Renal Nursing PDF

Electrolyte Imbalances ELECTROLYTES (summary): Sodium 136-145 mEq/L -​ maintenance of acid base balance and electroneutrality -​ maintains plasma and interstitial osmolarity Potassium 3.5-5.0 mmol/L -​ maintains plasma acid base balance -​ maintains electrical membrane excitability...

Electrolyte Imbalances ELECTROLYTES (summary): Sodium 136-145 mEq/L -​ maintenance of acid base balance and electroneutrality -​ maintains plasma and interstitial osmolarity Potassium 3.5-5.0 mmol/L -​ maintains plasma acid base balance -​ maintains electrical membrane excitability -​ regulate intracellular osmolarity Calcium 9.0-10.5 mg/dL -​ essential in cardiac, skeletal, and smooth muscle contraction -​ co-factor blood clotting cascade -​ excitable membrane stabilizer Chloride 98-106mEq/L -​ formation of hydrochloric acid -​ maintain plasma acid base balance Magnesium 13-2.1 mEq/L -​ cofactor in dna and protein synthesis, carbohydrate metabolism, and blood clotting cascade -​ excitable membrane stabilizer Phosphorus 3.0-4.5 mg/dL -​ activate b-complex vitamins -​ formation of ATP and other high energy substance -​ cofactor in carbohydrate, protein and lipid metabolism Sodium Imbalances: Sodium is a major extracellular fluid. It is responsible for impulse transmission in nerves and muscle and participates in sodium-potassium pumps. NORMAL VALUES 135-145 mEq/L Hypernatremia : elevated level of sodium in blood, maybe due to diarrhea, vomiting, diabetes insipidus, renal disease, high protein diet and side effects of osmotic diuresis. Can lead to loss of water and this imbalance may lead to confusion, seizures, and coma. Assessment and Rationale -​ monitor RR (metabolic acidosis, deep labored breathing w/ air hunger) , BP, I&O (assess presence and location of edema), LOC and muscle tone, strength and movement Interventions and Rationales:  -​ provide safety and seizure precaution,altered mental status are potential complications -​ hypernatremia can cause dehydration thus increasing skin damage, prevent breakdown or pressure ulcers -​ avoid foods high in sodium and encourage inc. oral and Iv intake -​ restrict sodium intake and administer diuretics as indicated Hyponatremia : low level of sodium in blood that causes water to ti move in to cells and this shift causes cells to swell. It leads to headache, confusion, seizures and coma. Cause; excessive water intake, fluid loss from vomiting or diarrhea and certain medications Assessment and Rationale -​ monitor RR( body compensates for metabolic alkalosis and may produce slow and shallow respiration) -​ I&O (calcullate fluid balance, weigh daily as flud excess or deficit may occur in hyponatremia) -​ LOC and neuromuscular response ( deficit in sodium levels leads to decreased mentation to coma as well as generalized weakness, cramps, or convulsions) -​ Note for fluid overload, administration of sodium containing IV in presence of heart failure increases its risk It is a common imbalance, especially to the elderly so early intervention is important. Severity of the imbalance may cause neurological damage or death if untreated properly Intervention and Rationales: -​ provide safety and seizure precaution, decrease CNS stimulation and risk of injury by providing cal and quiet environment -​ encourage food and fluids high in sodium , use fruit juices and broth instead of water, client may benefit better from slow replacement by oral method -​ provide or restrict fluid depending on fluid volume status MEDICATIONS 1.​ CAPTOPRIL - to correct fluid volume excess (FVE) especially with inc. risk of heart failure 2.​ DEMECLOCYCLINE - treat chronic SIADH or when severe fluid restriction can not be tolerated 3.​ FUROSEMIDE - reduces fluid excess to correct sodium and water imbalance (diuretic) 4.​ POTASSIUM CHLORIDE - correct potassium deficit especially during diuretic therapy 5.