FVE: gain

FVD: loss

very accurate if done on a standard schedule

FVE: increased ouput

FVD: decreased output

accurate if pt is healthy

FVE: decreased specific gravity, urine pale

FVD: increased specific gravity, urine darker color

FVE: edema, tears, salivation, no tenting

FVD: dry skin, decreased tears and salivation, skin tenting, sunken fontanels

FVE: edema

FVD: not presecent, unless ascites

FVE: increased

FVD: decreased, orthostatic ( drop of 15 mmHg and increased 20 BPM indicate positive orthostatic hypotension)

MAP: systolic + 2(diastolic)/3 (60-70)

FVE: increased, bounding

FVD: increased, thready

FVE: increase RR, SOB, orthopnea, crackles, wheezes

FVD: increased to normal

FVE: distended, increased CVP

FVD: normal to flat, normal CVP

-CVP is measured in jugular or subclavian vein, normal reading is 2-6 mmHg

- veins should be assessed in semi-Fowler's position

FVE: decreased

FVD: increased to to hemoconcentration

FVE: decreased BUN

FVD: increased BUN

- within cell membranes

- contains dissolved solutes

- most stable

- outside of cell membranes

- composed of plasma and ISF

- water, straw colored fluid component of lymph and blood in which WBCs, RBCs, and platelets are suspended

- least stable

- intravascular fluid

- interstitial fluid

- fluid that fills spaces b/t cells of body

- colloid osmotic pressure is stable on arteriolar and venular ends of vessel

- tissue COP is stable in extra-vascular space

- tissue HP is stable in extra- vascular space

- hydrostatic pressure decreases from arteriolar end of vessel to venular end of vessel, creating a pushing out pressure on arteriolar end and pulling in pressure on venular end

- albumin

- globulin

- fibrinogen

- fluids which supply primiarily water and sodium to maintain osmotic gradient b/t EVF and IVF

- capcity to expand IVF is related to sodium content of crystalloid floid

- crystalloids tend to move rapidly from the vascular space to the interstitial and intracellular spaces

uses: maintenance, fluid and electrolyte replacement

examples: NSS .9% (I), NSS .45% (hypo), hypertonic saline 3% & 5%, lactated ringer's (I), D5W (hypo)

uses: expand the intravascular volume

examples: dextran, hetastarch (hespan), 5% albumin, 25% albumin

.9% NS - 5 - 6 L

3% NS - 1.5 - 2L

5% colloid - 1 L

25% colloid - .5L

decreased renal bloodflow --> renin release -->vasoconstriction --> increased hydrostatic pressure -->edema

AND

increased secretion of ADH and aldosterone --> Na+ and resabsorption of water --> edema

1) primary disease which is idiopathic, 80& of which occurs in children

2) secondary disease r/t know glomerular damage (i.e. lupus, glomerulo nephritis aka chronic kidney infection, DM)

3) congenital, autosomal recessive gene (does not respond well to treatment)

- generalized edema (good medium for infection)

- anorexia, diarrhea

- irritability, fatigue, lathargy, decreased activity

- pallor

- normal BP or hypotension

- decreased urine output, dark frothy urine

- increased susceptibility to infection

- increased weight

- increased sp gravity

- decreased volume

-dark, frothy

- hyaline casts

- decreased protein

- increased lipids

- increased or wnl creatinine

- increased H&H

- fluid volume excess r/t fluid accumulation in tissues, decreased sodium excretion

- risk for intravascular fluid volume deficit r/t loss of protein, edema, effects of diuretics

- risk of infection r/t protein loss (immunoglobulins), edema, immunosuppressive therapy

- risk of impaired skin integrity r/t edema and decreased body defenses

- altered nutrition (less) r/t anorexia, protein loss, edema of bowel

- body image disturbance r/t changes in appearance

- activity intolerance r/t fatigue

- altered family processes r/t child with serious disease

- knowledge deficity r/t unfamiliar situation and anxiety

- corticosteroids and cytoaxan or neoral

- daily proteins for 4-6 weeks

- possibly autoimmune drugs

- monitor potassium

- plasma expander

- NAS, protein diet wnl, fluid restrictions

- diuretics used with caution

- prophylactic antibiotics

- observe closely

- good aseptic technique

- response usually seen within 7-28 days

- monitor for side effects of steroids

- small frequent meals

- increased calories

- normal protein

- fluid restriction

- I&Os

- assess edema

- daily weights

measure abdominal girth

- turn q 2 hours

- use Braden scale

- cellulitis assessment

- protect from sick people

- recognize in children relapse may occurs every 2-4 hours

- teach parent to test for protein in urine

- good follow up care, assessment for hypovolemia

- conserve/discard H20

- keep lytes WNL

- preserve acid/base balance

- eliminate nitrogenous waste that results from protein breakdown (urea nitrogen, creatinine)

