ESRD and Dialysis Complications

ESRD and Dialysis (Uremia)

• Oral symptoms include metallic taste and nausea/vomiting
• Muscular symptoms include wasting and cramping
• Skin symptoms include bruises and pruritus
• Vitals include elevated BP, HR, RR, and decreased pain

Post-Hemodialysis Complications

• Monitor for hypotension
  • Not a normal finding
  • Caused by pulling too much fluid off
  • Fatigue can result
• Increased HR indicates dehydration
• Assess the fistula for bleeding, thrill, and bruit
• Other possible complications include
  • Heart failure
  • Coronary artery disease
  • Stroke
  • Peripheral vascular disease
  • Anemia
  • Gastric ulcers
  • Renal osteodystrophy
  • Phosphorus deposits in skin
  • Shortness of breath
  • Sleep problems
  • Muscle cramps
  • Exsanguination
  • Dysrhythmias
  • Air embolism
  • Seizures
  • Decreased LOC

Fluid Overload in ESRD

• Pericarditis, pericardial effusion, tamponade, and pleural friction rubs can occur
  • Treat with emergency hemodialysis to remove fluid
• Symptoms include JVD, increased weight, dependent edema, and adventitious breath sounds

Patient Education: Fluid Overload in ESRD

• Instruct the patient when to notify the doctor for the following symptoms:
  • JVD
  • Pulmonary infiltrates
  • Crackles
  • Seizures
  • Confusion
  • Weakness (disequilibrium syndrome)
  • Rapid weight gain
  • Swelling
  • Fatigue
  • Decreased pulses
  • Hypervolemia

ESRD Lab Values

• High creatinine
• High BUN
• High Magnesium
• High Potassium which effects the heart
  • Monitor EKG/cardiac
  • Peaked T waves and wide QRS intervals
  • Treat with Kayexalate PO or retention enema
• Decreased urine output – less than 30mL/hr

ESRD Medications

• Calcium binders
  • Calcium acetate (PhosLo) - Used for high phosphorus levels (2-4.5mEq/L)
• Phosphate binder
  • Renagel (Sevelamer)
    • Lowers phosphorus
    • Binds dietary phosphorus in the GI tract
• Erythropoietin
  • Epoetin alfa
    • For anemia
• Anticonvulsants
  • Benzodiazepine/diazepam
  • Hydantoin/phenytoin
• Inotropes
  • Digoxin (cardiac glycosides)
  • Beta receptor agonist/Dobutamine
• Diuretics
• Avoid nephrotoxic antibiotics (Gentamicin)
  • Monitor creatinine and BUN values with any antibiotics

Medications to Hold Before Dialysis

• BP meds (antihypertensives) - losartan

Antihypertensive Drug Classes

• ACE Inhibitors (-prils): Lisinopril, Enalapril
  • Mechanism of Action: Inhibit ACE
  • Effect on BP: Decrease SVR, SV
• ARBS (-sartans): Losartan, Valsartan
  • Mechanism of Action: Block Angiotensin II Receptors
  • Effect on BP: Decrease SVR, SV
• Alpha Blockers (-osins): Doxazosin, Terazosin
  • Mechanism of Action: Block Alpha Receptors
  • Effect on BP: Decrease SVR
• Beta Blockers (-lols): Metoprolol, Labetalol
  • Mechanism of Action: Block Beta Receptors
  • Effect on BP: Decrease HR, SV
• Calcium Channel Blockers (CCBs) (-dipines): Amlodipine, Nicardipine
  • Mechanism of Action: Block Calcium Channels
  • Effect on BP: Decrease SVR
• Diuretics (-ides): Furosemide, Hydrochlorothiazide
  • Mechanism of Action: Facilitate Diuresis
  • Effect on BP: Decrease SV

ESRD Patient Education: When to Notify Provider ASAP

• Vision changes, headache, confusion, dizziness, hypervolemia = intracranial pressure and risk for falls

Acid/Base Imbalance Associated with ESRD and Hemodialysis

• Metabolic acidosis
  • Low pH: Less than 7.35
  • Normal PaO2: 80-100
  • Normal or High PaCO2: Greater than 35-45
  • Low HCO3: Less than 22

Dietary Restrictions for ESRD Patients

• Low phosphorus: Avoid milk, have eggs and cheese instead
• Low sodium: Less than 2-3 grams per day
• Low potassium:
  • Avoid: potatoes, oranges, citrus, salt substitutes, processed foods, avocados, sweet potato, antelopes, and coffee
  • Good foods: apple, berries, cauliflower, broccoli, eggplant
• Low protein: 0.6-0.8g/kg/day
• Vitamin supplements
• Fluid limitations

