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2014-10-16 14:36:18

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  1. 2 major causes of kidney disease:
    • 1- Diabetes (we want sugar levels below 200)
    • 2- High blood pressure
  2. We want morning BS to be close to:
  3. The percentage of people 65 and old with CKD is ____ whereas the percentage of younger people is ____
    Increasing; Decreasing

    (due to knowledge deficit!...we must educate)
  4. Stage 3 CKD means the patient:
    has to be on dialysis or transplant
  5. CKD is on the ___
  6. Which ethnic group has the highest incidence of end stage renal disease
    African Americans
  7. Ethnic group with the lowest end stage renal disease percentage:
  8. Internal Structures of the Kidney:
    • Nephron
    • Glomerular filtration membrane
    • Renal arteries and tubules
  9. Major risk of chronic high BP
    Killing their kidneys
  10. What should be checked about a drug before giving it to a CKD pt
    • Where it is metabolized
    • Where it is excreted
    • If it is nephrotoxic
  11. The Nephron consists of:
    • Glomerulus/Blood Supply
    • Bowman's Capsule
    • Bowman's Space
    • Tubular System
  12. The Glomerular filtration membrane consists of:
    • Glomerular endothelium
    • Basement membrane
    • Capillary epithelium
  13. Renal Blood flow is promoted by: (everything that makes it up)
    • Renal Arteries
    • Interlobar arteries
    • Arcuate Arteries
    • Interlobular Arteries
    • Afferent arterioles
    • Glomerular capillaries
    • Efferent arterioles
    • Peritubular capillaries and vasa recta
  14. Average amount of digoxin per day
  15. Renal Tubules consist of:
    • Proximal Tubule
    • Loop of Henle
    • Distal Tubule
    • Collecting Duct
  16. Function of Bowman's capsule and Glomerulus (within the bowman's capsule)
  17. Function of the Proximal Tubule
    • Reabsorption of
    • NaCl 
    • Glucose
    • Potassium
    • Amino Acids
    • HCO3
    • Protein
    • H2O

    • Secretion of
    • Hydrogen
    • Foreign Substances
    • Organic Anions
    • Organic Cations
  18. Tonicity of fluid within proximal tubule
  19. Function of Loop of Henle
    Concentration of urine

    Descending loop- water reabsorption, sodium comes in

    Ascending loop- sodium reabsorbed, water stays in

    Urea secretion in thin segment
  20. Tonicity of Fluid within Loop of Henle
    Isotonic - Hypertonic - Hypotonic
  21. Function of Distal Tubule
    Reabsorption of NaCl, H2O, HCO3

    Secretion of Potassium, Urea, H+, some drugs
  22. Tonicity of Fluid in the Distal Tubule
    Isotonic or Hypotonic
  23. Function of the Connecting Duct
    Reabsorption of H2O

    Reabsorption/Secretion of Na+, K+, H+

    Secretion of Urea in the medulla
  24. Tonicity of fluid in connecting duct:
    Final concentration
  25. Basic Kidney Functions:
    • Regulate Osmotic Pressure
    • Regulate Fluid Volume
    • Regulate Electrolytes
    • Excrete Metabolic Waste
    • Regulate pH
    • Secrete hormones
  26. Electrolytes that the kidney regulates:
    K, Na, Ca, Phos, Mg
  27. Best indicator of renal function

    **Check GFR when you give a nephrotoxic drug
  28. A person with glomerulonephritis with have s/s of:
    Edema, Puffiness, Periorbital Edema
  29. ***Normal GFR
    Greater than or equal to 90
  30. BUN is less reliable for kidney disease than ___ or ____
    Creatinine or GFR
  31. Tests of Kidney Function
    • Blood Tests
    •    -GFR (<90)
    •    -Creatinine
    •    -BUN
    •    -BUN/Cr Ratio

    • Urine Tests
    •    -Protein
    •    -Creatinine Clearance
    •    -Catecholamines
    •    -Urine analysis

    • Imaging Tests
    •    -Ultrasound
    •    -CT scan (contrast medium!!!)