​ SODIUM CHLORIDE - used to replace deficits in presence of ongoing or chronic losses Potassium Imbalances : Potassium is a major cation in the intracellular fluid (ICF). It is important for regulation if osmolarity of ECF by exchanging it with sodium, it also maintains normal neuromuscular contraction by its participation in the sodium-potassium pump NORMAL VALUES : 3.5 - 5.0 mEq/L Hyperkalemia : elevated level of potassium in blood, occurs in patients with renal disease due to kidney’s reduced ability to excrete potassium and patients who received massive BT due to release of potassium from stored blood cells, treatment side effects and chemotherapy Assessment and Rationales -​ monitor heart rate and rhythm, cardiac arrest may happen as potassium excess depresses myocardial conduction , bradycardia may progress to cardiac fibrillation and arrest -​ monitor RR and depth, encourage deep breathing and coughing exercise as pts may hypoventilate and retain carbon dioxide and can result to respiratory acidosis -​ assess LOC and neuromuscular status, as muscular paresthesia, weakness and flaccid paralysis may occur -​ monitor urine output, in kidney failure potassium is retained, potassium is contraindicated if oliguria or anuria is present Interventions and Rationales interventions aims to prevent life threatening cardiac dysrhythmias by reducing serum potassium levels -​ encourage frequent rest periods because generalized weakness decreased activity tolerance -​ encourage intake of CARBOHYDRATES AND FATS and low potassium foods. -​ discontinue dietary sources of potassium , beans, dark leafy green, potatoes, squash, yogurt, fish, avocados, mushroom and banana -​ REVIEW DRUG REGIMEN that contains potassium or affects in potassium excretion such as spironolactone, hydrochlorothiazide, amiloride, and penicillin G. -​ provide fresh blood or washed RBC is transfusion is indicated -​ infuse potassium based medication slowly, prevent concentrated bolus, it allows kidneys to clear excess free potassium -​ educate on the limit of intake of otc antacid and laxative MEDICATIONS: 1.​ FUROSEMIDE - loop diuretic that promotes renal clearance and potassium excretion 2.​ ALBUTEROL - administration of nebulization has been helpful to those receiving hemodialysis 3.​ CALCIUM GLUCONATE/CHLORIDE - temporary stopgap measure that antagonizes toxic potassium depressant effects on the heart and stimulates cardiac contractility  4.​ IV GLUCOSE WITH INSULIN AND SODIUM BICARBONATE - short term emergency measures to move into the cell, reducing toxic serum levels Hypokalemia : low level of potassium in blood, can occur due to diarrhea, vomiting, diabetic acidosis, renal failure, high sodium diet, and treatment related side effects. Assessment and Rationales: -​ monitor RR, depth and effort -​ monitor HR and rhythm, abnormalities in heart conduction and contractility are associated with hypokalemia. -​ note for signs of metabolic alkalosis ( tachycardia, dysrhythmias, hypoventilation, tetany, and changes in mentation -​ monitor gastric, urinary and wound losses. POTASSIUM SHOULD ONLY BE ADMINISTERED TO PATIENTS WITH GOOD URINARY FLOW. -​ observe for digoxin toxicity when used, (blurred vision, vomiting, nausea, inc. atrial dysrhythmias, and heart block. Interventions and Rationales: -​ encourage high potassium diet -​ monitor IV rate of potassium administration using microset or infusion pump to prevent bolus effect -​ review medication regimen for potassium wasting drugs such as amphotericin B, catecholamines IV, carbenicillin, furosemide, gentamicin, and hydrochlorothiazide. -​ administering potassium orally or intravenously may be required to correct deficiencies, IV potassium can be a life saving treatment. Calcium Imbalances : Calcium is a major cation that is regulated closely with magnesium and phosphorus. It is required for nerve, muscle and cardiac conduction by its participation in sodium-potassium pump, and also in hormonal secretion NORMAL VALUES: 8.5-10.5 mg/dL Hypercalcemia : excessive levels that can occur to patients with hyperparathyroidism, hyperthyroidism, renal disease or side effects of certain medications. It can disrupt the