Kidney Failure and Management

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Questions and Answers

What is the primary reason to avoid invasive procedures for 4 to 6 hours after dialysis?

Increased chance of vascular complications

Risk of infection

Anticoagulation resulting in bleeding risk (correct)

Potential for kidney impairment

Which of the following conditions is NOT an indication for dialysis?

Chronic liver disease (correct)

Drug toxicity

Hyperkalemia

Acute kidney injury

What is one of the key nursing actions before initiating hemodialysis?

Assess for lower extremity pulses

Perform venipunctures for blood sampling

Administer all medications as prescribed

Check for informed consent (correct)

What complication can occur due to rapid changes in BUN and fluid volume during hemodialysis?

Disequilibrium syndrome Signup and view all the answers

What is the most sensitive indicator of fluid balance in renal patients?

Weight measurement Signup and view all the answers

Which complication is associated with infections in hemodialysis patients?

Infection from graft placements Signup and view all the answers

What nursing action should be taken after the surgical creation of an AV fistula?

Elevate the extremity to reduce swelling Signup and view all the answers

What is a common complication of both hemodialysis and graft placements?

Hypotension Signup and view all the answers

What GFR level defines Stage 3 of kidney disease?

GFR 30-59 ml/min Signup and view all the answers

Which action should be avoided during the pre-procedure phase for a patient with an AV access site?

Measuring blood pressure Signup and view all the answers

Which symptom is NOT a common post-dialysis complication to monitor for?

Increased appetite Signup and view all the answers

During the intra-procedure phase of dialysis, which aspect should be consistently monitored?

Presence of air bubbles in blood tubing Signup and view all the answers

What should be done if there is oozing from the insertion site during dialysis?

Apply pressure and monitor Signup and view all the answers

In terms of weight comparison, what does a decrease in weight post-procedure indicate?

Fluid removal from the procedure Signup and view all the answers

Which laboratory values should be monitored closely during the post-procedure phase of dialysis?

BUN and electrolytes Signup and view all the answers

What is a key action to take during the pre-procedure preparation for a dialysis catheter placement?

Ensure informed consent is obtained Signup and view all the answers

What is one of the primary risks of dialysis disequilibrium syndrome?

Cerebral edema Signup and view all the answers

Which patient demographic is particularly at risk for dialysis disequilibrium?

Older adults Signup and view all the answers

What is a major indication for choosing peritoneal dialysis over other forms?

Difficulty with vascular access Signup and view all the answers

Which of the following is NOT a major complication of peritoneal dialysis?

Urinary tract infection Signup and view all the answers

What should the expected color of dialysate outflow be in peritoneal dialysis?

Pale yellow or amber Signup and view all the answers

What nursing action should be taken if there is poor dialysate outflow?

Reposition the client Signup and view all the answers

Which of the following is a common cause of insufficient inflow or outflow during peritoneal dialysis?

Constipation Signup and view all the answers

What is an important consideration when warming dialysate for peritoneal dialysis?

Heating uniformly without overheating Signup and view all the answers

What is the minimum mean arterial pressure (MAP) that should be maintained to help prevent kidney injury?

65 mmHg Signup and view all the answers

Which of the following medications is NOT known to cause nephrotoxicity?

Aspirin Signup and view all the answers

What dietary protein intake is recommended for hemodialysis patients per day?

1.2 gm/kg Signup and view all the answers

Which is a primary nursing priority to prevent kidney failure in an acute care setting?

Carefully monitor drug levels Signup and view all the answers

What is an appropriate potassium restriction for hemodialysis patients?

2 g/day Signup and view all the answers

What treatment method may be necessary for severe nephrotoxicity or kidney injury?

Dialysis Signup and view all the answers

Which dietary adjustment is NOT applicable to peritoneal dialysis patients?

Fluid restriction under all circumstances Signup and view all the answers

What is the purpose of nutrition support in patients with end-stage renal disease (ESRD)?

Preserve lean body mass and fluid balance Signup and view all the answers

What is the primary reason for keeping the outflow bag lower than the client’s abdomen during dialysis?

To ensure smooth drainage by gravity and prevent reflux Signup and view all the answers

Which medication class must be carefully managed in patients with end-stage renal disease (ESRD)?

Statins Signup and view all the answers

What is a key advantage of an AV fistula over an AV graft for vascular access?

AV fistulas have a lower risk of clotting and infection Signup and view all the answers

Which of the following complications is commonly associated with dialysis treatments?

Peritonitis Signup and view all the answers

How soon after placement can an AV graft typically be used?

2-4 weeks Signup and view all the answers

What is a primary benefit of Continuous Ambulatory Peritoneal Dialysis (CAPD)?

Allows for the patient to manage their own dialysis without a partner Signup and view all the answers

Which of the following is a common assessment related to AV access for dialysis?

Inspection for thrill and bruit Signup and view all the answers

What should be done if inflow or outflow is inadequate during peritoneal dialysis?