    Renal/Kidney Biopsy
  32. GFR of 60 is considered what stage CKD:
    Stage 2
  33. We want a ____ serum level and ___ protein in our pt urine test
    High serum, NO protein
  34. Rapidly progressive glomerulonephritis is usually detected by:
    renal biopsy
  35. Pathyphysiology of CKD-- Impaired Excretion of Acid and Depletion of Base
    • Metabolic Acidosis
    • Impaired Potassium Excretion
  36. Metabolic Acidosis is classified with pH and HCO3 of:
    • pH <7.35
    • HCO3 <22
  37. Nursing Action for pt with metabolic acidosis:
    • Arterial Blood Gases
    • **REPORT results!
  38. Tubule responsible for reabsorb bicarb
    • Proximal Tubule
    • (if this is not functioning, we will have LOW bicarb levels ...HCO3<22 metabolic acidosis)
  39. Impaired Potassium Excretion can lead to:
    • Hyperkalemia
    • Cardiac Arrhythmias
    • Cardiac Arrest
  40. Nursing Action/Intervention related to impaired potassium excretion (leading to hyperkalemia, cardiac arrhythmias, and cardiac arrest)
    • Serum K levels
    • Apical Pulse, ECG
    • Rapid Response
    • Dr. 99, Code Red, Code Blue
  41. When a pt holds on to hydrogen ions, they will become
  42. Pathophysiology of Impaired Excretion of Phosphate
    • Hyperphosphatemia
    • Hypocalcemia
    • 2nd Hyperparathyroidism
    • Uremic Osteodystrophy
  43. Nursing Assessment r/t hyperphosphatemia (leading to imparied excretion of phosphate)
    Phosphate Binders (calcium based)
  44. Give phosphorus drugs with ____
    meals! (mealtime is when you take in greatest amount of phosphorus)
  45. Nursing Assessment/Intervention related to Hypocalcemia (leading to impaired excretion of phosphate)
    • Calcium Supplements 
    •    -calcium gluconate
    • ***avoid calcium chloride
  46. Nursing Assessment/Care related to 2nd Hyperparathyroidism (leading to impaired excretion of phosphate)
    Parathyroidectomy-- post op care for swelling
  47. If you are going to increase your pt serum calcium level, give it to them when:
    2 hours after they eat!
  48. Calcium and Phos are ____ related
  49. Nursing Assessment/Care of Uremic Osteodystrophy (leading to impaired excretion of phosphate)
    • Musculoskeletal Assessment!
    •    -history of fractures (bones are brittle)
    •    -bone pain
  50. Pathophysiology of Increased Renin Production
    • Hypertension (Hypertensive Encephalopathy)
    • Fluid overload (CHF, Pulm Edema)
  51. Nursing Assessment/Care for pt with Hypertensive encephalopathy (leading to increased renin production)
    • H/A, Dizziness, Retinopathy
  52. Nursing Assessment/Care for pt in fluid overload (leading to increased renin production)
    • Respiratory Assessment:
    • Edema, Anorexia
    • Frothy Sputum
    • S-3 Gallop
  53. Pathophysiology of Impaired Erythropoietin Production and End products of metabolism:
    Decreased RBC production/life span


    Increased Cr, BUN, and decreased GFR
  54. Nursing Assessment/Care related to decreased RBC production/life span (leading to impaired erythropoietin production and end products of metabolism)
    CBC- rbc, hgb, hct,reticulocytes (represent immature RBC), wbc
  55. Nursing Care/Assessment for Anemia (leading to impaired erythropoietin production)
    BCP/Chem (GFR, BUN, Cr)
  56. Nursing Assessment/Care related to impaired erythropoietin production and end products of metabolism:

    BCP/Chem (GFR, BUN, Cr)

