240- Exam 5 Mercy College
differential shows
% of cells. should =100.
ESR
0 to 15-20 mm/hr. Elevated in infectious or inflammatory processes.
Normal ESR range
0-20 mm/hr. 0 to 15-20mm/hr.
vancomycin level
0-20. if above don't give. call doc.
creatinine in AKI
0.5-1.5mg/dl. will be increased.
types of PC: continuous ambulatory peritoneal dialysis (CAPD)
1 -2L of dialysate is instilled in the peritoneal cavity and exchanged 4-5 x /day. Can lead a fairly normal life-no machine needed. Can leave connected or disconnected.
1 Liter
1 Kg
3 phase
1 exchange
performing the exchange: fill
1-2 L warm, sterile dialysate is attached by tubing and instilled into peritoneal cavity as rapidly as possible (about 10-20 minutes). Solution is pre-warmed to 100° F to increase rate of diffusion.
sodium and fluid restriction
1-3 g Na diet and fluid intake based on U.O. (Uremic, non-dialyzed patient). Dialysis- 2-4 g Na. Fluid Restriction- U.O. + 500-600 mL (insensible loss).
5 key steps to reduce MRSAA
1. Perform hand hygiene 2. Make sure patient rooms are cleaned well ~ "terminally cleaned" 3. Actively look for MRSA 4. Implement contact precautions to prevent transmission 5. Bundle up best practices.
phosphorus in AKI
1.7-2.6 (2.5-4.5) will be increased.
minimum of time for the AVG to mature
10 days
degrees of solution for PD
100 degrees
venofer- iron sucrose injection (anemia)
100 mg during each dialysis treatment for a total of 10 doses (1000 mg). Hypersensitivity reactions including ANAPHYLAXIS.
slow pump flow in CRRT
100-200ml/min
hemoglobin level
12-18
minimum of time for a AVF to mature
14 days
Peramivir (Rapivab) age
18 yrs or older
3 stool samples are sent to culture if
1st stool comes back negative
oliguria/anuria time frame
2 days to 2 weeks.
diuretic time frame
2 weeks. lasts about 1-2 weeks.
NA intake in dialysis patient
2-4 g of NA.
protein in AKI
2-8mg/dl (negative and or reagent test) will be increased.
uric acid in women in AKI
2.8-6.8 mg/dl. will be increased.
protein is having in CKF. should be
2/3 biological high. like eggs, dairy products, meats.
protein restriction in ESKD
2/3 should be high biological value (dairy products, eggs, meat). Based on degree of renal impairment and severity of symptoms.
preliminary results of CS take about
24-48 hours
sodium ferric gluconate complex (ferrlecit) (anemia)
25 mg test does is given first- no reactions full dose may be given. Cumulative dose of 1 Gm given over 8 consecutive dialysis treatments (125 mg/day). Too rapid infusion may cause hypotension, flushing, chest pain, weakness. Monitor BP and K levels. Side effects- above, ANAPHYLAXI
uric acid in AKI
250-750 mg/24hr. normal diet. will be decreased.
MRSA lives on hands for
3 hours!
recovery phase time frame
3-12 months.
albumin in AKI
3.5-5.0g/dl. will be decreased.
potassium in AKI
3.5-5meq/l. will be increased.
uric acid males in AKI
3.5-8.0mg/dl. increased.
hemocrit level
34-48%
4L=
4,000ml
calcium in AKI
4.5-5.5meq/l. will be decreased. (not absorbing).
oliguria
400ml/day
WBC w/diff normal
5,000-10,000/mm3
WBC w/diff
5-10,000/mm3. Critical values: < 2,500 or > 30,000. Differential shows the % of cells; should=100. Neutrophils - 1st cells to respond to bacterial infection. Increase in neutrophils indicates bacterial infection- segmented. Increase in bands (less mature neutrophils)" Shift to the left". Absolute neutrophils count (ANC). Actual number of mature circulating neutrophils.
