NSG 450 Exam #3 Study Guide PDF

**Kidney Disorders - Part 1** **[Objectives for this presentation and post-class activity]** - Review the patho for selected kidney disorders. - Identify the diagnostic tests for selected conditions. - Discuss the medical treatment for selected conditions. - Identify problems/nursing di...

**Kidney Disorders - Part 1** **[Objectives for this presentation and post-class activity]** - Review the patho for selected kidney disorders. - Identify the diagnostic tests for selected conditions. - Discuss the medical treatment for selected conditions. - Identify problems/nursing diagnoses for selected conditions. - Select nursing interventions to address problems/nursing diagnoses. - Evaluate expected outcomes. - Identify potential unexpected outcomes. - Can all lead to chronic kidney disease, which can lead to dialysis **[If you need to review...............]** - Iggy Chapter 60, p. 1302-1306 reviews the anatomy and physiology of the kidney. - ATI RN Medical Surgical Nursing Unit 8, Chapter 58 reviews laboratory and diagnostic tests. **[Disorders to be covered today]** - Urolithiasis - Pyelonephritis - Glomerulonephritis (acute and chronic) - Polycystic kidney disease - Kidney trauma We will define each of these disorders. There is a table in the module that identifies the specific laboratory and diagnostic tests that will be done. In general, the diagnostic tests confirm the anatomic abnormalities that are present. For example, a CT-scan for urolithiasis will show the presences and location of the stones (unless they have been passed). - Kidneys filter out waste, toxins, and water - So when kidneys are not working right, we see symptoms related - First 3 have to do with inflammation or infection (itis) **[Laboratory and Diagnostic Tests]** - Table in the module identifies which ones are most common. - In general, diagnostic tests will show the abnormality that is causing the disorder. - Most common laboratory test: urinalysis - Specific disorders will have specific results - Will sometimes do culture to look for infection There is a table in the module that identifies the specific laboratory and diagnostic tests that will be done. - When we do a CT or x-ray it is to see abnormality **[Urolithiasis]** - Presence of calculi (stones) in the urinary tract. - Symptoms do not usually occur until they move. - Most common cause: dehydration. - Most stones contain calcium. - More infrequently can be struvite, uric acid, or cystine - High urine acidity or alkalinity (depending on the substance) and certain medications contribute to stone formation. - Any stone can obstruct the urinary tract. - If the stone blocks the ureter, it cuts off the flow of urine and the ureter dilates. It can lead to enlargement (hydorureter). A diagram of a human body Description automatically generated - Can get stuck down in ureter - Need to stay hydrated in order to not develop kidney stones and to flush them out easier - Struvite stones come from infection - Uric acid stones com from uric acid or (gout) - Can also have cystine - High urine acidity or alkalinity will form certain types of stone - Stones form when crystals form - Where dehydration comes into play, crystal to not dissolve and form into stone - Metabolic factors that contributes - Sometimes inherited trait to develop kidney stones **[Urolithiasis: Assessment (Recognizing Cues)]** - Family and personal history of stones - Was analysis done to determine content of stones? - Family history strong association - Genetic variations associated with stone formation - Obesity - Diabetes - Gout - Diet history (table in book) - Fluid intake - Vitamin and mineral supplement usage - Obesity, diabetes, and gout are metabolic syndrome that increase risk - Diet, fluid, and vitamin can be controlled - Foods that are higher in uric acid or cysteine - The amount of fluid that they are drinking, what are they drinking - Vitamin and minerals -- calcium? **[Urolithiasis: Signs & Symptoms (Recognizing Cues)]** - Pain can be excruciating. Location of pain helps identify location of stone. - Flank pain: stone is probably in the kidney or upper ureter - Flank pain extending toward abdomen or floor of pelvis: stone is probably in lower ureter or bladder. - Bladder distention - Palpate it and feel distention - May appear pale, diaphoretic, and have nauseas and vomiting (renal colic). - Can happen suddenly When it comes to pain, think about all the things that go with pain assessment as well as other signs that someone is in pain. - Flank is either side of the back - If stone is blocking urine, we can see less urine or anuria (no urine) **[Urolithiasis: Laboratory and Diagnostic Test Results (Cue recognition and analysis)]** - Urinalysis - pH: high or low is associated with specific substances - Low: uric acid and cystine stones - High: calcium phosphate and struvite stones - Hematuria: RBC presence related to trauma to lining of bladder - WBCs and bacteria MAY be present - Elevation of serum WBC [IF] infection is also present - Increased serum levels of calcium, phosphate, or uric acid - Last two things, we are drawing blood - First one is urinalysis **[Urolithiasis: Medical Treatment]** - Most people pass stones without intervention. - Lithotripsy - Break stone up by using waves and vibration to then have it flow downwards - Use moderate sedation because it is not very pleasant - Stenting - Place a stent in the ureter to help dilate it and make passageway bigger - Ureterolithotomy - Go in and remove stone - Can be done percutaneously -- use scopes and instruments to go in and take it out - Open procedure -- used for larger stones that cannot be removed other ways - Other treatments focus on preventing infection and preventing obstruction. - If infection is present: antibiotic therapy - Infection always occurs with struvite stones - They are a byproduct of a UTI - High intake of fluid to dilute