Reposition the client Signup and view all the answers

Study Notes

Kidney Failure Prevention

Monitor lab values: BUN, creatinine, electrolytes
Maintain MAP pressure above 65 mmHg
Close I&O recordings
Careful IV fluid administrations
Monitor drug levels
Fluid challenges
Diuretic dosing and outputs management

Nephrotoxic Medications

Vancomycin
NSAIDs
Steroids
Gentamycin/Tobramycin
Chemotherapy: Cisplatin
Cocaine, heroin, Tylenol OD, diuretics, fluoroquinolones, some OTC medications

MAP Pressure

Normal range: 70-100 mmHg
Acute care setting acceptable range: 65 mmHg
Calculation: MAP = Diastolic BP + 1/3 x (Systolic BP – Diastolic BP)
Low MAP: inadequate cardiac output, blood flow to vital organs is compromised
High MAP (over 100 mmHg): organ damage due to high pressure against blood vessels

ESRD Nutrition

Purpose: maintain nutritional status, preserve lean body mass, fluid balance, preserve kidney function
Hemodialysis:
- Protein: 1.2 gm/kg/day
- Sodium: 2-3 gm/day
- Potassium: 2.03 g/day
- Calories: 30-35 kcal/kg/day
- Phosphorus: 0.6-1.2 g/day
- Iron supplement: if receiving erythropoietin injections
- Fluids: depends on urine output (600-1000ml/day)
Peritoneal dialysis:
- Protein: 1.2-1.3 g/kg/day
- Calories: 25-30 kcal/kg/day
- Sodium: 2-4 g/day
- Potassium: 2-3 g/day
- Phosphorus: 0.6-1.2 g/day
- Calcium: individualized
- Iron: if taking erythropoietin injections
- Fluids: unrestricted if weight and BP controlled
Kidney specific supplements: Supplena, Nepro, Nova Source
- Low in phosphorus, sodium, and potassium
- Given orally or through tube feedings
TPN: mixed by physician, pharmacy, and dietician to meet specific patient needs

Treating Nephrotoxicity

Restore fluid volume
Adjust medication doses or discontinue medication
Steroids: for interstitial nephritis
Dialysis: if necessary

GFR Stages

Stage 1: GFR < 90 ml/min
Stage 2: GFR 60-89 ml/min
Stage 3: GFR 30-59 ml/min
Stage 4: GFR 15-29 ml/min
Stage 5: GFR < 15 ml/min

Dialysis Catheter Placement

Pre-procedure actions:
- Informed consent
- Temporary hemodialysis dual-lumen catheter/subcutaneous device until long-term device is available
- Assess patency of long-term devices (AV fistula or AV graft): presence of bruit, palpable thrill, distal pulses, circulation
- Avoid BP measurement, injections, venipuncture, IV catheter insertion in access arm
- Elevate extremity after AV fistula creation to reduce swelling
- Assess vital signs, lab values (BUN, creatinine, electrolytes, Hct), and weight
- Discuss medication withholding with provider until after dialysis
- Withhold dialyzable medications and medications that lower blood pressure
Intra-procedure actions:
- Monitor for dialysis complications: circuit clotting, air bubbles in blood tubing, dialysate temperature, ultrafiltration regulation, hypotension, cramping, vomiting, bleeding at access site, equipment contamination
- Monitor vital signs and coagulation studies during dialysis
- Monitor for bleeding: oozing from insertion site
- Administer anticoagulants (heparin)
- Keep protamine sulfate ready to reverse heparin
- Provide emotional support and offer activities
Post-procedure actions:
- Monitor vital signs and lab values (BUN, creatinine, electrolytes, Hct)
- Assess for hypotension, access site clotting, headache, muscle cramps, bleeding
- Monitor for bleeding or infection at access site
- Assess for disequilibrium syndrome findings
- Assess for hypovolemia findings (hypotension, dizziness, tachycardia)
- Avoid invasive procedures for 4-6 hours after dialysis due to bleeding risk
- Reinforce AV fistula/AV graft precautions
- Compare pre-procedure weight with post-procedure weight to estimate fluid removal (1 L fluid = 1 kg)

Dialysis Function

Hemodialysis: filters blood using a machine (dialyzer) to remove waste products
Peritoneal dialysis: filters body wastes through the peritoneum in the abdomen using varying fluid bags, hours, and treatment methods

Dialysis Indications and Presentations

Renal insufficiency
Acute kidney injury
Chronic kidney disease
Drug toxicity
Chronic hyperkalemia
Hypervolemia