balance of other electrolytes such as potassium and magnesium. Assessment and Rationales -​ assess LOC and neuromuscular status, nerve and muscle activity is depressed, thus it can progress to convulsions or coma  -​ monitor bowel sounds, because hypotonicity leads to constipation. -​ monitor cardiac rate and rhythm as hypercalcemic crises may lead to cardiac arrest. -​ Monitor I&O, calculate fluid balance. -​ review drug regimen, note the use of calcium elevating drugs such as heparin, methicillin, phenytoin, and tetracycline. Interventions and Rationales: -​ strain urine if there is flank pain, large amount of calcium is present in kidney, parenchyma may lead to stone formation, -​ identify and restrict sources of calcium intake -​ encourage fluid intake, include sodium containing juices, acid ash juices if kidney stones are present. -​ encourage repositioning and ambulation -​ administer isotonic saline and sodium sulfate, these are emergency measures in severe hypercalcemia that increases urinary excretion. MEDICATIONS: 1.​ CALCITONIN - promotes movement of serum calcium into bones, esp. if there is incd. parathyroid hormone 2.​ DISODIUM EDETATE (EDTA) - chelating actions lowers serum calcium level. 3.​ DIURETICS - promotes excretion of calcium and reduce fluid excess from isotonic infusion 4.​ MITHRAMYCIN ‘mycin”- antibiotic which lowers serum calcium 5.​ SODIUM BICARBONATE - induces alkalosis thus reduces the ionized calcium fraction Hypocalcemia : a low level of serum calcium, occurs in chronic laxative use, diarrhea, renal failure and certain side effects. It disrupts phosphate and magnesium can be mild to severe and be life threatening if untreated. Assessment and Rationales: -​ monitor RR and depth, may cause arrest -​ monitor HR and rhythm, the heart muscle may irregularly contract. -​ observe for possible beeding, petechiae and ecchymosis, altered coagulation -​ observee for trousseau’s and chvostek's signs -​ observe for medications such as digoxin, insulin, mithramycin and parathyroid injection Interventions and Rationales: -​ educate on the use of antacid and laxative as it may have negative effects on metabolism of calcium -​ reduce CNS stimulation and seizure precautions  -​ stress importance of calcium needs MEDICATIONS: 1.​ CALCIUM GLUCONATE, GLUCEPTATE OR CHLORIDE IV - rapid treatment in acute calcium deficit esp on presence of tetany and convulsions 2.​ CALCIUM BICARBONATE/LACTATE PO - oral prep useful for correcting subacute deficiencies 3.​ VITAMIN D SUPPLEMENT - enhance calcium absorption once phosphate deficiency is corrected 4.​ MAGNESIUM SULFATE IV/PO - hypomagnesemia is a precipitating factor in calcium deficit Concept of Fluids -​ 50-60% of the body weight is water -​ Intracellular - inside the cell -​ Extracellular - outside the cell -​ average oral intake daily is 2,500 mL a day and the average output a day is 2,500 mL ( urination 30-50mL/hr) counterbalance to the input to maintain equilibrium -​ major ICF are Potassium, Phosphorus, and magnesium -​ major ECF are Sodium, Bicarbonate and Chloride -​ Osmotic pressure a power solution to draw water towards an area of greater concentration -​ Diffusion is movement of solutes and molecules from higher concentration to lower concentration -​ Facilitated diffusion requires assistance from carrier molecule eg. insulin-glucose -​ Active Transport is movement of solute from lower concentration to higher concentration using energy (ATP) -​ 180L of fluid from blood is being filtered by the kidney each day ACID BASE IMBALANCE metabolic acidosis ALL ARE LOW metabolic alkalosis ALL ARE HIGH respiratory acidosis LOW pH HIGH hco3 and paco2 respiratory alkalosis HIGH pH LOW hco3 ad paco2 Respiratory Acidosis -​ Lower RR, damaged gas exchange or to muscle used to breath -​ retained co2  -​ DEPRESS - drugs (opioids), edema, pneumonia, respi center on brain (stroke), emphysema, spasms (asthma), sac elasticity damaged (COPD) -​ look at the ABG, acidic blood pH, pco2 more than 45 mmhg, hc03 normal, uncompensated, greater, partial compensation. -​ s/sx : confused, drowsy, headache hypoxic, inc. HR hypotension, inc co2 -​ administer 02, look at neuro status, cough and deep breathing education Respiratory Alkalosis -​ inc. ventilation, inv in blood ph level , co2 lv drop -​ TACHYPNEA - temp inc (fever), aspirin toxicity, controlled ventilation excessive, yelp!