    Activity Intolerance (drowsiness, lassitude, fatigue)

    Skin Assessment (itching, ecchymosis, purpura)
  57. Coating on RBCs from uremia lead to
    shorter lifespan (RBC 60 days instead of 90-120)
  58. Nursing Care/Assessment of Pt with Increased Renin Prduction
    Full Neuro Assessment (ha, dizziness, retinopathy)

    Respiratory Assessment (edema, anorexia, frothy sputum, S-3 gallop)
  59. Nursing Assessment/Care of pt with Impaired Excretion of Phosphate
    • Phosphate binders
    • Calcium supplements-- avoid calcium chloride
    • Parathyroidectomy
    • Musculoskeletal assessment
  60. Nursing Assessment of pt with impaired excretion of acid/depletion of base

    K levels

    Apical Pulse

    Rapid Response if needed (cardiac arrest)
  61. Avoid false results of BUN by:
    Assessing your pt hydration status!
  62. Normal range of BUN
  63. Increase in BUN could be due to:
    Dehydration, excessive protein intake and impaired renal function
  64. Decreased BUN could be due to
    Overhydration, liver damage, malnutrition
  65. With renal impairment, serum Cr goes ____ but urinary creatinine clearance goes ____
    Up, Down
  66. Normal Serum Cr
    • Men= .8- 1.8
    • Women = .5- 1.5

    **increases with kidney malfunction!
  67. Normal Urinary Cr Clearance
    85-135 ml/min

    • *requires a 24hr urine specimen 
    • *decreases with renal malfunction
  68. what should always be marked about Creatinine and Creatinine clearance:
    Time and date you start and stop collection

    ...if one sample is accidentally thrown away, start completely over!!!
  69. Watch potassium levels in pts with:
    • renal failure
    • hydration imbalances
    • acid-base imbalances
    • cellular damage- burs, accidents, surgery
    • diabetes
  70. S/S of increased potassium
    • Increased irrability/anxiety
    • Muscle Twitching, Cramps, Paresthesia
    • Diarrhea/Abdominal cramping
    • Decreased BP
    • ECG changes
  71. S/S of decreased potassium levels:
    weakness, decreased reflexes, dysrhythmias, ECG changes
  72. Normal/Safest potassium level:
    3.5- 5.0
  73. Normal Serum Calcium
  74. Normal Phos
    3.0- 4.5
  75. In renal disease, what does the phos/cal relationship look like:
    High phosphorous, Low calcium
  76. Normal Hgb ranges
    • Male = 14-18
    • Female= 12-16
  77. Reasons for high Hgb
  78. Norm WBC
    4500 - 10000
  79. Psychological Effect of Non-Functioning Kidneys
    Denial, Anxiety, Depression, Psychosis
  80. Cardiovascular Effect of Non-Functioning Kidneys
    • Hypertension
    • CHF
    • Atherosclerotic heart disease
    • Pericarditis
    • Myocardiopathy
    • Pericardial effusion
  81. GI Effect of Non-Functioning Kidneys
    Anorexia, N/V, GI bleeding, Peptic ulcer, stomatitis, gastritis
  82. Endocrine/Reproductive Effect of Non-Functioning Kidneys
    • Hyperparathyroidism
    • Thyroid Abnormalities
    • Amenorrhea
    • Infertility
    • Sexual Dysfunction
    • Azoospermia
  83. Metabolic Effect of Non-Functioning Kidneys
    • Carbohydrate intolerance
    • Hyperlipidemia
    • Nutritional deficiencies
    • Gout
  84. Hematologic Effect of Non-Functioning Kidneys
    • Anemia
    • Bleeding
    • Infection
  85. Neurologic Effect of Non-Functioning Kidneys
    Fatigue, H/A, Sleep disturbances, lethargy, muscular irritability, seizures, confusion, coma
  86. Ocular Effect of Non-Functioning Kidneys
    Hypertensive Retinopathy
  87. Pulmonary Effect of Non-Functioning Kidneys
    • Uremic Lung
    • Pulmonary Edema
    • Uremic Pleuritis
    • Dyspnea
    • Pneumonia
    • Depressed cough reflex
  88. Integumentary Effect of Non-Functioning Kidneys
    Pallor, Pigmentation changes, Pruritus, Ecchymosis, Excoriations, Uremic frost, dry scaly skin
  89. Peripheral neuropathy Effect of Non-Functioning Kidneys
    • Paresthesias
    • Motor Weakness
    • Restless leg syndrome
  90. Acute renal failure develops:
    rapidly (reversible or irreversible)
  91. Causes of ARF
    Pre-renal: hypo-perfusion of kidneys, shock, large vessel surgery...anything that decreases perfusion to kidneys

