MedSurg I Renal 2

olanjones's version from 2017-04-01 03:19

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)


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
-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?I know what the fuck that is now!!!


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)

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