urine, unless they have a condition that contraindicates that (CHF) - Drug therapy to prevent stone formation. Diluting urine prevents the crystals that are present from forming stones. If the client has surgery, the care is similar to a nephrectomy as the incision will be similar. Surgical interventions can also require drains or tubes postoperatively. **[Urolithiasis Problems/Nursing Diagnoses (Prioritizing hypotheses)]** - Pain - Fluid Balance - Infection (either active or risk for) - Nutrition - Diet high in uric acid or sodium The primary problem is pain. And it is severe. Because dehydration can contribute **[Urolithiasis Nursing Interventions (Taking action)]** - Pain control: around the clock administration of medications during first 24-36 hours: regular dosage or continuous infusion. - Opioid analgesics - NSAIDS - Monitor for kidney impairment - NSAIDS eliminates in kidneys and can be hard on kidney (need to monitor lab values) - Spasmolytic drugs help. - Maintain fluid balance (avoid over hydration or underhydration). - Monitor intake and output. - Strain for stones and send to laboratory for analysis as ordered - Teach client to strain urine for stones. - Administer other medications as ordered - Antibiotics (struvite stones) - Thiazide diuretic and allopurinol may used to help excrete stones. - Used in conjunction with high fluid intake. - Thiazide diuretic is used because it is potassium sparing - Manage anxiety - Instruct on what to expect with regards to any procedures - Some are fearful of developing them again. If the client is being treated outpatient, teach them to strain for stones. If a stone does not pass in 1-2 months, it probably will not and other interventions may be needed. - If stone does not pass in a couple months, there may need to be something else done **[Urolithiasis Evaluation]** - Pain should be managed while stone is on the move - Typically, 24-36 hours - Pain should resolve when stone is passed - No signs of infection - No fever, elevated WBC, chills, fatigue - Fluid balance maintained (no dehydration) - Intake and output is similar (should not take in liter and urinate 2) - Dehydration -- not urinating, dry mouth, dry mucous membranes - If applicable, dietary teaching is effective. - Teach back -- identify foods to avoid and what to drink and eat - What happens when stone is not resolved? - Serious kidney injury can occur (more on that in a little bit) - They will come back to hospital If the stone is not resolved, other medical treatments are needed. **[Pyelonephritis]** - Infection starts in the bladder and moves upward to infect the kidneys. - Acute: active bacterial infection (current) - Want to try to keep it from becoming a chronic problem - More likely to occur in young sexually active women - Chronic: repeated or continuous infections. - Mostly occurs in people with anatomic abnormalities of the urinary tract. - Can occur from urinary statis from prolonged bed rest, obstruction, or reflux - Can lead to chronic kidney disease - More likely occurs when urine refluxes from bladder to ureters and then kidneys but can occur from organisms in the blood (client usually has immunity issues) - Most common causative organism: Escherichia coli - Is in stool, why it is common to get into urinary tract Acute is more likely to occur in young, sexually active women. Is often managed outpatient, but may be in hospital if they are very ill or cannot tolerate oral antibiotics. **[Pyelonephritis: Assessment (recognizing cues)]** - Ask about recurrent UTIs, DM, kidney stones, and known defects of urinary tract. - Defect of urinary tract -- (structure) ureters narrow, valves are not good, angle - Ask about reduced immunity (this can lead to chronic) - Chronic autoimmune disease - Ask about kidney function and chronic kidney disease. - Since it is more frequent in young women, inquire about pregnancy before radiographic imaging is done. **[Pyelonephritis: Signs and Symptoms (Recognizing cues)]** - Acute: - Assess for general symptoms of infection: fever, chills, fatigue - Assess for symptoms specific to condition: flank, back, or loin pain (butt area); abdominal discomfort; burning, urgency or frequency of urination; nocturia (peeing a lot at night), recent cystitis or UTI, tenderness at costovertebral angle (middle back) - In older adults assess for acute confusion: sometimes it is the main sign - Young people may feel guilty (due to association with sexual activity) - Chronic - Assess for hypertension, inability to conserve sodium, decreased urine concentrating ability (lighter, clear urine), nocturia, hyperkalemia and acidosis Signs and symptoms are different depending on if it is acute or chronic. See p. 1\`357 of book - Hyperkalemia and acidosis have to do with kidneys not functioning well **[Pyelonephritis: Laboratory and Diagnostic Test Results (Cue recognition and analysis)]** - Urinalysis: positive leukocyte esterase and nitrate and presence of WBC - May also have RBC and protein - Urine culture for specific organism via clean catch method (preferably) but will use catheter if necessary - Blood cultures if systemic infection is suspected - C-reactive protein and ESR to identify presence of inflammation - Diagnostic tests include x-rays of kidney, ureters, and bladder or CT scan. Renal scan can identify abscesses and active pyelonephritis. - If they see things like early sepsis, will think infection came form someplace else and will do blood culture **[Pyelonephritis: Medical Treatment]** - Drug therapy to treat - Pain (acetaminophen and opioids) - Antibiotics for bacterial causes - Important to complete full course (can develop resistance and super infection). - If client already has a catheter, change before starting antibiotics - To prevent contamination that is in old catheter - Ensure adequate nutrition - Control blood pressure to prevent CKD - Can be associated with pyelonephritis - Surgical treatment is to correct problems (structural issues or stones) - How to assess adequate nutrition - Albumin - Managing weight - Observe eating - Balance in nutrients - Ensure adequate fluid intake **[Pyelonephritis Problems/Nursing Diagnoses (Prioritizing hypotheses)]** - Pain - Infection - Fluid balance - Elimination - Altered nutrition - Self-care management **[Pyelonephritis Nursing Interventions (Taking action)]** - Monitor kidney function - Creatinine and BUN - I&O - Daily weight to understand fluid balance - Monitor intake and output - Encourage fluids to avoid dehydration - Monitor blood pressure - Provide medication to relieve pain - Acetaminophen or opioids - Antibiotic therapy - Teach client to take all the medication - Instruct on signs and symptoms of infection and diet (if needed) - Want to make sure we don't underhydrate and overhydrate **[Pyelonephritis: Evaluation]** - Client will be free from symptoms of infection. - Decreased WBC, no fever, decreased pain, no chills - Pain will be controlled. - If elderly and confused, confusion improves. - Client will be knowledgeable about disease, treatment, and interventions to prevent CKD. - Client maintains a diet that meets individual needs. - Fluid intake is appropriate. - I and O balance is maintained. - Blood pressure is controlled. **[Acute Glomerulonephritis]** - Reflects an immune response in the kidneys. - Glomeruli are inflamed - Blood traveling to the kidney is carrying microorganisms - Can be primary or secondary - Primary: occurs as a result of infection - Onset of symptoms about 10 days from time of infection - Typically has other s/s of infection before this - Secondary associated with other conditions such as SLE, and liver disease - Has to do with a condition that causes inflammation and altered immunity - Can lead to progressive damage resulting in CKD Glomeruli filter the blood. Because the blood is filtering through the kidney, bacteria come into direct contact with the glomeruli. - Anemia and high cholesterol can result from this **[Acute Glomerulonephritis: Assessment (Recognizing cues)]** - Ask about recent infections, especially skin and upper RT. - Ask about recent travel or other potential microbe exposure. - Hanta virus is only seen in other places - HIV exposure are more at risk because of altered immunity - Ask about diseases that alter immunity (list is on p. 1360). - Lupus - Assess for possible sources of infection (outside the urinary tract). - Skin - Piercings - Recent surgeries or invasive procedures A lot of the assessment has to do with identifying possible sources of infection. **[Acute Glomerulonephritis: Signs and Symptom (Cue recognition)]** - May report change in elimination patterns (not urinating as often) and characteristics of urine. - Frequency and Volume - Clarity, odor, color (cloudy, smelly) - Assess for edema. - Fluid and sodium retention can result in edema, including pulmonary edema. - Peripheral edema, periorbital edema, anywhere edema - Kidneys are not doing their job and not filtering out fluid and sodium is being retained - Fluid overload can lead to hypertension. - May have associated with uremia such as fatigue, anorexia, nausea and vomiting. - Symptoms in elderly can be confused with heart failure. - Because of fluid overload, especially if they develop pulmonary edema Uremia is where toxins build up in the blood because the kidneys are not filtering them out. It is more often associated with chronic kidney disease. **[Acute Glomerulonephritis: Laboratory and Diagnostic Test Results (Cue recognition and analysis)]** - Urinalysis : RBCs and protein - 24-hour urine: increased protein excretion rate (may be up to 3 g/ 24 hours - Serum albumin levels: reduced due to protein loss and dilution - Serum creatinine and BUN levels: elevated - GFR estimates: reduced - Kidney biopsy: provides precise diagnosis An early morning urine specimen is preferred as it is most concentrated **[Acute Glomerulonephritis: Medical Treatment]** - Managing infection: PCN, erythromycin, or azithromycin for strep infections. - Manage excessive inflammation: immunosuppressive drugs. - Corticosteroids - Cyclosporin - Short term dialysis may be necessary (more on that in a later module). - To get rid of fluid - Manage excess fluid and electrolyte imbalances - May need diuretics to help kidneys function and to eliminate fluid - May need sodium and fluid restrictions - Hyperkalemia: may need to restrict potassium in diet - May need protein restriction if BUN is elevated. - BUN is blood urea nitrogen that is a biproduct of protein metabolism If not caused by infection but inflammation, corticosteroids and other immunosuppressive drugs such as cyclosporine are used). The kidneys have to work harder to remove the protein. **[Acute Glomerulonephritis: Problems/Nursing Diagnoses (Prioritizing hypotheses)]** - Fluid and electrolyte imbalance - Infection/Immunity - Perfusion (hypertension) - Make sure BP is controlled - Nutrition - They get nutrients they need with restrictions necessary - Fatigue - Plan out care that doesn't make them tired - Spread out activities **[Acute Glomerulonephritis: Nursing Interventions (Taking action)]** - Administer medications as ordered. - Antibiotics - Corticosteroids or cytotoxic drugs - Diuretics - Anti-hypertensive medications - Monitor fluid status. - Intake and Output - Weight - Edema - Coordinate care to conserve energy. - Educate client for self-management - BP and weight everyday at the same time - Is weight going up, edema, BP going up, or is it stable - Diet and fluid restrictions - Make sure they understand what their limit looks like (2L is sprite bottle) - Medication self-administration **[Acute Glomerulonephritis: Evaluation]** - Elimination pattern returns to normal. - Weight and BP return to baseline. - BUN and Creatinine are normal. - Symptoms of infection or inflammation are reduced. - Client