    Intra-renal: damage to internal structures (Acute Tubular Necrosis, nephrotoxic drugs, rhabdomyolosis)

    Post-renal: damage to external structures (BPH, calculi)
  92. Nursing Implications of ARF (acute renal failure)
    • Assess V/S post op
    • Assess and know side effects of drugs
    • Assess history including genogram
  93. If a pt is pulled out of ARF quickly it is____
    reversible (the longer they stay in ARF, the less likely they are going to do well)
  94. Phases of ARF (acute renal failure)
    • *Assess client carefully to detect changes in s/s based on the phase of ARF...clinical condition can fluctuate between phases before stabilizing
    • Oliguric (<400 ml/day)
    • Diuretic (>3L/day)
    • Recovery (metabolic wastes cleared)
  95. Phase of ARF where metabolic wastes are cleared (creatinine, nitrates, uric acid)
  96. Phase of ARF where pt has output less than 400ml/day...lasts about 10-14 days (up to 3 weeks)
  97. Phase of ARF where pt has urine output of over 3L/day

    *just because you're diuretic, doesn't mean you are getting rid of everything
  98. Nursing Care during the Oliguric Phase of ARF
    Fluid and Electrolytes! (check for abnormalities and uremia)

    CBC, BCP, Urinary output, apical pulse (pt may be in fluid overload and potassium levels may be increased...need to see if they are in metabolic acidosis)

    Monitor Strict I&O, v/s, daily weight, Dialysis

    Patient is NPO!!!
  99. Meds ordered for Oliguric Phase of ARF:
    • Kayexalate (oral, enema)
    • IV glucose with insulin
    • sodium bicarb (buffer to help acidosis)
    • Lasix
    • Calcium gluconate
  100. Nursing Assessment/Care for Diuretic Phase of ARF
    Severe Uremia and Fluid Imbalance

    CBC, BCP, urinary output, apical pulse

    Monitor strict I&Os, V/S, Daily Weight, Dialysis

  101. If BP is down in pt that is in diuretic phase of ARF, administer:
    IV fluid (then wean back down)
  102. Nursing Assessment/Care for pt in recovery phase of ARF
    Metabolic Stabilization