- rid body of bacterial toxins and water soluble drugs

- produce erythopoetin

- regulate renin production which regulates BP

- activate vit D for calcium function

- glomerular filtration

- tubular resabsorption

- tubular secretion

125L/day is filtered, 1.5L of urine produced

- elderly lose nephrons with age and are more prone to DM and hypertension

- children are more likely to regain renal function

male: prostate

female: more UTIs

- AA 3-4x more likely to devolop renal disease, but live longer and do better on dialysis

- Native and Mexican Americans more likely to develop kidney disease

- family hx may influence development of renal disease

- sever impairment or total lack of renal function (kidneys can maintain function with as little as 25% of functioning nephrons)

- results in ability to excrete metabolic waste

- disturbs function of all body systems

- decline in glomerular filtration

- accumulation of nitrogenous waste products (azotemia)

- fluid restriction: based on circumstances/dialysis

- limited protein as it breaks down into nitrogenous waste; proteins should be of high biologic value (eggs, meat, fish, poultry)

- K+ and Na+ restriction bc kidneys have a difficult time excreting

- avoid salt subs (K+)

- foods increased in potassium to be avoided

- dietary restrictions most severe in non-dialyised pt, most liberal for CAPD

- movement of fluid and molecules across a semi-permeable membrane from one compartment to another

- fluid and molecules move from blood through a semi-permeable membrane into the dialystate

- blood is bathed in dialystate material

- diffusion

- osmosis

- ultrafiltration

- peritoneal: uses the peritoneal membrane as the semipermeable membrane

- hemodialysis: uses an artificial membrane as the semipermeable membrane

- Tenckhoff catheter through abdominal wall

- sometimes used right away, sometimes not used for up to 2 weeks after insertion

- in 18 month maximum

- 1-2 L bags of concentrated glucose solution

- warmed for comfort and vessel dilation

- substances are added to bag in order to control what is filtered

inflow, dwell, drain

- automated: cycler controls phase of each cycle, catheter only opened 2x per day

- CAPD: 4-5 exchanges/day with 4-8 hr dwell time at night (mimics normal renal function)

- peritonitis (cloudy dialysate return)

- infection at exit site

- abdominal pain (usually disappears after 1-2 wks)

- bleeding

- resp difficulties

- low back pain

-cath obstruction (heparin to prevent)

- hernias

- protein loss (can leak into dilystate)

- CHO and lipid abnormalities if lipid or glucose leaks

- multiple surgieres (adhesions)

- recurrent hernias

- advance peripheral arterty disease (won't work)

- very obese

- chronic back problems

- COPD/breathing issues

- intrabdominal pathologies

- daily cath care, periodic tubing changes, aseptic technique

- dialysate warmed to body temp

- weigh pt before and daily

- i and os

- turn, massage pt to promote drainage

- pt ed: must be very motivated, education usually done at dialysis center

-emotional support

- artificial membrane is dialyzing surface

- usually done 3x/week for 3-5 hours

- major vessel (subclavian Quinton, external jugular, femoral vein Sheldon)

- "Ash" cath

- double lumen

- allows very quick dialysis

- allows dialysis while other site is healing

- permacath or life site

- tunneled w/ implanted port

- decreaed risk of infection

- external AV shunt

- internal AV fistula

- internal AV graft if vessels are not good

- can't use fistula for 4-6 weeks

- has to ripen

- can't use graft for  2-4 wks

- assess for thrill, brui

- no BP, blood draws or heavy lifting on that side

- assess for hand steal syndrome

- clotting off

- infection

- anurism

- hand steal syndrome, where perfusion to hand is affected

- primed with NSS

- blood enters top, fills fibers

- dialysate comes up through bottom, bathes outside of fibers

- bubble detector insures no bubbles enter blood

- flused with NSS last

- access AVG/AVF with 14-16 gauge needles

- blood leaves pt

- heparinized

- goes through dialyzer

- goes through bubble detector

- blood returns to pt

- disequilibrium syndrome

- cardiobascular: arrhythmias, hypotension, blood loss, air embolus, hemorrhage, steal syndrome