understands how to manage the condition. Now, these are all the things we want to see happen. However, the problems may not totally resolve before the client is discharged. It is important to see progress towards normal. **[Chronic Glomerulonephritis]** - Develops over time (years) - Exact cause is not known but can occur from infection, hypertension, poor blood flow to kidneys (diabetes causes this, vascular disease that impacts perfusion to kidneys), hyperimmune system activity (lupus, certain medications that alter immune system) - Kidney tissue atrophy and tissue shrinkage - Neuron loss leads to reduced glomerular filtration - Always leads to end-stage kidney disease - Trying to slow down progression because ESKD needs dialysis **[Chronic Glomerulonephritis: Assessment (recognizing cues)]** - Ask about other health problems, kidney problems and infections - Ask about increasing fatigue - Ask if frequency of urine has increased or if the quantity of urine has decreased - Ask about changes in cognition, changes in memory, irritability and confusion - Toxins building up in blood causes this **[Chronic Glomerulonephritis: Signs and Symptom (cue recognition)]** - Assess for fluid overload - Crackles - Peripheral edema - S3 heart sound (Kentucky), JVD - Assess BP - Assess for uremia - Excess toxins in blood that can make skin look weird - Inspect skin for yellow color and texture changes, ask about itching - Assess psychosocial responses: may be depressed, angry or anxious - Asterixis -- flapping tremors in fingers - slurred speech - Impaired coordination **[Chronic Glomerulonephritis: Laboratory and Diagnostic Test Results (Cue recognition and analysis)]** - Urinalysis: specific gravity is fixed (about 1.010) RBCs, and casts may be present - Does not fluctuate because kidneys are not working - GFR is low - Serum BUN and creatinine are elevated - Sodium level altered - May make them look like they have a low sodium level but they do not because of fluid level - Watch sodium level - s/s of electrolyte dysfunction - Hyperkalemia - Kidneys cannot filter - Hyperphosphatemia - Kidneys cannot filter - Metabolic acidosis due to HCO3 loss and H retention - X-ray or CT shows small kidneys - Atrophied - May make them look like they have a low sodium level but they do not **[Chronic Glomerulonephritis: Medical Treatment]** - Manage fluids and diet. - Dialysis will likely be required at some point. **[Chronic Glomerulonephritis: Problems/Nursing Diagnoses (Prioritizing hypotheses)]** - Fluid and electrolyte imbalance - Acid-Base imbalance - When kidneys stop doing filtering that they should be doing, we will start to see metabolic acidosis - Perfusion (hypertension) - Nutrition - Fatigue **[Acute Glomerulonephritis: Nursing Interventions (Taking action)]** - Administer medications as ordered. - Diuretics - Anti-hypertensive medications - Monitor fluid status. - Intake and Output - Weight - Edema - Monitor electrolytes and acid-base balance. - Coordinate care to conserve energy. - Educate client for self-management. - BP and weight everyday at the same time - Diet and fluid restrictions - Medication self-administration **[Chronic Glomerulonephritis: Evaluation]** - The desired outcome is for the problem to stabilize, but this may not occur as this condition leads to chronic kidney disease (CKD) **[Polycystic Kidney Disease]** - Genetic disorder - Fluid filled cysts form in the nephrons leads to progressive kidney enlargement. - Cysts can rupture - Most with this disorder also have hypertension. - Which make sense with the connection of kidneys with hypertension **[Polycystic Kidney Disease: Assessment (recognizing cues)]** - Ask about family history - Age at which kidney problem diagnosed - History of sudden deaths or strokes - May also develop cerebral aneurism -- common - May cause death - Most common genetic kidney disease but not common - Can develop cysts in liver and blood vessels as well **[Polycystic Kidney Disease: Signs and Symptom (cue recognition)]** - Pain, abdominal discomfort, constipation - Changes in urine color or frequency - Hypertension - Headaches - Come from sodium imbalance - Abdominal distention - Dull aching pain from enlarging kidney - Sharp intermittent pain when cysts rupture - Red or rust colored urine when cysts rupture - Early symptoms is nocturia - At first have hyperfiltration - Lose sodium and water - Then glomerular filtration rate decreases and we have these issues **[Polycystic Kidney Disease: Laboratory and Diagnostic Test Results (Cue recognition and analysis)]** - Ultrasound to measure size of kidney and identify cysts - Urinalysis: proteinuria, hematuria, bacteria (if cysts have ruptured and become infected - BUN & creatinine are elevated **[Polycystic Kidney Disease: Medical Treatment]** - There is not treatment. - Supportive therapies: manage hypertension, pain, and constipation. **[Polycystic Kidney Disease: Problems/Nursing Diagnoses (Prioritizing hypotheses)]** - Fluid and electrolyte imbalance - Acid-Base imbalance - Acidosis - Perfusion (hypertension) - Low sodium diet - Lose weight - Drug therapy with ACE inhibitors - Chronic pain - Can be opioids but may be other things - Nutrition - Fatigue - Space out activities - Anxiety/depression **[Polycystic Kidney Disease: Nursing Interventions (Taking action)]** - Administer antihypertensives as prescribed - Monitor I & O, weight, and blood pressure - Monitor electrolytes - Manage pain - Measures to prevent constipation - Reduce complications from infection - Education on drugs, diet and general disease management **[Polycystic Kidney Disease: Evaluation]** - Disease process will be slowed. - Blood pressure will be lower. - Fluid balance will be maintained. **[Renal Trauma: Overview and Assessment]** - Occurs from both penetrating injuries and blunt force injuries. - Classified in 5 grades with 1 being the least amount of injury and 5 being