CRRT Candidates

• CVVH: Just hemofiltration (3 times per week; lasts several hours)
• CVVHD: Hemofiltration with dialysate (continuous over 24 hours, slow process)
• CVVHD indications:
  • Clinically unstable patient for renal dialysis
  • Septic
  • Hypotension
  • Decreased urine output with backflow
  • Patients whose BP would drop drastically

Signs and Symptoms of Uremia

• Affects every system
  • Symptoms include signs of fluid overload, confusion, weakness, uremic fetor (urine odor in breath), thin hair and nails, ulcer formation, hiccups, cardiac tamponade, and pericarditis
• Hyperkalemia
  • EKG changes: peaked T waves and wide QRS intervals
  • Treat with Kayexalate PO or retention enema

Pathophysiology of ESRD

• Buildup of toxins (uremia), increasing urea, uric acid, and nitrogenous wastes in blood
• Azotemia: Kidneys can no longer efficiently get rid of nitrogen metabolites, leading to the formation of urea
• Decreased renal function
  • Low GFR (less than 15), low filtration
    • Estimated amount of blood that passes through glomeruli each minute
• Uncontrolled diabetes is the typical cause

ESRD Fluid Overload Complications

• Anemia: Due to decreased erythropoietin production, decreased RBC lifespan, GI bleeds from toxin/ulcer formation, and blood loss from hemodialysis
• Bone disease & metastatic and vascular calcifications: Due to retention of phosphorus, low serum calcium, abnormal vitamin D metabolism and high aluminum levels
• Hyperkalemia (peaked T waves; wide QRS intervals): Due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (nutrition, fluid, and meds)
  • Treat w/ Kayexalate PO or retention enema
• Hypertension: Sodium and water retention (angiotensin); help with heart health
• Pericarditis, pericardial effusion, and tamponade

Imbalanced Nutrition Nursing Interventions in ESRD Patients

• Promote high biologic value protein like eggs, dairy, and meat
• Provide a high calorie, low protein, low sodium & potassium diet
• Assess weight changes
• Labs: electrolytes, BUN, creatinine, protein, transferrin, and iron levels
• Assess patient's diet history, food preferences, and calorie counts
• Assess factors that can contribute to altered intake: anorexia, nausea/vomiting, depression; diet unpalatable to patient, lack of understanding of restrictions and stomatitis
• Provide patients food preferences within the restrictions
• Schedule medications so that they are not given right before meals

Complications of a Nephrectomy

• Bleeding
• Infection
• No urine output
• Monitor bowel sounds
  • Assess bowel movement (paralytic ileus)
• Palpate bladder
  • Should be non-palpable

Interventions for Impaired Urinary Elimination in Post-Op Nephrectomy Care

• Monitor respiratory status, circulation, blood loss, pain and watch for DVT
• Assess urinary drainage system immediately
• Assess adequacy of urinary output and patency of drainage system
• Assess lab values
• CT scans with contrast are hard on the kidneys: question the order
• Use asepsis and hand hygiene when providing care and manipulating drainage system
• Maintain a closed urinary drainage system
• If irrigation is needed use sterile gloves, a sterile solution, and a closed drainage/irrigation system
• Maintain adequate fluid intake
• Assist and encourage early ambulation
• Patient education and discharge instructions

Patient Education for Catheter at Home

• How to prevent complications (obstruction, infection, DVT, atelectasis, and pneumonia)
• Assist patient in turning, moving in bed and when ambulating to prevent displacement/removal of the urinary stent or catheter
• Observe urine color, amount, and components
• How to minimize trauma and manipulation of the system
  • Do not manipulate it
• How to care for catheter
  • Clean catheter gently with soap and water
  • Clean with a spiral, start at the site of the urethra
  • Go over the leg, don't hold bag above bladder to prevent backflow
• Anchor drainage tube
• Avoid back and forth motion to prevent irritation of the urethra
• Change stoma every 3-7 days
• Never patch stoma with tape
• Avoid soap and lotion over the site
• Monitor for moisture on bed linens for leakage and infection
• Keep urine pH below 6.5
  • Give ascorbic acid
• If there is a foul-smelling urine
  • Catheterize stoma for C&S
• Mucous mixed with urine, mucous membrane to form conduit
  • Reassure the patient that this is normal; increase fluids
• How to measure I&Os
• When to contact the physician
  • If no urine in ostomy