(pain, anxiety fear), pneumothorax, neuro damage, embolism in lungs, ascending altitude -​ look at ABG blood ph greater than 7.45, paco2 less than 35, hco3 if normal, but two are abnormal, uncompensated, if less than 22 with two abnormal, partial compensated -​ s/sx: fast RR, neuro changers, anxiety fear, dizziness, inc hr ecg changes, hypocalcemia and hypokalemia (tetany, cramps and dysrhythmias -​ REST rebreather mask or paper bag to slow down breathing, electrolytes monitored, sedative/antianxiety, teach relaxation Metabolic Acidosis -​ too much acid -​ fall of blood ph along with hco3 -​ body is unable to get rid of the acid -​ ACIDS accumulation of lactates, chronic diarrhea, impaired renal function, DKA, salicylates toxicity -​ kussmaul’s breathing -​ ABG ph less than 7.35 hc03 less than 22 paco2 can be normal or less than 35 (partial compensated) -​ confused, weak, low bp, cardiac hypokalemia. Metabolic Alkalosis -​ elevated ph and hc03, an excessive loss of acid and increase in baseline bicarbonate -​ ALKALI - acid loss in stomach, low chloride level, hypokalemia, aldosterone elevated, loop and thiazide effects, infused too much sodium bicarb IV, -​ alkalotic - bradypnea -​ abg ph greater than 45, hco3 greater than 26, paco2 normal, uncompensated, greater than 45 partially compensated -​ s/sx: bradypnea, dysrhythmia, tetany, tremors, cramps -​ watchout for low k and cl  -​ hold diuretics, and medication acetazolamide TIC TAC TOE METHOD Normal Values pH 7.35-7.45 PaCO2 35-45 mmHg HCO3 22-26 mEq/L 1.​ determine the acidity or alkalinity of the blood (below 7.35 is acidic; above 7.45 is alkaline) 2.​ interpret value of paco2 (below 35 is alkaline ; above 45 is acidic 3.​ interpret value of hco3 (below 22 is acidic ; above 26 is alkaline) 4.​ determine whether it is respiratory or metabolic if under ph is under paco2 it is respiratory if under hco3 it is metabolic 5.​ determine compensation -​ normal pH = fully compensated -​ all three values are abnormal = partial compensation -​ one is abnormal other one is normal (hco3 and paco2) = uncompensated eg pH 7.1 paco2 40 hco3 18 metabolic acidosis uncompensated RENAL DISORDERS Pyelonephritis -​ chronic bacterial infection of the kidney -​ s/sx: flank pain, fever, malaise, urinary frequency w/ burning sensation -​ med mgmt: gentamicin w./w.o ampicillin cephalosporin, ciprofloxacin Glomerulonephritis -​ most frequent in pedia(boys) and young adults -​ s/sx: nausea, malaise, headache, periorbital edema, pain/tenderness in kidney area -​ no specific treatment as patients may recover spontaneously Urolithiasis (kidney stones) -​ presence of calculi in urinary tract -​ s/sx: sudden, severe and sharp flank pain, chills, fever, urinary retention, and dysuria Renal Failure -​ inability of nephrons to maintain F&E, acid base balance, excrete waste products and perform regulatory function -​ acute renal failure: sudden, rapid decrease in renal function, reversible if there is early and aggressive treatment -​ chronic renal failure; progressive and irreversible dmg to the nephrons Management: Peritoneal Dialysis - uses lining of abdomen to filter blood, a silicone rubber catheter is surgically placed in abdominal cavity for infusion of dialysis (fill,dwell,drain) 1-2L of dialysate is infused over 10-20 minute period Hemodialysis- most common renal replacement therapy, anticoagulants (heparin) are given during therapy to prevent clots; mahurkar cath. polyurethane for short term access - permcath cath. silicone for long term access. Renal Transplant - most effective therapy for end stage renal disease (CKD S5), organ can come from live or deceased donors, organ goes to iliac fossa