the greatest. - Focus is on prevention (p. 1371). - Wear seatbelt, wear appropriate equipment - Document mechanism of injury. - How did they get it? - Inspect both flanks, abdomen, and lower back for bruising and symmetry of injury. - Urinalysis will show RBCs. - Diagnostic tests: ultrasound, CT, abdominal x-ray. **[Renal Trauma: Medical Treatment & Nursing Interventions]** - Most are managed without surgery - Avoid activity that reinjure, encourage rest - Drug therapy and fluid to replace blood - Teach signs and symptoms for infection - Monitor for hematuria - Sign that they are still bleeding **Acute Kidney Injury\ Chronic Kidney Injury** **[Concepts]** - The priority concept for this chapter is - Elimination The interrelated concepts for this chapter are - Acid--base balance - Fluid and electrolyte balance - Immunity - Perfusion - Elimination -- excess water, waste, toxins - Acid base balance -- hydrogen and sodium bicarbonate ions is impaired - Immunity infections that can lead to AKI - Perfusion -- one of the main causes of AKI is hypoperfusion **[Acute Kidney Injury (AKI)]** - Pathophysiology Overview - Rapid reduction in kidney function resulting in failure to maintain waste elimination, fluid and electrolyte balance, and acid--base balance - Occurs over a few hours or days - Ways to define these - Decrease in serum creatinine in last 48 hours - Need to know baseline to know what change has happened - Most are already in hospital for another problem and develop aki **[Acute Kidney Injury (AKI): Etiology]** - Reduced perfusion to kidneys, damage to kidney tissue, obstruction of urine outflow Risk factors -- shock, cardiac surgery, hypotension, prolonged mechanical ventilation, sepsis Older adults or adults with chronic diseases are at higher risk - May have condition that is already altering perfusion to kidneys - Things that can obstruct urine outflow - Kidney stones - BPH (pressure on urethra) - 3 types -- treated differently - Pre renal - Before kidney is causing decrease in perfusion (sepsis, shock, hypovolemia, dehydration) - Intrinsic - Inside the structure of kidney is decreasing perfusion (blood clots, drugs that are toxic to kidneys - vancomycin, nsaids) - Post renal - Something is obstructing flow of urine (kidney stones, pressure on urethra) - Prerenal and postrenal - The body responds by activating the renin angiotensin pathway, which increases ADH - The goal is to increase retention of fluid to increase kidney perfusion **[Acute Kidney Injury (AKI):\ Health Promotion and Maintenance]** - Teach healthy adults to drink 2 to 3 L of water daily Avoid exposure to nephrotoxic drugs - NSAIDs are over the counter so can be more common - Need to remind people of this - We have to adjust this if unhealthy (CHF) - In acute care, this is one of the reasons that I&O are important to detect early **[Acute Kidney Injury (AKI):\ Assessment: Recognize Cues (1 of 3)]** - History - Changes in urine appearance, frequency, volume - We can see volume higher or lower depending on where we are for AKI - Recent surgery or trauma, transfusions, allergic reactions - Allergic reactions -- we can see AKI as late as 10 days after an allergic reaction - Drug history - Abx, NSAIDs, and contrast medium (toxic to kidneys and restricts blood flow) - Coexisting conditions - Person with kidney disease can still get AKI, diabetes, HTN, sepsis, liver disease, AIDS - Immunity-mediated AKI - Looking for people who have had influenza, gastroenteritis, or sore throat with strep - Anticipate AKI after hypotension or shock - Can show up after everything resolves (AKI comes from hypoperfusion) - History of obstructive problems - Structural differences in urinary tract, stones **[Acute Kidney Injury (AKI):\ Assessment: Recognize Cues (2 of 3)]** - Physical Assessment/Signs & Symptoms - Hourly urine output - May have foley catheter in - Assess for fluid overload - Edema, crackles, blood pressure, SOB, JVD, differences in I&O, weight - Evaluate vital signs for hypoperfusion and hypoxemia - MAP \ - We usually do not see anemia form kidney problem - Will have anemia from hypoperfusion from blood loss (different from chronic) **[Acute Kidney Injury (AKI): Interventions: Take Action]** - Avoid hypotension, maintain normal fluid balance - Hypoperfusion to kidneys can occur without much hypotension Reduce exposure to nephrotoxic agents and drugs - Check kidney function before giving nephrotoxic drug - Provider may need to adjust dosage for many issues - Renal, liver problems, and elderly Frequently monitor laboratory values Closely watch I/O Drug therapy - May receive diuretics to get rid of fluid Nutrition - Dietician can identify specific protein, sodium (how much of a sodium restriction -- no added salt, or more intense), fluid needs for person Kidney replacement therapy - Dialysis and kidney transplant - AKI may need short term dialysis -- temporary catheter to get rid of extra fluid and electrolytes, toxins to get kidney to catch up - If we do not get rid of excess fluid it gets worse - Sometimes people with AKI may get fluid challenge to increase fluid to kidneys, as long as they are not in fluid overload (urine output should increase) - Referred to as fluid responsive (reacting positively to fluid challenge) **[Elimination Concept Exemplar:\ Chronic Kidney Disease (CKD)]** - Pathophysiology Overview - Progressive, irreversible disorder - We try to slow the progression down - End-stage kidney disease (ESKD) - Also called this - Azotemia - Uremia - Uremic syndrome - Altered kidney function lasting 3 months or more - Azotemia, Uremia, Uremic syndrome - All the same thing -- just CKD (fancy way of saying it) - The build up of nitrogen waste in body **[Stages of CKD]** - Five stages based on GFR category - Stage 1 - Labs are normal but GFR is reduced - At risk - Trying to slow down progression - Stage 2 - Slight reduction in kidney function - Trying to reduce