Peritoneal Dialysis Catheter Procedure

Graft/Shunt Placement Complications

Clotting: can lead to reduced blood flow, requiring intervention
Infection: can lead to sepsis, requiring antibiotics and possibly removal of the graft/shunt
Disequilibrium syndrome: rapid decrease in BUN and fluid volume, leading to cerebral edema and increased intracranial pressure
- Manifestations: nausea, vomiting, altered consciousness, seizures, agitation
- Risk factors: advanced age, rapid changes in fluid and electrolyte status
Hypotension: can be caused by fluid removal during dialysis, requiring careful monitoring and adjustments
Anemia: common in patients with ESRD, requiring erythropoietin injections
Abdominal cramping: can occur during peritoneal dialysis, requiring positioning adjustments and pain management
Infectious diseases: greater risk in patients with compromised immune systems, requiring vigilant monitoring and treatment

Hemodialysis Pre-procedures (ATI)

Informed consent
Assess patency of long-term devices (AV fistula or AV graft): presence of bruit, palpable thrill, distal pulses, circulation
Avoid BP measurement, injections, venipuncture, IV catheter insertion in access arm
Elevate extremity after AV fistula creation to reduce swelling
Assess vital signs, lab values (BUN, creatinine, electrolytes, Hct), and weight
Discuss medication withholding with provider until after dialysis
Withhold dialyzable medications and medications that lower blood pressure

Weight as an Indicator of Fluid Status

1 lb = 2.2 kg
Weight is the most sensitive indicator of fluid loss or gain
Standing or sling weight is preferred over bed measurement for renal patients

Hemodialysis Complications

Clotting: leads to reduced blood flow, requiring intervention
Infection: can lead to sepsis, requiring antibiotics and possibly removal of the access device
Disequilibrium syndrome: rapid decrease in BUN and fluid volume, leading to cerebral edema and increased intracranial pressure
- Manifestations: nausea, vomiting, altered consciousness, seizures, agitation
- Risk factors: advanced age, rapid changes in fluid and electrolyte status
- Nursing actions: slow dialysis exchange rate, administer anticonvulsants/barbiturates if needed

Peritoneal Dialysis Indications

Older adults requiring dialysis
Unable to tolerate anticoagulation
Difficulty with vascular access
Chronic infections or unstable condition
Chronic diseases (diabetes mellitus, heart failure, severe hypertension)

Peritoneal Dialysis Complications

Peritonitis: infection of the peritoneum, requiring prompt treatment with antibiotics and possibly hospitalization
Infection: can occur at the catheter insertion site or in the peritoneal cavity, requiring prompt treatment with antibiotics
Protein loss: can occur through the peritoneum, requiring nutritional adjustments
Hyperglycemia: can occur in patients with diabetes, requiring careful monitoring and management of blood glucose levels
Hyperlipodemia: elevated blood lipid levels, requiring careful monitoring and management

Peritoneal Dialysis Dialysate Flow Observations

Poor inflow or outflow:
- Causes: obstruction or twisting of the tubing, constipation, client positioning, fibrin clot formation, catheter displacement
Nursing actions:
- Reposition client
- Milk the tubing to break up clots
- Check tubing for kinks or closed clamps
Outflow color:
- Should be pale yellow or amber
- Cloudy outflow: possible infection
- Brownish outflow: possible peritonitis (emergency)
Outflow amount:
- Should equal or exceed inflow amount
Other observations:
- Fever
- Bloody, cloudy, or frothy outflow
- Drainage at access site
- Respiratory distress
- Abdominal pain
- Insufficient outflow
- Wetness at access site dressing (dialysate leakage)
- Exit-site infections

AV Shunt vs. AV Graft

AV fistula: uses patient's own arteries and veins, considered the best choice for vascular access
- Provides good blood flow
- Lower risk of clotting/infection
AV graft: uses artificial material (e.g., Gore-Tex)
- Provides a solution for small or weak veins
- Can be used 2-4 weeks after placement
- Outpatient surgery under local anesthetic
- Used when permanent access sites are exhausted

Medications to Avoid in ESRD

Statins: doses adjusted due to liver and diabetes conditions
NSAIDs: kidney clearance problems, can build up in the blood
Pain medications: kidney clearance problems, can build up in the blood
Antibiotics: kidney function should be evaluated before administration
Antivirals: kidney function should be evaluated before administration
Certain diabetes medications: kidney clearance problems
Antacids: can affect electrolyte and acid-base balance

Continuous Ambulatory Peritoneal Dialysis (CAPD) Advantages

Performed by the patient
4-2 liters of dialysate exchanged into the peritoneal cavity
Dwells for 4-8 hours, 7 days a week
Continuous connect system or disconnect for later exchange
No machine or partner required

Common Problems After Dialysis

Peritonitis: infection of the peritoneum, requiring prompt treatment
Pain: can occur at the access site or in the muscles
Infections: can occur at the access site or in the body
Hypotension: can be caused by fluid removal during dialysis
Muscle cramps: can occur during or after dialysis
Blood loss: can occur during procedures, requiring prompt intervention

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Description

This quiz covers essential topics related to kidney failure prevention and management. It includes monitoring lab values, understanding nephrotoxic medications, managing MAP pressure, and nutrition for patients with end-stage renal disease (ESRD). Test your knowledge and enhance your understanding of kidney health and treatments.