BUN AKI
5-25mg/dl. will be increased.
anuria
50ml/day
Zanamirvir (Relenza) age
7 years or older
clean environment in c diff. spores live up too
70 days in the environment
final results to CS take about
72 hours.
creatinine clearance in AKI
85-135mL/min. will be decreased.
chloride in AKI
95-105meq/l. will be increased.
anemia in ESKD- goals
: Participation of activity within tolerance. Assess RBC, H/H, avoid unnecessary blood draws, soft toothbrush. Recombinant human erythropoietin (EPO, Epogen, Procrit). May be given IV or SQ 3x /week. Increases energy & Hct, decreases need for blood transfusions; Thrombotic events if Hgb>= 12. Watch BP- may cause HTN Darbepoetin Alfa (Aranesp). May be given IV or SQ weekly. Side effects- cardiac arrhythmias, CHF, sepsis, vascular access thrombosis, seizures, MI, stroke. Watch Hgb levels- hold dose if > than 12.
urine output is usually in AKI.
< then 40ml/hr in AKI. but may be normal or increased.
critical valves of WBC
<2,500. or >30,000
Normal CK levels
<200
antihypertensives and cardiovascular agents for ESkD
ACE Inhibitors- "prils" -Captopril (Capoten) ARB's - "sartans"- Valsartan (Diovan) Beta Blockers- "lol" -Metoprolol (Lopressor) Ca Channel blockers- diltiazem (Cardizem) Alpha-adrenergic-clonidine (Catapres) If single agent is unsuccessful may use a combination of drugs.
dialysis can be used in
AKI AND CRF
dialysis disequilibrium syndrome happens more commonly in
AKI or extreme BUN (150mg/dl)
Tricyclic Glycopeptides: treats
ATB of choice->MRSA. PO dosing can be used to treat c. Difficile when Flagyl is ineffective.
why diarrhea happens in C diff
ATB reduce the ability of intestinal microflora to break down unabsorbed carbohydrate. Accumulate in colon - increases osmotic pressure and causes movement of water from extracellular fluid into intestinal lumen = diarrhea.
carbapenems- important fact!
ATB that has the broadest action of any ATB.
most common cause of AKI
ATN
Nitroimidazole: nursing care
AVOID ETOH during treatment (before and after). Disulfiram-like reaction. Take on empty stomach or small amt. food. Monitor LFT's.
about ATN
Accounts for 85% of intrinsic cases. Usually described as postischemic or nephrotoxic.
risk factors associated with acinetobacter baumanni
Advanced age, ATB therapy w/in past 90 days, use of artificial devices-> vent, hemo, catheters, sutures, severe immunocompromised, prolonged hospitalization.
Prerenal Kidney Injury~ Medical Management: re-establish blood flow to the kidney
Aggressive Fluid Resuscitation, diuretics.
tx for rhabdomyolysis
Aggressive crystalloid volume resuscitation- NS. Up to 20L/24 h. Loop diuretics. Mannitol. IV Bicarb to alkalinize urine. Dialysis.
intermittent hemodialysis: frequency and duration of treatment depends on
Amount of metabolic waste to be cleared. Amount of fluid to be removed. Clearance capacity of the dialyzer. Usually three 3-4 hr treatments/week.
performing the exchange: Dwell
Amount of time that the dialysate solution remains in the peritoneal cavity that is prescribed by the physician . Tubing is then clamped. Maximal osmosis of fluid and diffusion of particles into the dialysate occurs in 20-30 minutes.
Beta-Lactam Antibiotics: Penicillins
Amoxicillin (Amoxil){aminopencillin}; Nafcillin (Methicillin) { penicillinase-resistant PCN); Piperacillin/tazobactam (Zosyn) {Extended-spectrum PCN}.
cephalosporins; SE
Antibiotic- associated pseudomembraneous colitis; anaphylaxis; possible cross-sensitivity to PCN. Same as PCN.
risk for injury in ESkD
Assess Morse Falls Scale Score q shift ; Obtain detailed drug history;Monitor for drug related complications (Adjust dosages accordingly); If on Digoxin- Monitor for s/s of toxicity; Give opioids cautiously; Monitor patient receiving heparin, Coumadin, or other anticoagulants QS for bleeding.
risk for infection in ESKD
Assess WBCs, Sed Rate, temp; Meticulous care where skin integrity has been broken ; Inspect vascular access/PD catheter QS for s/s of infection.