- muscle cramps

- infectious disease

- sepsis

- pt doesn't feel well day of dialysis

- may be attributed to build up of nitrogenous waste in CSF

- slowing rate of dialysis may help

- if BP decreased, fluids or salt poor albumin

- medications may vary in timing d/t dialysis

- may receive periodic infusions which increases rate of Hep B/C

- surgical implantation of a human kidney from one person to another

- wait time is around 18 months

- restores non-excretory function

- 1 yr survival 90% or higher

- allows normal G&D in kids

- good renal function

- no evidence of infection

- no long-standing diabetes

- no hx cancer

- no major systemic health problems

- informed consent w/ psych evaluaion

- family consent for cadaver kidney

- medical evluation

- psychosocial evaluation

- DM

- hx of cancer, greater than 5 years w/o metz

- very young, very ld

- hep b or c

- active/chronic infection

- chronic respiratory disease

- disseminated malignancies

- refractory heart disease

- extensive vascular disease

- unresolve psychosocial issues, e.g. non compliance, chemical dependancy

- ABO blood grouping

- HLA tissue typing, exact match is brought to top of list

- blood and tissue typing, EKG, blood transfusion if necessary

- pre-op teaching

- dialysis day before surgery

- may have immunosuppressive therapy pre or intra op

- donor kidney

- kidney is transplanted with vessels and ureter

- kidney is transplanted into reciepient's iliac fossa

- bilateral nephroctomies usually not done

 - diuretics given

- SICU for 24 hrs

- carefully monitor fluid balance

- check labs

- foley

- check dressing

- vitals

- cough, turn, DB, OOB

- mouth care

- psychologica care

- education

- rare

- occurs intraop or w/in a few hours

- occurs within days to weeks

- s/sx: increased temp, increased BP, increased creatinine, s/sx of uremia

- can be managed with immunosuppressents

- occurs months to years later

- graft is destroyed by ischemia

- s/sx: increaed wt, increased BP, increased creatinine, s/sx of uremia

- nothing can be done

- increased risk of infection

- increased risk of cardiovascular disease and atherosclerosis

- 100x greater risk of malagnancies

- recurrence of renal disease

- corticosteroid related complications: joint damage, cataracts, DM, PVD

- goal: to adequately suppress the immune system to prevent rejection of the transplanted kidney

- triple drug approach: corticosteroids, cellcept, neoral or Prograf

- prophylactic bactrum for UTI, niastatin for fungal infection, Protonix

- prevents rejections

- complications: infection, malagnancies, recurrent renal dx

- meds to prevent infection/ulcers

- private room

- meticulous care of invasive lines

- pt education

- accumulte, prolonged may be r/t multiple losses

- decreased functioning may occur

- sense of powelessness

- new waves occur with exacerbations

- help pt understand disease

- link pt with needed services

- encourage communication of concerns/feelings with family and caregivers

- help pt use coping strategies

- support family

- decreased RBC production

- decreased lifespane of RBC d/t metabolic toxins

- iron defiencies in d/t blood sampling, blood loss during hemodialysis, and nutritional deficiencies

- decreased H&H

- normal: male, 13.5-18, female 12-16

- decreased iron levels

- tachycardia

- pallor

-SOB d/t decreased o2 carrying capacity

- activity intolerance

- erythropoetin (Epogen, Procrit) IV or SQ may cause bone paint

- darpopoetin (Aranesp), long acting form of erythropoetin

- iron preps: po- Niferex, IV-Infed, Venofer

- Folic acid, B12, multivitamins

- O2 as needed

- decrease activity as needed

- dont' administer iron with antacids

- blood calcium decreased (hypocalcemia)

- blood phosphate increased (hyperpohsphatemia)

- skin calcifications with pruiritis

- renal osteodystrophy resulting in weakned bones: osteomalacia, osteoporosis, growth retardation