risk factors - Stage 3 - Moderate reduction in kidney function - Really try to slow disease progression - Stage 4 - Severe reduction in kidney function - Trying to handle complication - Stage 5 - End stage - Need dialysis or transplant - Permanent dialysis **[Chronic Kidney Disease (CKD): Changes]** - Kidney changes - Do not produce as much urine - Will be able to meet body's needs until lost 75% of function Metabolic changes - Fluid and electrolyte balance is disrupted - How disrupted depend on where we are - Early -- hyponatremia - Late -- hypernatremia, hyperkalemia - Calcium and phosphorous -- kidneys make hormone to balance calcium and phosphorous, - Low calcium and high phosphorus -- more at risk for bone loss (fractures) - Can create crystals that can build up in places from calcium and phosphorous imbalance (itchy skin) - Acid-base balance is disrupted - As nephrons loss, they lose the ability to secrete the acid and do not reabsorb bicarbonate - Metabolic acidosis Cardiac changes - Hypertension - Hyperlipidemia - Changes in fat metabolism, increase risk for CAD - Heart failure - Increased workload from all th extra fluid in the body - Pericarditis - Pericardium becomes inflamed Hematologic and Immunity changes - Anemia GI changes - Peptic ulcer disease, n&v, hiccups Cognitive and functional changes - Lethargic **[Chronic Kidney Disease (CKD): Etiology and Genetic Risk]** - More than 100 different disease processes can result in progressive loss of kidney function Two main causes of CKD leading to dialysis or kidney transplantation - Hypertension - Diabetes mellitus - Need to manage diseases - Do not need to know number **[Chronic Kidney Disease (CKD): Incidence and Prevalence]** - About 15% of adults in U.S. are estimated to have CKD Most adults that have CKD do not know they have the disease (CDC, 2019) - Do not need to know number - Most do not know it **[Chronic Kidney Disease (CKD):\ Health Promotion and Maintenance]** - Control diseases that lead to CKD - Manage diabetes, HTN - There has been greater emphasis recently on what is considered HTN Dietary adjustments - Low sodium diet - Watch protein - Adjust cholesterol -- with CKD, people can have higher levels Weight maintenance Smoking cessation Exercise Limitation of alcohol - 1 to 2 drinks per day - Slows progression but does not stop it **[Chronic Kidney Disease (CKD): Assessment: Recognize Cues (1 of 4)]** - History - Weight and height; weight gain or loss - Medical history, especially of kidney or urologic origin - Drug use - Dietary habits - GI and GU problems **[Chronic Kidney Disease (CKD): Assessment: Recognize Cues (2 of 4)]** - Physical Assessment/Signs and Symptoms - Neurologic changes - Lethargy, decreased concentration, slurred speech - Cardiovascular symptoms - HF, HTN, increasing edema, cardiac tamponade, and pericarditis - Respiratory symptoms - Pulmonary edema, kussmauls respirations (rapid, deep breaths -- same intensity each time) - KR is compensatory mechanisms because metabolic acidosis to blow off CO2 to balance - Hematologic symptoms - Anemia, decreased WBC, increased risk for bleeding - Skeletal symptoms - Bone pain, fractures - Urine symptoms - Polyuria (early), oliguria or anuria (later), proteinuria (building up in body and losing ability to get rid of it) - Skin symptoms - Yellow, gray, dry skin, decreased skin turgor - Page 338 in iggy key features box **[Chronic Kidney Disease (CKD): Assessment: Recognize Cues (3 of 4)]** - Psychosocial Assessment - Anxiety, fear - Chronic disease and will die if no dialysis or kidney transplant - Coping mechanisms - Support recommendation of mental health professional - May need ongoing psychosocial support **[Chronic Kidney Disease (CKD): Assessment: Recognize Cues (4 of 4)]** - Laboratory assessment - Creatinine, BUN - elevations - Sodium, potassium, calcium, phosphorus, bicarbonate - Hyperkalemia, hypocalcemia, hyperphosphatemia - Hemoglobin and hematocrit - Hgb will decrease because of anemia, hct depends on fluid overload (indicator of fluid volume) - GFR - Decrease across time - Urinalysis - Depends on stage they are at Imaging assessment - X-ray findings (few are abnormal) - May see shrinkage of kidneys - Kidney or CT scan **[Chronic Kidney Disease (CKD): Analysis:\ Analyze Cues & Prioritize Hypotheses]** - Fluid overload due to the inability of disease kidneys to maintain body fluid balance - Decreased cardiac function due to reduced stroke volume, dysrhythmias, fluid overload, and increased peripheral vascular resistance - Weight loss due to inability to ingest, digest, or absorb food and nutrients as a result of physiologic factors - Potential for injury due to effects of kidney disease on bone density, blood clotting, and drug elimination - If kidneys build up drugs, leads to toxicity and continue to work overtime - Potential for psychosocial compromise due to chronic kidney disease **[Chronic Kidney Disease (CKD): Planning and Implementation: Responding]** - Managing fluid volume - I&O, daily weights - Improving cardiac function - Enhancing nutrition - Preventing injury - Minimizing psychosocial compromise - Page 1391 of iggy book -- drug therapy - Need to know categories of drugs and why being given - Loop diuretics - to increase urine output if elimination is still present - Vitamins and minerals -- to replace what is loss by dialysis and to address the calcium, phosphorous,d vitamin d abnormalities - Erythropoietin -- anemia - Parathyroid hormone modulator -- used to reduce parathyroid gland production of of parathyroid hormone by decreasing the gland's sensitivity to calcium. This action helps maintain blood calcium and phosphorous levels closer to normal and can reduce osteodystrophy **Kidney Replacement Therapies** **Dialysis and Kidney Transplants** **[Who needs dialysis?]