    ***Make sure they understand all the meds they are on
  103. End result of CKD
    Systemic Disease involving every organ
  104. CKD ____ progresses (insidous onset)
  105. Each year ____ people die from causes related to renal failure
  106. Up to ____% of the GFR may be lost with few changes in the functioning of the body in CKD
  107. ***Stages of Renal Failure:
    • Diminished Renal Reserve
    • Renal Insufficiency
    • Uremia/Azotemia
  108. Stage of renal failure where there is no metabolic waste accumulation;...polyuria, nocturia, polydipsia
    Stage 1 (Diminished Renal Reserve)
  109. Stage of Renal Failure where metabolic wastes begin to accumulate dietary, chemical, metabolic changes handled poorly....Dialysis may be needed
    Stage 2 (Renal Insufficiency)
  110. Stage of Renal Failure where the kidney absolutely loses ability to maintain homeostasis, oliguria to anuria, electrolyte imbalances, nitrogenous wastes accumulate...Life Can Not Be Sustained without Dialysis or Transplant with Uremia/Azotemia
    Stage 3 (Uremia/Azotemia)
  111. Kidney Damage with normal or increased GFR
    Stage 1
  112. Kidney damage with mild decrease in GFR (60-89)
    Stage 2
  113. Kidney damage with moderate decreased GFR (30-59)
    Stage 3
  114. Kidney damage with severe decreased GFR (15-29)
    Stage 4
  115. Kidney Failure (GFR <15 or dialysis)
    Stage 5
  116. Kidney damage or GFR <60 for >3 months
    Chronic Kidney Disease
  117. Clinical findings of Chronic renal failue...DIMINISHED RENAL RESERVE
    • GFR > 90ml/min
    • Observe/Control BP
    • 24 hr urine for Cr clearance to detect loss of renal reserve
    • Kidney damage with normal or increased GFR
    • Decreased Urinary Concentration- nocturia
    • Treatment of Comorbid conditions (diabetes, HTN, renal artery stenosis)
  118. Clinical findings of Chronic Renal Failure...RENAL INSUFFICIENCY
    • H/A
    • Decreased ability to concentrate urine
    • Polyuria 
    • Increased BUN and Serum Cr
    • Edema
    • GFR decreases from 90 to 30ml/min
    • Mild Anemia
    • Increased BP
    • Weakness fatigue
  119. Clinical findings of Chronic Renal Failure...END STAGE RENAL DISEASE
    Neurological weakness/fatigue/confusion

    Increased BP, pitting edema

    Pulmonary SOB, Depressed cough, thick sputum

    • Ammonia Odor to Breath
    • Metallic Taste
    • Mouth/Gum ulcerations
    • Anorexia
    • N/V

    Withdrawn behavior changes

    Hematological Anemia

    Dry, flaky skin; Ecchymosis; Pruritus

    Musculoskeletal Cramps, Renal osteodystrophy, Bone Pain
  120. Never use CRF pt's extremety that has:
    a graft/fisula
  121. What to evaluate on hemodialysis pt:
    Patency/Signs of infection of site

    Do NOT take BP or blood samples from this extremity!
  122. Nursing Assessment/Care for CRF (Chronic Renal Failure) pt
    similar to ARF care (assess v/s, labs, tx hx, teach dietary management/meds)

    • Administer meds carefully including:
    •    -kayexalate
    •    -calcium
    •    -digoxin
    •    -anti-hypertensives

    Monitor dialysis-peritoneal and hemodyalisis
  123. Diasylate is a ____ solution
    Dextrose (the more you have, the more fluid it pulls in)
  124. Complications of Peritoneal Dialysis:
    Exit Site Infection


    Abdominal Pain

    Outflow Problems


    Lower Back Problems


    Pulmonary Complications

    Protein Loss

    Carbohydrate and Lipid Abnormalities

    • Encapsulating Sclerosing Peritonitis and
    • Loss of Ultrafiltration

    Effectiveness of and Adaptation to Chronic
  125. Dialysate and Blood flow are ______ related
    Inversely (go in opposite directions)
  126. Post-Kidney Hyperacute Transplant Rejection Signs:
    • Onset within 48 hours
    • Malaise, high fever
    • Graft tenderness
    • Organ must be removed to decrease S/S!!!
  127. Post-Kidney Acute Transplant Rejection Signs:
    • 1 week to 2 years later
    • Oliguria, Anuria
    • Increased Temp 
    • Increased BP
    • Flank Tenderness
    • Lethargy
    • Increased BUN, K, Creatinine
    • Fluid Retention
  128. Post-Kidney Chronic Transplant Rejection Signs:
    • Gradual over months- years later
    • Increased BUN and Cr
    • Imbalances in Proteinuria Electrolytes
    • Fatigue
  129. pts that have had transplant will need:
    to be on anti-rejection meds the rest of their life