Nephrology Lecture - Acute & Chronic Illness Theory PDF

NEPHROLOGY LECTURE NUPD 701 Acute and Chronic Illness Theory  OBJECTIVES Describe Explain Develop Discuss Explain Describe the Explain the Develop an Discuss Explain the pathophysiolog nursing...

NEPHROLOGY LECTURE NUPD 701 Acute and Chronic Illness Theory  OBJECTIVES Describe Explain Develop Discuss Explain Describe the Explain the Develop an Discuss Explain the pathophysiolog nursing understanding important care necessary y, assessments of renal assessments to promote manifestations required for replacement and on-going health and and laboratory people living therapies and monitoring prevent illness abnormalities with chronic how they work. needed for in patients with of chronic kidney disease patients with renal disease. kidney disease and end-stage renal disease and end-stage kidney disease. undergoing kidney disease. dialysis and what to report. TERMS TO CONSIDER Creatinine Breakdown product of creatinine phosphate in muscle Filtered by the kidney Used to estimate kidney function Inversely proportional to function = higher creatinine the lower the filtration (Gfr ) BUN Urea is formed through the breakdown of protein by the liver Filtered by kidney and used to measure function High BUN reflects low filtration Caveat - some meds can cause BUN to rise without kidney function such as steroids and some antibiotics Oliguria < 400-500 ml of urine in 24 hours Anuria < 100 ml of urine in 24 hours ACUTE KIDNEY INJURY  AKI a sudden episode of kidney failure or damage that happens within a few hours or days  Causes build up of waste products in your blood making it difficult for kidneys to keep the right balance of fluid in body  Approx. 5 -7% of hospitalized and critically ill patients develop AKI ( usually medication) RISK FACTORS Advanced age Diabetes Hypotension CAD CAUSES OF AKI Infection/sepsis Low cardiac output – kidney is a very vascular organ receives 25% of total CO Renal tubules are highly sensitive to reduced blood flow Kidney auto regulates to maintain a mean arterial pressure of 65- 180 mmHg cardiac output = reduced renal perfusion = ischemia Nephrotoxic drugs aminoglycoside antibiotics, contrast dyes, ethylene glycol, diuretics, NSAIDS AKI HAS 3 TYPES AND 4 PHASES TYPES OF ACUTE KIDNEY INJURY  PHASES OF ACUTE KIDNEY INJURY * Consider possible ‘risks’ during the Oliguric & Diuretic phase CHRONIC KIDNEY DISEASE  CHRONIC KIDNEY DISEASE  According to the National Institute for Health and Clinical Excellence (NICE) (2008): Chronic kidney disease (CKD) is ‘defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health  This includes all people with markers of kidney damage and those with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage)’  CHRONIC KIDNEY DISEASE  Progressive, irreversible loss of kidney function  Nephrons begin to lose their function ability, glomerular filtration rate decreases and the kidneys are unable to filter waste products from the blood (azotemia). Normal GFR 125 mL/min, which is reflected by urine creatinine clearance  Two main causes of renal failure:  Diabetesmellitus  Hypertension GFR CATEGORIES  EFFECTS OF CHRONIC KIDNEY DISEASE MANIFESTATIONS: CHRONIC KIDNEY DISEASE  TAKING A CLOSER LOOK: THE MANIFESTATIONS OF CKD Cardiovascular Click to edit Master Nursing Assessments Click to edit Master Manifestations text styles text styles Ask patient if they feel any irregular  ↑blood pressure Ask heartbeats Inspect skin for fluid retention  ↑ heart rate Inspect (edema)  Dysrhythmias /ECG changes Weigh Weigh daily (1 kg = 1 litre of fluid)  Abnormal heart sounds Listen to heart sounds for Listen abnormalities (irregular beats, rate  Fluid retention (peripheral or rhythm) Take pulse and BP both upright and edema; pulmonary edema) Take supine (note orthostatic changes) Assess for peripheral vascular  Pericardial friction rub Assess changes (color, pulses, sensation, capillary refill, edema) Assess Assess for jugular vein distention Challenge yourself… Auscultat Auscultate lungs for edema e (crackles) What is the pathophysiological basis for each of the above Monitor Monitor vital signs frequently manifestations? Monitor Monitor lab values (CBC, electrolytes) RESPIRATORY Nursing Assessments Manifestations Click to edit Master Click to edit Master text styles text styles  ↑respiratory rate Inspect thorax for Inspect  Kussmaul symmetrical movement respirations  Crackles Inspect Inspect skin for pallor  ↓ oxygen saturation Auscultate lung fields  Shortness of breath (anterior and posterior)…note Ausculta changes is rate, rhythm and (SOB) te effort of breathing and presence of fluid (crackles) Monitor Monitor oxygen saturation, arterial blood gases RENAL Manifestations Click to edit Master Nursing Assessments Click to edit Master text styles text styles Decreased urinary  Strict intake and output output  Assess for Azotemia costovertebral tenderness, abdominal distention and Proteinuria tenderness  Test urine for protein Hematuria and red blood cell casts  Monitor renal function Hyperuricemia tests (BUN, creatinine) INTEGUMENTARY Manifestations Click to edit Master Nursing Assessments Click to edit Master text styles text styles  Bruises  Inspect skin, hair  Pruritus  and nails Dry skin   Monitor liver Skin color changes (ashen grey to yellowish) function tests (ALT,  Dry brittle hair and nails AST, bilirubin), uric acid levels, platelets Challenge yourself… What is the pathophysiological basis for bruises, pruritus and the color changes? ABDOMEN Manifestations Click to edit Master Nursing Assessments Click to edit Master text styles text styles  Anorexia Inspect Inspect abdomen for distention  Nausea, vomiting Auscultat Auscultate bowel sounds and listen e over abdominal aorta for bruits  Halitosis, metal Palpate Palpate abdomen for tenderness taste in mouth  Bleeding in GI tract Monitor Monitor bowel movements for frank or occult blood Assess emesis for appearance Assess (frank, coffee-ground) Monitor nutrition status closely (at Monitor risk for malnutrition) Weigh Weigh daily NEUROLOGICAL Manifestations Click to edit Master Nursing Assessments Click to edit Master text styles text styles Peripheral neuropathy  Assess for the 3 spheres (person, place and time) Restless legs  Assess for changes in LOC (are they alert, somnolent, Change in level of stuporous, comatose) consciousness (LOC)  Assess memory Lethargy (immediate, recent and past)  Confusion Cranial nerve assessment  Motor assessment (test Encephalopathy motor strength and compare bilaterally)  Changes in motor function Muscle tone assessment MUSCULOSKELETAL Click to edit Master Manifestations Nursing Click to edit Master text styles text styles Assessment Renal  Assess for osteodystrophy musculoskeletal Decreased pain and limitations calcium  Monitor electrolyte Impaired vitamin levels (especially D phosphate and Hyperparathyroidi calcium) sm Pathological fractures IMMUNE Manifestations Click to edit Master Nursing Assessments Click to edit Master text styles text styles  Increased risk of Monito infection r Monitor wounds for redness, swelling, pain, heat, drainage (local)  Local  Systemic Assess for fever, chills, malaise, Assess leukocytosis, (systemic) Monito Monitor WBC’s r HEMATOLOGICAL Click to edit Master Nursing Assessments Click to edit Master Manifestations text styles text styles  Monitor CBC Weakne (Hemoglobin, Anemia ss platelets, albumin, hematocrit) Fatigue Pallor Letharg Bleedin y g  As glomerular filtration rate continues to decline (