- signs of hypocalcemia: tetany, Chvostek's sign, Trousseau's sign

- aluminum hydoxide antacids: Amphogel; avoid magnesium containing antacids d/t inability of kidneys to excrete

- phosphate binders: Phoslo, Renegal, Forsenol

- calcimimetics: snesipar

- activated vit D: recaltral, calcijex, zemplar

- assess for bone tenderness, fractures, weakness

- safety precations: careful handling and fall precautions

- given phosphate binders with meals

- assess and treat constipation caused by phosphate binders and fluid restrictions

- dysrhythmias when K+ level above 6.5

- EKG changes

- treat  K+ greater than or equal to 5.5

- sodium polystyrene po or enema

- 50% glucose and insulin

- sodium bicarb

- 10% calcium gloconate

- assess serum potassium

- EKG

- HR, rhythm

- ph less than 7.35

- decreased venous CO2

- increased chloride

- monitor lab values

- assess

- neurologic irritability

- seizures when hyponatremic

- decreased urine volume, less than 1L/day

- decreased and fixed specific gravity

- protein loss in urine with glomerular disease

-edema

-SOB

- fluid restriction

- Lasix

- dialysis

- daily weights

- i and os

- good skin care

- elevate HOB

- O2 as needed

- assess fluid volume status

- elevate BP

- increased risk for heart failure and CVA

- diuretics: thiazides, loop

- beta blockers: Lopressor

- calcium channel blockers: Norvasc, Cardizem, Calan, Procardia

- ACE inhibitors: Capoten, Vasotc

- ARB: Cozaar

- monitor BP, HR

- monitor I and O

- weights daily

- increased creatinine (.6-1.2)

- increased BUN (10-20)

- decreased creatinine clearance

- BUN/Cr ratio: increased

- MI

- CVA

- CAD

- chest pain

- paresis, paralysis, aphasia

erratic blood glucose

glucose intolerance

- blood glucose monitoring

- assess response to insulin

- reg insulin dose may need reduction

- purpura

- GI bleeding

- monitor platlet count

 - careful handling of pt

- utilize safety measures or prevent fall/injury

- monitor stools for blood

- no ASA

- anorexia

- n/v/d

- metallic taste in mouth

- uremic factor: urine smell to breath

- gastroenteritis, stomatitis

- hiccups

- dialysis

- antemtics: Compazine, Tigan, Zofran

- low protein, low K+ diet

- i and os

- assess for symptoms

- body weights

- serum albumin

- small, frequent meals

- monitor electrolytes

- uremic encephalopathy

- peripheral neuropathy

- uremic ence: lethargy, confusion, apathy, memory impairment, decreased ability to concentrate, insomnia, errors in perception of people/objects, delirium, seizures, coma

- perph nuero: RLS, burning feet, gait disturbance, parasthesias

- dialysis

- nuerotontin for peripheral neuropathy

- neurological assessment

- assess legs and feet

- safety precautions if impaired neurological functioning

- uremic dermattis, uremic frost, pruritis

- yellowish skin color with underlying pallor

- dry skin, thin brittle nails, brittle hair

- dialysis

- antipruritics: Benadryl

- assess skin color, integrity

- assess hair and nails

- keep nails short to prevent scratching

- skin care with cool to tepid water, using creams or oils

- decreased estrogen

- decreased testosterone

- amenorrhea

- decreased vaginal lubrication

- infertility

- decreased testicular size, sperm count, impotence

- decreased libido

- dialysis

- transplant

- counseling

- encourage to express feelings with significant other

- explore alternate ways to express sexual feelings

- depressed immune function d/t metabolic wastes

- decreased WBCS, decreased phagocyte function

- delayed healing

- aseptic technique

- prevent/assess for infection

- psysiologic changes

- stress r/t chronic illness

- loss/reudction in work

- changes in self concept and body image

- role reveral

- loss/reduction at work

- financial strain and lifestyle changes

- coping strategies

- support systems

- fewer dietary restrictions

-less cardiovascular stress

- perferred for children

- bacterial or chemical peritontitis

- hyperglycemia

- contraindications in pt with ab surgery

-longer

- faster

-less protein loss

- lowers serum triglyc

- dietary and fluid restrictions

- disequalibrium

- need specially trained personal

cyclosporine: neoral

tracolimus: prograf

corticosteroids: predisone, solumedrol

mycophenolate mofetie: cellcept

- decline in glomerular filtration

- accumulation of waste products: azolemia

- hypovolemia: burns, diuretics, dehydration, hemorrhage (2/3 of cases)