** - **A**: Acid-Base Problems - Usually acidosis - **E**: Electrolyte problems - Hyperkalemia, sodium, phosphorous - **I**: Intoxications - Buildup of waste products and medications - **O**: Overload of fluids - Edema - **U**: Uremic symptoms - Most common reason for starting it\ they get fatigue, nauseous, skin yellow-gray, tremors - GFR gets less and less with each stage of CKD - By stage 5 they usually need dialtsis **[Let's talk about drugs and dialysis]** - Many medications are partially removed by dialysis. - Pay attention to antihypertensives: most ACE inhibitors are partially removed by dialysis (captopril, enalapril, lisinopril). Some beta blockers are partially removed, and some are not. - This matters because it might not work because it is getting removed - Does not mean drug is not given but timing may be changed - Many are not all impacted at all. - Dosages for medications may need to be adjusted in clients with CKD. - Herbal products and supplements should be avoided. - We do not know enough info whether they could buildup in body Whether or not a drug is removed by dialysis is important to note. It does not mean that a medication is not used in a dialysis patient, but when the drug is administered is important: a medication that is largely removed curing dialysis would not be given right before the client has dialysis. As for drugs that are not removed during dialysis, it is important to note that some of these are not given in dialysis patients because **[Let's talk about diet and dialysis]** - The exact diet and recommended fluid volume will be individualized, but most clients will have some sort of restriction. - Limit fluid - Limit potassium - Limit phosphorus (relationship to Calcium) - High quality protein is encouraged (meat, poultry, fish, eggs) - But avoid proteins we see in processed foods - Processed foods should be avoided because they often contain large amounts of sodium and processed meats (hot dogs, some lunch meat, some canned foods with meat like chili) also contain phosphorus. - Sodium should be limited as well - More sodium causes more fluid retention **[What is dry weight?]** - Dialysis clients should be weighed before and after dialysis. - Dry weight is the weight after dialysis has removed the fluids - Weight should decrease after dialysis **[How is type of dialysis determined?]** - There are a lot of factors that are considered. - PD is contraindicated for some conditions - Each method has advantages and disadvantages. - One key factor is the client's ability to self-manage dialysis at home. - Resources such as storage space (especially for peritoneal dialysis ), plumbing, electricity. - A lot of people cannot or choose not to self manage at home You do not need to know for testing purposes but for your professional knowledge: PD is contraindicated in certain conditions: people with abdominal scarring, colostomies, ileostomies, liver disease with ascites. p\. 1395 (do not need to know this) - People who have colostomies, ileostomies, and extensive abdominal surgeries cannot have dialysis **[Kidney Replacement Therapies: Hemodialysis]** - Hemodialysis - Patient selection - Dialysis settings - Procedure - Anticoagulation - Vascular access - Precautions - Access complications - Temporary vascular access - Hemodialysis nursing care - Post-dialysis care - Complications of dialysis - Done in the hospital - Can also have portable units for ICU - Is possible to do it at home - Hemodialysis catheter that is temporary or permanent fistula - they need to be taught how to access catheter and maintain sterility - Possibility for blood clot - Will often use heparin to prevent - For 4-6 hours after dialysis there is increased risk for bleeding - They may give heparin during dialysis and protamine after to reverse heparin or wait it out to watch for bleeding - Catheters will have 2 ports to remove and return blood to body - Can cause infection and bleeding - If they have AV fistula -- connect vein and artery - No BP, IV, blood draw, BS sticks in that arm - Will take several months to heal and be usable, so might use temporary catheter until this - Do not put pressure on fistula (do not carry healthy objects, do not lay on fistula) - Can have problems with vascular access, whether fistula or catheter it can clot - Can have infection - If someone needs dialysis now they will put in temporary and the fistula but may just need temporary dialysis (acute glomerulonephritis) - Watch for complications - Teach for when drugs should be removed - Monitor for infection - teach that having dialysis can cause hypoglycemia - Will take at least 4 hours - At least 2-4 times a week - Cannot skip it - Complications - Hypotension - Stop or slow the rate of removing fluid - Headache, nausea, vomiting, muscle cramps - Has to do with fluid shift and electrolytes moving around - Disequilibrium syndrome - Severe - LOC decreased, coma, death - Mild - Nausea, tired, headache, restless - Slow down or stop - Dialysis - Particles moves with diffusion - Osmosis is water moving - Dialysis uses a combo of diffusion and osmosis - Hemodialysis -- membrane that you are running blood through one way and dialysate another way, how stuff is removed is in the diasylate (can make it so it either pulls more water or particles out -- electrolytes, medications, waste products) -- will monitor labs closely and adjust depending on what patient needs **[Kidney Replacement Therapies: Peritoneal Dialysis]** - Peritoneal Dialysis - Patient selection - Procedure - Process - Dialysate additives - Types of PD - Complications - Nursing care during in-hospital PD - People used to prefer peritoneal dialysis because it allowed them to do it at home, but now they can do hemo at home - Good for people who cannot take anticoagulants (used in hemo) - They insert a catheter in abdomen into peritoneum (surgery) - Peritoneum is membrane and they instill fluid (fill time) and blood vessels act as other side and sits for a prescribed period of time (dwell time) and