Term
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Definition
The kidneys are responsible for…
Fluid/electrolyte regulation
Na and fluid balance
Potassium balance
Phosphate elimination
What does this mean for calcium?
Secretion of erythropoetin
Secretion of HCO3 (bicarb)
Excretion of toxins/waste
Activation of Vitamin D |
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Term
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Definition
Renal ischemia resulting in direct cellular death
Nephrotoxic injury – necrotic tubules slough and plug
Type of ARF |
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Term
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Definition
| accumulation of nitrogenous waste in blood stream (BUN, creatinine) |
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Definition
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Definition
H&P
Laboratory tests
BUN
Serum Crt
Serum elytes
Urinalysis/culture
Hemoglobin/Hematocrit |
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Term
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Definition
Body Water Regulation
Fluid volume is altered when the kidney loses its ability to excrete water
FVO
How is sodium affected?
Other factors:
proteinuria
Proteinuria occurs in response to damage of the glomeruli
loss of albumin in the urine: fluid shifts from intravascular space to interstitial space because of decreased oncotic pressure
Due to decreased GFR, aldosterone released from adrenal cortex so kidneys to reabsorb sodium and water
Fluid retention results in development of respiratory and cardiovascular clinical manifestations
Assessment Findings
When damaged, kidneys do not secrete potassium well.
Leads to hyperkalemia
EKG changes
R/f decreased CO
Lack of phosphate excretion
Causes hypocalcemia
Manifestations:
Can be recalled by the mnemonic "CATS go numb"- Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and lips.
Chvostek’s sign/Trousseau’s sign
Laryngospasm
Cardiac—prlonged QT
Hyperparathyroid due to hypocalcemia
Kidneys normally convert inactive vitamin D to its active form: 1,25- dihydroxycholecalciferol
Impaired vitamin D synthesis results in decreased absorption of calcium in the gastrointestinal tract
When the serum level of calcium decreases, the parathyroid gland increases its secretion of parathyroid hormone, causing calcium to be released from the bone and compensating for the decreased serum level of calcium
Anemia and Bleeding
Anemia
kidneys produces erythropoietin to stimulate bone marrow to release red blood cells
normochromic, normocytic anemia
Bleeding
Altered platelet function and increased gastric acid secretion from increased release of parathyroid hormone
Metabolic acidosis
Tubules cannot excrete hydrogen ions (H+)
Bicarb not secreted effectively
What are s/s of metablic acidosis?
Assessment Findings
Uremia
Syndrome that incorporates all signs and symptoms seen in various systems throughout the body
Azotemia
Nitrogenous waste products from protein metabolism are retained in the body
Evidenced by the increased serum levels of urea nitrogen and creatinine
Causes confusion, metallic taste in mouth, halitosis, and ulcers in the mouth (bacteria break down urea into ammonia)
Pruritus
excretion of waste products (and phosphate) through the skin
Assessment Findings
Other symptoms
Depression |
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Term
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Definition
Fluid Volume Overload
Decreased Cardiac Output
Altered Tissue Perfusion
Risk for Injury |
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Term
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Definition
Correction of fluid volume overload
Nutritional therapy
Erythropoietin therapy
Calcium supplementation, phosphate binders
Antihypertensive therapy
Measures to lower potassium
Adjustment of drug dosages to degree of renal function
Independent nursing interventions |
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Term
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Definition
IV insulin
IV glucose to manage hypoglycemia
IV 10% calcium gluconate
Raises threshold for excitation
Sodium bicarbonate
Shift potassium into cells
Correct acidosis
Sodium polystyrene sulfonate (Kayexalate)
Cation-exchange resin
Resin in bowel exchanges potassium for sodium
Evacuates potassium-rich stool from body
Educate patient that diarrhea may occur due to laxative in preparation
Antihypertensive drugs
Diuretics
β blockers
Calcium channel blockers
Angiotensin-converting enzyme (ACE)
inhibitors
Angiotensin receptor blocker agents
Drug Therapy
Phosphate problems
Phosphate binders
Calcium carbonate (Tums)
Bind phosphate in bowel and excreted
Sevelamer hydrochloride (Renagel)
Lowers cholesterol and LDLs
Should be administered with each meal
Side effect: Constipation
Supplementing vitamin D
Calcitriol (Rocaltrol)
Serum phosphate level must be lowered before administering calcium or vitamin D
Drug Therapy
Anemia
Erythropoietin
Epoetin alfa (Epogen, Procrit)
Administered IV or subcutaneously
Increased hemoglobin and hematocrit in
2 to 3 weeks
Side effect: Hypertension
Iron supplements
If plasma ferritin <100 ng/ml
Side effect: Gastric irritation,
constipation
May make stool dark in color
Folic acid supplements
Needed for RBC formation
Removed by dialysis |
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Term
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Definition
Protein restriction
0.6 to 0.8 g/kg body weight/day
Sodium restriction
Diets vary from 2 to 4 g depending on
degree of edema and hypertension
Sodium and salt should not be equated
Patient should be instructed to avoid
high-sodium foods
Salt substitutes should not be used because they contain potassium chloride
Nutritional Therapy
Potassium restriction
2 to 4 g
High-potassium foods should be avoided
Oranges
Bananas
Tomatoes
Green vegetables
Phosphate restriction
1000 mg/day
Foods high in phosphate
Dairy products
Coffee
Most foods high in phosphate are also high in calcium
Nutritional Therapy
Fluid restriction
Fluid volume intake is based on 500 mL/day (insensiblefluid loss) plus fluid equal to the urine output of the preceding 24 hours. |
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Definition
Must occur when GFR can no longer sustain life (<15 ml/hr).