Patient Teaching for a Kidney Transplant

• Damaged kidney is not removed
• New kidney is placed in the iliac fossa (anterior to the iliac crest)
• Living donor kidney
  • Must see urine output before closing
• Deceased donor kidney
  • May take 2-3 weeks to produce urine
• Kidney transplant > check for rejection > check for flow
  • Hyper rejection: within 24 hours = remove
  • Acute rejection: 3-14 days

Brain-Dead Organ Donor (Glasgow Coma Scale <5)

• Maintain perfusion
• Maintain perfusion with ventilation, IV fluids, nutritional supplements in order to preserve the kidneys
• Maintain perfusion (MAP over 65): so the organ is useable: keep BP up so the organ is perfused
• Use vasoconstrictors and vasopressors

Post-Kidney Transplant Nursing Assessment

• Rejection s/s
  • Looks like kidney failure: fluid overload, toxin buildup
  • Oliguria
  • Edema
  • Fever
  • Increased BP
  • Weight gain
• Infection s/s
  • Fever
  • Tachycardia
  • Tachypnea
  • Increased WBC
  • Shaking/chills

Post-Kidney Transplant Patient Teaching

• Medication compliance for immunosuppressive therapy (under more risk for cancer) and anti-rejection meds (cyclosporine (neoral), dexamethasone, prednisone)
  • Pt will be more at risk for infections
  • Implement neutropenic precautions
• Follow up care
• Dental checks
• Must have proper nutrition
• Support groups
• Signs and symptoms of complications of rejection and infection
• No contact sports
• May try to have a baby after 1 year = healing
• Donor and receiver must wait a year to meet

Risk Factors for Bladder Cancer

• Men
• Caucasian
• Older than 50
• Common s/s include painless hematuria, dysuria, frequency, UTI, flank pain
• Smoking
• Radiation
• Exposure to Rubber cement and dyes, aniline, and leather

Common Sites of Metastasis for Bladder Cancer

• Lymph nodes
• Liver
• Lungs
• Bone
• Brain
• Kidney
• Diagnose with cystoscopy with bladder biopsy

Risk Factors for Renal Cancer

• Most common: Asbestos (paint/tile)
• Smoking
• Obesity (BMI >30)
• HTN
• DM
• PKD
• African American
• Male
• Older
• Clinical manifestations typically asymptomatic until advanced, CVA tenderness, pain, palpable abdominal mass, hematuria, dyspnea, cough, bone pain

Possible Post-Op Nephrectomy Complications

• ABCs
  • Notify physician, call rapid response
• Atelectasis
  • Treat with ambulation to promote gas exchange
• Infection
• Bleeding
• Paralytic ileus

Patient with a Nephrostomy

• Primary concern is body image
• Emotional support may be needed
• Provide referral support groups during discharge
• Foods to avoid: asparagus, fish, eggs, cheese

Dietary Recommendations for Bariatric Surgery Patients

• Small, frequent meals (6+) - smaller than 1 cup
• Eat slowly
• Chew thoroughly
• Do not drink with meals
• No liquid carbs
• No candy or soda
• Take dietary supplements
  • Vitamin B12 (IM) to prevent anemia
• Walk 30 min/day
• More water in between meals
• Drink plenty of fluids 30 minutes before meals or 30–60 minutes after and between meals
• Eat in low Fowler's and stay in that position for 30 minutes after meal time
• Encourage electrolyte drinking
  • Sugar-free Gatorade
• No coffee as it can cause dehydration (diuretic)

Early S/S of Dumping Syndrome After Bariatric Surgery

• Tachycardia due to fluid loss
• Abdominal cramping
• Dizziness
• Sweating
• Nausea/vomiting/diarrhea
• Bloating

Bariatric Surgery Complications

• Hemorrhagic shock
• Bile reflux
• Dumping syndrome
• Gastric outlet obstruction

Risk Factors and Early Detection for Lip, Oral, Esophageal Cancer

• Smoking
• HPV
• Excessive ETOH consumption
  • Teach to go to dentist
• Obesity
• GERD
• Previous head or neck cancer (especially thyroid)
• Not sugar diet
• Clinical manifestations
  • Painless oral lesions, difficulty swallowing, speaking, chewing

