weeks to heal