- decreased cardiac output: MI, heart failure, dysrhythmias

- intravascular pooling blood: dilates vessels, septic shock

- renal vascular obstruction: clot, renal stenosis

- prolonged pre-renal disease

- nephrotoxins

- intra-tubular obstruction

- infection

- trauma

- malignent hypertension

- PIH

- systemic disease: lupus

- mechanical: calculi, tumors, strictures, BPH

- functional: nuerogenic bladder eg after spinal cord injury, with diabetic nephropathy

- onset

- oliguric phase

- diuretic phase

- recovery phase

- initial insult or injury occurs

- immediate intervention may cause reversal

- s and sx may not apear for a week

- 8-14 days

- u/o < 400 cc/day, may be anuric

- decreased sp gravity and fixed

- increased creatinine, BUN, K+, metabolic acidosis

- Na wnl or decreased r/t renal wasting and hemodilution

- fluid retention with edema

- decreased h&h

- decreased ca+ with increased phosphate-

- uremic snydrome

- nitrogenous waste products build up and affect various body systems

- n/v/d

- hiccups

- toxic to brain: h/a, confusion, seizures, coma

- toxic to heart: pericarditis, pericardial effusion

- cellular and humoral immunity

- lasts 1-3 weeks

- marks recovery of glomerular filtration

- azotemia remains but levels off

- osmotic diuresis

- fluid and electrolyte fluctuations

- may l/t dehydration, tachycardia, hypotension

- still requires dialysis

- lasts up to 12 months

- improved renal function

- BUN and Cr start to stabilize and decrease

- labs begin to normalize

- may be some residual impairment

- KUB: radiology looking for cysts, size, shape, tumors

- IVP: dye injected goes to kidney looks for stones, tumors, cysts; use with caution

- ultrasound: kidney size, cysts, tumors

- renal scan: nuclear medicine, radioactive dye, gamma camera

- CAT scan: show more subtle differences

- NPO after midnight

- bowel prep

- no allergies to seafood or iodine

- after procedure increase fluid intake to flush drugs out of system

- oral mucimist as it is a renal vasoldilator and helps to prevent kidney damage as result of contrast dye (contrast induced nephthropay)

- metformin must be stopped before studies

- renal arteriogram: inject dye through femoral artery to kidney, shows stenosis, masses, etc; check pulses, check site

- renal biopsy: open or percutaneous, pt lays on belly, local anesthesia, requires sign consent, coag studies prior to procedure, pressure on site afterwards, pt lies still, 24 hour bedrest, check vitals after frequently, check site for bleeding, flank pain could be sign of bleeding, check urine for blood, H&H, increased fluids

- determine and correct precipitating cause

- manage complications

- provide supportive therapy

- prevention: close assessment to prevent dehydration, sepsis, shock

- early intervention: restore circulating blood volume

- replace insensible loss and measured loss

-daily weights

- strict i&o

-look for signs of fluid volume excess

- replace electrolytes

- phosphate binders

- treat hyperkalemia: can be very toxic to heart, treatment same as chronic renal failure

- monitor ABGs

- give NAHCO3

- dialysis

- decreased protein (breaks down into nitrogenous waste), increased CHO, increased fat and calorie

- protein should be of high biological value: meat, fish, poultry, eggs (complete amino acids)

- nepro: supplemnent

- monitor and treat other effects of uremia: anemia, seizures, dialysis

- judicous abx use (monitor carefully)

- avoid foley catheter unless absolutely needed

- hyperkalemia if it cannot be brought down

- fluid volume excess that must be brought down

manage fluid and electrolyte balance: careful fluid and electrolyte replacement may be done based on 2 hour volume output

- dialysis may still be needed

- progressive, irreversible destruction of both kidneys

- nephrons and glomeruli are replaced by scar tissue

- results in uremia

- systemic disease affecting every body system

- congenital malformations

- systemic disease: HTN, DM

- acute that progresses

- infection

- toxins including drugs

- obstructive nephropathy