Risk Factors for Gastric Cancer

• Diet (smoked, salty, pickled foods – low in fruits and veggies)
• H.pylori and Epstein Barr
• Chronic gastritis
• Smoking
• Obesity
• Ulcers

Diet for Esophageal Cancer Patient After Surgery

• Soft mechanical diet
  • Mashed potatoes
  • Pudding
  • Apple sauce
  • Oatmeal
  • Diced peaches
  • Canned fruit
• Small sips of water
• Limit spicy foods
• Moderate alcohol
• Good mouth care

Patient Education for Colorectal Cancer

• Prevention is number one priority
  • Screening starting at age 50
  • Screening starts sooner if increased risk

Risk Factors for Colorectal Cancer

• Smoking
• UC or Crohn's disease
• African American
• Older age

S/S of Colon Cancer

• Change in bowel habits
• Ribbon-like stools
• Blood/mucous in stool
• Excessive diarrhea
• Unexplained anemia, anorexia, weight loss, fatigue
• Rectal pain
• Melena
• Tenesmus (feeling of incomplete evacuation)

S/S and Assessment of Pancreatitis

• Patho: pancreatic duct becomes obstructed and hypersecretion of pancreatic enzymes occurs, enzymes are activated before release & start digesting the pancreas itself causing inflammation
• Etiology: biliary tract disease, cholelithiasis, alcohol
• Diagnose: CT scan (gold standard)
• LUQ pain that radiates to back (epigastric pain)
• Acute pain after heavy or high-fat meals or ETOH ingestion
• Tenderness on palpation
• Anorexia
• Steatorrhea
• Nausea/vomiting
• If dizzy, indigestion, pain in neck and jaw
  • Can be heart attack

Risk Factors for Pancreatitis

• Heavy ETOH drinkers
• Obesity
• Diabetes

Treatment for Acute Pancreatitis

• Opioid pain medications
• Semi-Fowler's position; frequent position changes
• Assess respiratory status
• Glucose checks every 4-6 hours
• NG tube to low wall suction (monitor suction and output)
• H2 antagonists
  • Ranitidine (Zantac)
  • Cimetidine (Tagamet)
• PPIs
  • Omeprazole
• Pancrelipase (creon)
• Avoid antacids
  • Do not provide relief
  • Pepsid
• Avoid Demerol (meperidine)
  • Risk for seizures
• TPN

Patient Education for Pancreatitis

• NPO
• Avoid high-fatty foods and ETOH
  • A small diet of 6 meals a day can eventually be given

Care Plan Nursing Interventions for Imbalanced Nutrition with Pancreatitis

• Assess current nutritional status and increased metabolic requirements
• Monitor serum glucose levels and give insulin as prescribed
  • Glycemic control
• Administer IV fluid and electrolytes, enteral or parenteral nutrition as prescribed
• Provide high carb, low protein, and low-fat diet when tolerated
• Instruct patient to eliminate alcohol and refer to AA if indicated
• Counsel patient to avoid excessive use of coffee and spicy foods
• Monitor daily weights

Labs Drawn for Pancreatitis

• Amylase (increased for short time): 56-190
• Lipase (increased for several days): 0-110
• Trypsin (increased)
• WBC (increased): 5-10
• Glucose (increased): Greater than 110
• Glucosuria (increased)
• Bilirubin (increased)

Risk Factors for Pancreatic Cancer

• Older
• AA
• Males
• Obesity
• ETOH
• Smoking
• Type 2 diabetes
• Environmental exposure
• Chronic pancreatitis
• High fat diet and diet high in meats
• Diagnose w/ Percutaneous fine-needle aspiration biopsy

S/S of Patient with Pancreatic Cancer

• Ascites
• Insulin deficiency
• Glycosuria
• Hyperglycemia
• Abnormal glucose intolerance
• Diabetes (earliest indicator)
• Pain management; hospice, end-of-life care

S/S of Cirrhosis

• Portal vein hypertension
• Abdominal pain, liver enlargement
• Ascites
• Vitamin deficiency and anemia
• Mental disorientation

Diagnosis for Cirrhosis

• Increased AST, ALT, LDH, bilirubin, ammonia
• Decreased albumin, PLT, sodium
• Prolonged PT/INR

Medications for Cirrhosis

• Vitamins and supplements (milk thistle)
  • A, B, K, C
• Ranitidine
  • Histamine H2 antagonist (decreases GI distress)
• PPI
• ABX if infection present
• Spironolactone (K sparing diuretic) (call doc before administering)