Calcium and Phosphorus Binders (bone disease)
Assess calcium, phosphorus, albumin levels.
goals from hypertension in ESKD
Assess daily weight, I/O, NVD, BP, Pulse, RR, edema, skin turgor. Drug Therapy: Diuretics (renal insufficiency- some u.o)- Lasix, Bumex, Demadex Diet: Na+ and Fluid restriction. Dialysis. Frequent oral hygiene.
excess fluid in ESKD
Assess daily weight, skin turgor, NVD, VS, lung and heart sounds; enforce prescribed FR.
macrolides: nursing intervention
Assess for anaphylaxis. Administer with meals to decrease GI distress. Avoid concurrent use with Cardizem, verapamil, HIV protease inhibitors tachydysrhythmias -> poss. Cardiac arrest.
ESKD- hyperkalemia tx
Assess for muscle weakness, ECG changes, diarrhea. Sodium Polystyrene Sulfonate - (Kayexelate). P.O./Enema. Exchanges Na+ for K+ in large intestine then is excreted. 50mL of 50% Dextrose with 5-10 Units of Regular insulin IV. 10% Ca Gluconate IV followed by Hemodialysis.
imbalance nutrition in ESKD
Assess lab values (BUN/Cr/GFR, e-lytes, protein, albumin) ; promote high biologic-value protein; encourage high calorie, low K, low Na, low protein snacks.
peritonitis: nursing management
Assess nutritional status. Lose lg amt protein through peritoneum. Meticulous sterile technique. Assess for s/s of infection. Administer ATB. Teach patient s/s and prevention. Monitor VS esp. Temp. If peritonitis is suspected, obtain a culture of the outflow.
nursing management for AVF
Assess patency at least q shift. "Feel a thrill, Hear a bruit". Assess circulation below the fistula. Think 6 P's. Instruct patient to avoid compression of fistula. Instruct patient to assess for S/S of infection. No BP,IV, venipuncture in that arm! Teach hand exercises.
nutritional therapy: goal in ESKD
Attain and maintain adequate nutrition. Regulate protein, minimize fluid & electrolyte imbalances. Provide enough calories for growth and repair. Assess daily weight, for edema, delayed wound healing, electrolytes, protein, albumin, BUN/Cr/GFR, Iron levels.
foods high in potassium
Avoid green leafy vegetables, citrus fruits, and salt substitutes, milk.
macrolides: examples
Azithromycin (Zithromax);Erythromycin (E-mycin); Clarithromycin (Biaxin).
never in AVF+AVG
BP. venipunctures. IV. or compression.
infection:
Bacteria cause signs and symptoms of disease. Colonized patients more predisposed to infection with the colonized organism. Patients can become infected without first being colonized.
nursing management for peritoneal dialysis patient
Baseline VS before treatment. Assess respirs w/ breath sounds. Weigh w/ same scale daily ,before treatment (monitor fluid status). Accurate I/O. Maintain sterile technique always!!!!. If outflow is less than inflow- count as intake.
oliguria/anuria phase of AKI
Begins when U.O. < 400mL/day (anuria < 50 mL/day) Usually 48 hours after injury Lasts 8-15 days, but may last several weeks Major problem is the inability: To excrete fluid loads To regulate electrolyte imbalances (increase K, decreaseNa, increaseBUN/Cr, decrease in GFR increase Phos and metabolic acidosis). To excrete metabolic wastes. The longer in this stage the higher the risk of irreversible renal damage and CRF.
recovery (convalescent) phase of AKI
Begins when labs return to normal. Lasts 3-12 months. Kidneys are extremely vulnerable!!!! Avoid nephrotoxic agents!! Evaluate fluid and electrolyte levels and degree of renal damage.
Aluminum hydroxide- (Amphojel, Alu-cap). bone disease
Binds dietary phosphate to form insoluble aluminum phosphate to be excreted. 10-30 mL of suspension 1 hour p.c. and HS.
Characteristics of Outflow in PD
Bloody- monitor pulse, BP. May be small amount of blood initially. Menstruating women . Brown- suspect bowel perforation.
influenza
CDC recommends influenza vaccination as the first and most important step in protecting against the flu!Droplet isolation.