then drained out - This process is one exchange - How many exchanges depends on prescribed - Typical fluid put in is 1-2 liters - When they first start, they may have fluid leak out but after a couple weeks will go away - Continuous ambulatory peritoneal dialysis - 4 2 L exchanges - 4-12 hours - Automated - At home - Machine cycles in 30 min exchanges - Can be done overnight - Intermittent - Uses osmotic pressure to force in - 30-40 exchanges a week - Diacylate additives - Depends on patient condition - May add k+ to prevent hypokalemia - May put heparin in diacylate (for those that can take it to prevent clotting) - Complications - Peritonitis - Sterile technique is important - Pain common (cramping if they do not warm diacylate -- do not warm in microwave, potential for burning) - Infection around catheter (exit site infection) - Want drainage bag below body - Weight self everyday with same scale and same amount clothing - Measure and record how much comes out - Should be the same or remove a bit more - Everything put is considered intake **[Peritoneal Dialysis Exchange]**  The image above explains peritoneal dialysis exchange for control of fluids, electrolytes, nitrogenous wastes, blood pressure, and acid--base balance. [ ] **[Kidney Transplantation (1 of 3)]** - Candidate selection criteria - Advanced kidney disease - Reasonable life expectancy - Not expected to die in the next year - Medically and surgically fit for procedure - Cannot have certain diseases (cancer, infection) - In U.S. -- waiting list when GFR \< 20 mL/min - Donors - Living donors (highest rate of graft survival) - Non-heart-beating donors - Death is from circulatory collapse (different from a brain dead donor) - There is a window of time where kidney is not getting perfusion - Cadaveric donors - People who have consented (donated body to science) - May have been dead for slightly longer - There is a window of time where kidney is not getting perfusion - They should talk initially about being a candidate because it takes a long time to get one - Needs to be on dialysis - Cannot have an active psych disease that is uncontrolled, no substance abuse - Has to be able to adhere to medication regimen and dialysis schedule - More common transplant because of more availability (potential for living donors) - Family member is best candidate (human leukocyte antigen match) **[Kidney Transplantation (2 of 3)]** - Preoperative care - Immunologic studies - Donor kidney has to have same blood type - Human leukocyte antigen testing to make sure - Will need meds after to make sure - Dialysis 24 hours before surgery - Blood transfusion before surgery - Operative procedures - Procedure varies depending on status of donor - Failed kidneys are left in place (unless infected or enlarged, causing pain) - New kidney placed in right or left anterior iliac fossa **[Transplanted Kidney]** 071016 The image above shows the placement of a transplanted kidney in the right iliac fossa. **[Kidney Transplantation (3 of 3)]** - Postoperative care - Urologic management - Assess hourly urine output × 48 hours - CBI (occasionally prescribed) - Monitor I/O - Complications - Rejection - Thrombosis - Renal artery stenosis - Other complications - Immunosuppressive drug therapy - Will have foley catheter to measure output exactly and to prevent stretch on sutures (attached ureter to bladder) - Continuous bladder irrigation to prevent blood clots from forming inside bladder (we have attached a ureter to bladder and is potential for clots there) - When they hook kidney up, they put out a lot of fluid and need to make sure not dehydrated and hypokalemic - Rejection - Hyperacute - Within 48 hours - Acute - Within 1 week - Will alter immunosuppressant therapy - Chronic - Months or years, function of organ gets less and less - Thrombosis - Within 2-3 days of surgery - Renal artery stenosis - Narrowed from scar tissue formation - Can result in hypertension - Infection, hematomas - Will have to take immunosuppressant drug therapy to prevent rejection - At risk for infection - Many times infections that normal people do not get - Can get CMV (should not be cleaning litter boxes, digging in garden) - Cannot take many vaccines **[Kidney Transplantation:\ Care Coordination and\ Transition Management]** - Home care management - Self-management education - Drug regimen and diet - Health care resources - Social services - Dietician - Mental health - Home care - Will often have case manager to make sure pieces come together **[Kidney Replacement Therapies:\ Evaluation: Evaluate Outcomes]** - Achieve and maintain appropriate fluid and electrolyte balance - Maintain an adequate nutrition status - Dietary adjustment but also make sure they get nutrients that they need - Hypocalcemia -- impact cardiac, musculoskeletal function - Vitamin D - High quality protein and limit the total amount (depending on BUN) - Avoid infection at the vascular access site - Sepsis risk (going directly into blood stream - Use effective coping strategies - Prevent or slow systemic complications of CKD, including osteodystrophy - Report an absence of physical signs of anxiety or depression - Random info - BUN, creatinine - Potassium, sodium, calcium, phosphorous, hgb, hct - May not see anything on imaging but may see shrinking, polycystic kidneys - Concepts related to kidney disease: fluid balance (too much), perfusion (hypertension, CKD), electrolyte balance, acid base, nutrition (diet may be altered somehow), - If someone has AKI and renal trauma and urolithiasis will hopefully resolve - May not need long term diet therapy - Monitor I&O, daily weight, urinalysis, monitor BP, assess fluid status, assess for edema, heart sounds, monitor electrolytes - Comorbidity: diabetes, HTN - How often are you urinating? What does it look like? Is it painful? Do you get up at night? Recent infection (triggers)? Surgery or trauma? Outside of country?