S/S and Complications of Fluid Overload in Liver Disease

• Ascites
• Crackle
• Esophageal varices
• Portal hypertension
• Hypertension

Patient Education for Cirrhosis

• Diet high in carbs and protein (1.2-1.5 g/kg/day)
  • Good: fruits, veggies, nuts, seeds, tofu, and legumes
  • Bad: pork, eggs, cheese, tuna, raw foods, and processed meats
• Avoid constipation (use stool softeners)
• Rest
  • Complications of Rest: atelectasis, pneumonia, pressure ulcers, and DVTs
• No ETOH
• Avoid Tylenol
• Avoid sports
• Don’t use razors to avoid bleeding and injury

Ascites in Cirrhosis

• Portal obstruction causes a backup in the spleen and GI, protein-rich fluid accumulates in the peritoneal cavity that pulls fluid into the peritoneal cavity
• Lack of protein in the liver

Effectiveness of Lactulose

• Evaluate effectiveness of lactulose by measuring reduction in ammonia levels and improvement of complications
• Increased ammonia can lead to confusion, disorientation, and potentially coma

Nursing Interventions to Reduce Ammonia Levels in Hepatic Encephalopathy

• Occurs when the liver fails due to portal hypertension and shunting of blood to the systemic circulation
• The liver produces enzymes that help break down protein into amino acids
  • The left over amino acids become ammonia
• EEG
• Clinical manifestations: Asterixis (hand flapping), hyperactive DTRs, fetor hepaticus (fecal breath)
• Promote safety
• Treat metabolic alkalosis
• Prevent injury, bleeding, and infection
• Encourage deep breathing to blow off ammonia
• Lactulose (IV): decreases ammonia by drawing it into the colon to be excreted:
  • If watery stool, sign of overdose
  • If pt in coma: use NGT or enema route
  • Effect can take up to an hour

Liver Abscess

• S/S:
  • Fever with chills
  • Diaphoresis
  • Malaise
  • Anorexia
  • N/V
  • Weight loss
  • Dull abdominal pain/tenderness in RUQ
  • Pleural effusion may develop
• Nursing Interventions:
  • Monitor for drainage and skin care
  • Infection prevention
  • Monitor vital signs
  • Labs

Neomycin

• Kills bacteria in the gut that break down protein

IV Glucose (Continuous D5W)

• Decreases protein breakdown

Impaired Liver Function Care Plan

• Diet high in carbs
• Adequate protein intake
• Reduce sodium to treat edema and ascites
• Avoid intra-abdominal pressure
• Provide skin care/prevent skin breakdown
• Reduce risk of falls and bleeding
  • Provide padded side rails and bleeding precautions
• Measure abdominal girth and weight daily

Patient Teaching for pt that has Oral Cancer going through Chemo

• Regular dental hygiene and dentist visits
• Promote nutrition
• Avoid crowds
• Antibiotics
  • Prevent infection
• Treat pain

5 Stages of Grief

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

Patient Wants to Stay in Bed Post-Op and Doesn't Want to Ambulate

• Educate the importance of early ambulation to reduce pulmonary stasis
• Tell them to notify staff whenever they are ready to get up
• Tell them about the importance of deep breathing and incentive spirometer

Peritonitis (PRIORITY) (SBP)

• Clinical manifestations
  • Hypovolemia
  • Rigid board-like abdomen
  • Paralytic ileus
  • Nausea/vomiting
  • Fever
  • increased pulse
  • Pain aggravated by movement
• Diagnosis Culture of aspirated fluids; WBC, HH, and electrolytes
• Treatment Lactated ringers (isotonic fluids), broad-spectrum antibiotics, and Phenergan for treatment of both nausea and vomitting
• If left untreated: sepsis

Priority Nursing Assessment Findings in Abdominal Trauma and How to Respond

• Infection
  • Monitor WBC and temp
• Bleeding
  • Monitor VS

Priorities for a Patient with a Gun Shot Wound to the Liver

• ABCs are priority (cervical spine)
• NPO
• Clinical Manifestations Abdominal US, labs
• New or worsening condition call MD
• Labs for type and screen

Penetrating Visceration

• Treat with a sterile moist dressing with normal saline

Hemorrhage

• Treat with fluids (normal saline)
• Fresh whole blood or packed RBCs
• Fresh frozen plasma (massive transfusion protocol)
• Stop bleeding (external bleeding, then internal bleeding)
• Vitamin K helps clotting
• Give broad-spectrum ABX; tetanus