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MedSurg I Renal 2

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olanjones's version from 2016-11-05 16:45

Chronic Kidney Disease

Question Answer
CKDProgressive, irreversible destruction of nephrons in both kidneys
Functional deteriorationcreatinine clearance (measured in 24-hour urine test), should = approx. GFR, in CKD this slowly decreases
Stage 1Kidney damage with normal or ↑GFR (>90); Plan: Dx & tx, CVD risk reduction, slow progression
Stage 2Kidney damage with mild ↓GFR (60-89); Plan: Estimation of progression
Stage 3Moderate ↓GFR (30-59); Plan: Eval & tx complications
Stage 4Severe ↓GFR (15-29); Plan: Prep for renal replacement (dialysis or kidney transplant)
Stage 5Kidney failure GFR < 15 (or dialysis); Plan: Renal replacement tx (if uremia present & pt wants tx)
CKD manis are aresult of retained substances, affects every system
Urinary ManisFluid retention (may not have in early stages)
Metabolic ManisWaste product accumulation, Altered carbohydrate metabolism, ↑triglycerides
Electrolyte Manis*Hyperkalemia, Altered sodium levels (hyper from ↓excretion or may have dilutional hypo from fluid retention)
*Altered Ca++, Phosphate, Magnesium levels
*Metabolic acidosis (cannot excrete acid-NH3)
Hematologic ManisAnemia, Bleeding (altered platelet function), Infection (altered leukocyte function, cellular/humoral immune suppression)
Cardiovascular ManisHTN, edema, CAD, PAD, HF, pericarditis
GI ManisStomatitis, Metallic taste/ammonia breath odor, Anorexia, N&V, GI bleeds, Gastroparesis
Neurological ManisFatigue, Confusion, HA, Encephalopathy, Peripheral neuropathy
Respiratory ManisDyspnea (fluid overload, pulmonary edema, resp. infection), Thick sputum, Kussmauls (w/ severe acidosis)
Endocrine ManisHyperparathyroidism, Thyroid abnormalites, Amenorrhea, ED
Musculoskeletal ManisTissue calcification, Cramps, Osteomalacia, Bone pain
Integumentary ManisPruritis, Ecchymosis/purpura, Dry, scaly skin
Uremiasyndrome in which kidney function declines to the point that symptoms may develop in multiple body systems
Nutritional therapyProtein restriction (Stages 1-4, reduces kidney decline), Water restriction (intake may depend on UO), Na+ & K+ restriction, Phosphate restriction
*more protein allowed in Stage 5 because dialysis can remove breakdown byproducts (urea & creatinine)
ND for CKDExcess fluid volume, Risk for electrolyte imbalance, Imbalanced nutrition: less than body requirements
Teaching for CKD-Managing dietary/fluid needs, Thirst reduction methods
-Meds/ rationales & common SE
-S/S of electrolyte imbalance (esp. ↑K+), Important s/s to report (wt gain >4 lbs, ↑BP, SOB, edema, ↑weakness/fatigue, confusion/lethargy)
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Dialysis

Question Answer
AEIOUAcid-base problems, Electrolyte problems, Intoxications, Overload of fluids, Uremic symptoms
Principles of dialysis*Diffusion (movement of solutes from area of ↑concentration to area of ↓concentration)
*Osmosis (movement of fluid from ↓concentration to ↑concentration)
*Ultrafiltration (water & fluid removal by increasing the osmolality of the dialysate)
CUP OF TEA principleThe longer the stronger - relates to dialysis; the longer dialysis is performed the more solutes will be shifted
Disequilibrium syndrome Initial nausea/HA &/or jerk/twitch (from mild cerebral edema -> rapid solute loss from extracellular fluid), Can be minimized by dialyzing in smaller bites
Peritoneal dialysisPerformed through abd wall (into cavity), Two types:
*Automated (machine cycles while pt sleeps, leave fluid in during the day
*Continuous ambulatory (done manually, can be disconnected, variable sched)
How long does it take PD catheter to seal?about 1 to 2 weeks
PD benefits-More independence (can be done at home), fewer dietary restrictions
-Avoids venous access problems (e.g. older pts w/ CVD)
-Diabetics (better BP control, gradual fluid shift, insulin put in dialysate, no heparin)
PD complications-Hyperglycemia or hyperlipidemia, Protein loss <be> -Peritonitis (s/s: fever, pain, drainage cloudy, hypoactive BS, N&V)
-Infection (from: poor hand washing, contaminated dialysate, poor catheter care)
-Inflammation (rxn to dialysate, wrong concentration of dialysate)
HemodialysisBlood removed and run through a dialyzer membrane then returned to the body (done when BUN=80, Creatinine=8, maybe K+=6.0 w/ EKG changes?
HD accessBest - Fistulas (anastomosis of artery & vein), less likely to clot, must have good BV
Graft (synthetic), more easily infected & more likely to clot, Site must be protected (no BP/IV/venipuncture)
Rare – Shunts (external), not used much anymore
HD benefits-Rapid fluid removal, rapid removal of urea & creatinine, effective K+ removal
-Less protein loss, lowering of triglycerides
-Home dialysis possible
HD complications-Vascular access problems, Heparin used
-Dietary/fluid restrictions
-Requires extensive equipment/specially trained people, Is time consuming (3xs/wk-4hrs @ a time)
ND for dialysisRisk for infection (high), Risk for impaired circulation, Fluid volume excess, Pain r/t phosphate overload in bones, Activity intolerance secondary to anemia
Continuous Renal Replacement Tx?
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Transplants

Question Answer
Why is perfect compatibility not an issue?Can remove incompatible blood from donor kidney
Immunosuppressive drugs are used (but are usually responsible for most long-tern problems)
Signs of rejectionFever, Weight gain, Decreased UO, Increased BP (hour by hour monitoring UO, then cc by cc)
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Renal Physiology

Question Answer
Renal artery blood flow1200 mL/hr
Bowman’s capsulereceives filtrates (NO blood cell, platelets, or large proteins)
Glomeruluscluster of capillaries, uses hydrostatic pressure, is semi-permeable, filters by size
Post glomerular GFR125 mL/hr
Proximal tubule80% of electrolytes, 100% of glucose, 100% of amino acids are placed back in bloodstream; creatinine & H+ ions are brought into tubule
How does filtration differ between the proximal and distal loops?proximal=fixed, distal=variable
Distal loop variables*IF ↑BP, ANP released (from R atria) – negates ADH, H2O not pulled back
*If ↓blood volume, Renin released – H2O pulled back
*If ↓blood volume w/↓K+ & Na+, Aldosterone released – Na+ & H2O conserved, K+ is wasted
*If ↓blood volume w/ ↑serum osmolality, ADH released – H2O conserved
*If ↓Ca++, PTH released – Ca++ conserved
Volume held in collecting tubule3-5 mL
Formula for Creatinine Clearance(140 – Age) (Kg)/(72 x serum Cr mg/dL)
Excretion rate to ureters/urinary bladder1 mL/min
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