ESRD
Acts as an external/”fake” kidney
Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure |
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Term
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Definition
Peritoneal dialysis
Hemodialysis
Cleans the blood
What does this mean for medication administration?
Blood from patient leaves and is sent outside the body
Enters dialyzer, where semipermeable membrane separates blood from dialysate
Hemodialysis
Relies on a permanent fistula/graft in patient.
Assessment:
Bruit
Thrill
No B/P or sticks
Hemodialysis
Graft/fistula is accessed and connected to dialysis machine.
Usually run ~4 hours 3 times per week, depending on severity.
Complications
Hypotension
Bleeding
Infection
Cramping
http://www.youtube.com/watch?v=Dza8sTJixog
Hemodialysis
Can be done with temporary catheter in acute situation |
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Term
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Definition
Peritoneal access is obtained by inserting a catheter through the anterior wall.
Uses patient’s peritoneum as the membrane across which fluids and dissolved substances are exchanged from the blood.
Three phases of PD cycle
Called an exchange
Inflow
Dwell
Drain
Dwell
Diffusion and osmosis occur between patient’s blood and peritoneal cavity
Duration of time varies
Drain
15 to 30 minutes
May be facilitated by changing position
Exit site infection
Peritonitis
s/s?
Abdominal pain
Outflow problems
Hernias
Bleeding
Pulmonary complications
Protein loss |
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Term
| ARF Etiology and Pathophysiology |
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Definition
Acute renal failure is a life threatening illness with high mortality despite advances in supportive care
A sudden loss of kidney function caused by failure or renal circulation or damage to the tubules or glomeruli
Can be reversible, with spontaneous recovery in a few days to weeks
Ischemia is primary cause: when allowed to persist for more than 2 hours, produces irreversible damage to tubules
Acute Renal Failure
Three major types:
Prerenal
decreased renal blood flow (40–70% of cases) R/T decr. Blood flow to kidneys
R/T severe dehydration or hypovolemia
Intrarenal
direct renal parenchymal damage (intrinsic renal causes; 10–50% of cases)
Postrenal
obstructed urine flow (post-renal or obstructive causes; 10% of cases) |
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Term
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Definition
Lack of perfusion to kidneys
People at high risk include
elderly patients with atherosclerotic cardiovascular disease
patients with pre-existing chronic kidney disease
and patients with renal hypoperfusion caused by volume depletion, hypotension, or renal artery stenosis |
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Term
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Definition
Caused by diseases affecting the glomeruli, renal tubules, interstitium, or vasculature.
Most common cause is acute tubular necrosis.
Medications/Contrast dye
aminoglycosides
Rhabdomylolysis
Infection/pyelonephritis |
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Term
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Definition
Obstructive nephropathy presents as acute renal failure relatively infrequently
At risk populations include older men with prostate disease and patients with intra-abdominal, particularly pelvic, malignancy
Stones
Clinical consequence is the substantial diuresis that generally occurs once obstruction is relieved, which needs careful monitoring and appropriate fluid replacement to avoid volume depletion |
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Term
| Acute Renal Failure Presentation and Clinical Course |
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Definition
Presentation:
Depends on underlying etiology (pre/intra/post)
S/S as with CKD—differing etiologies
Clinical course
Oliguria (8-14 days)
Diuretic phase (7-14 days)
Nephrons cannot concentrate urine
Recovery phase (several months-1 year) |
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Term
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Definition
H &P
Serum elytes
Imaging studies
Aim is to find underlying etiology and treat it |
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Term
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Definition
As with CKD
Fluid vol. deficit (in diuretic phase)
Health maintenance—prevention |
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Term
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Definition
Depends on underlying etiology
May or may not involve dialysis |
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Term
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Definition
A type of continuous, at-the-bedside hemodialysis that is safer for hemodynamically unstable patients
Acid–base status/electrolytes adjusted slowly and continuously
Can be used in conjunction with HD
Contraindication
Presence of manifestations of uremia requiring rapid resolution
Can be continued for 30 to 40 days
1:1 nurse to patient ratio required |
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Term
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Definition
Continuous rather than intermittent
Solute removal by convection (no dialysate required) in addition to osmosis and diffusion
Less hemodynamic instability
Does not require constant monitoring by HD nurse
Does not require complicated HD equipment |
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