Nitroimidazole: contraindications
CNS disease, blood dyscrasias, 1st trimester pregnancy, nursing mothers. Hepatic disease / alcoholism.
Cyclic Lipopeptide: SE
COLITIS, hyper/hypotension, elevated CPK levels, renal failure, anemia, back pain, muscle cramps.
calcium carbonate (TUMS ) bone disease
Calcium supplements.
Exit site/tunnel infection in PD
Can lead to peritonitis. Clinical manifestations- redness, tenderness, pain, drainage, excessive crustPatient education on site care. Monitor site and provide site care daily. Avoid tugging or pulling on catheter. Treatment-ATB (usually PO , occasionally topical).
long term tunneled catheters
Can use immediately. Long term therapy (>1yr).
temporary vascular access
Can use immediately. Subclavian, internal jugular, emoral veins. Temporary catheter.
types of PC: hard cannula
Can use immediately. Usable for 1 week.
Clinical Manifestations of ESKD effects
Cardiovascular. Integumentary. Neurologic. Pulmonary. Gastrointestinal . Hematologic. Reproductive. Musculoskeletal
Fourth Generation Cephalosporins
Cefepime (Maxipime)- getting better with gram positive and negative.
5th generation cephalosporins
Ceftaroline (Teflaro) great with gram positive and negative
Third Generation Cephalosporins
Ceftriaxone (Rocephin) ER, good for gram positive and negative.
cephalosporins
Cephalexin(Keflex){1st gen. Ceftriaxone (Rocephin) {3rd gen). Cefepime (Maxipime) {4th gen}. Ceftaroline (Teflaro) { 5th generation}.
peritoneal dialysis procedure: during the procedure, the nurse
Check drainage. Color clarity. Check patient comfort. No pain is norm. Check flow. Should be brisk.
Quinolones: examples
Ciprofloxacin (Cipro); Moxifloxacin(Avelox); Levofloxacin (Levaquin).
6 Steps to Prevention of C. Diff: step 5
Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with C. difficile has been treated there.
peritonitits: complication of PD: S&S
Cloudy dialysate outflow (effluent). Fever. Rebound tenderness. Abdominal Pain. General Malaise. N/V.
Clostridium Difficile: about
Colonizes in human intestinal tract only after normal flora have been altered by antibiotic therapy. antibiotic associted colitis.
abdominal pain in PD
Common at first due to peritoneal irritation. Try warming dialysate solution...K-pad. Place a heating pad on the abdomen during the inflow on low setting.
Nitromidazoles: tx
Complicated intra-abdominal infections, c. difficile, anaerobic infections.
Dialysate Solutions
Consists of a combination of water and variable concentrations of electrolytes. K, NA, Cl, Mg, Ca. Increasing the amount of glucose makes the solution more hypertonic... increasing osmotic pressure, resulting in more fluid removal. 1.5%, 2.5%, 4.25% Dextrose.
types of PC: Continuous Cyclic Peritoneal Dialysis -(CCPD
Cycler is used to instill and drain dialysate from the patient. Connect at bedtime, set machine, and undergo dialysis while asleep. Built in alarms and monitors. Sterile catheter is violated less often. Final exchange is left to dwell through the day and drained the next evening ( Prolonged dwell time during the day).
Chronic renal failure
Damage is progressive and irreversible deterioration of renal function resulting in azotemia. Slow process that occurs over a number years. Some can develop total irreversible loss of kidney function acutely. Usually direct traumatic kidney injury.
tx for VRE
Daptomycin [Cubicin]. Linezolid [Zyvox].
rhabdomyolysis clinical manifestations
Dark, red, cola, or tea colored urine. Profound Muscle tenderness. Weakness, pain, swelling, stiffness.
fluid overload in PD
Decrease PO intake. Increase to hypertonic solution. Weigh frequently. Monitor breath sounds for pulm edema.
Complications of CRRT
Decreased UF rate. Filter clotting. HPTN. FL&E Imbalances. Bleeding. Access dislodgement or infection.
culture
Definitive diagnosis of an infectious disease. Specimen can be obtained from any body fluid or tissue. Cultures from sterile body fluids are diagnostic. Cultures from nonsterile sites (wound drainage) may signify colonization. Always clean open wound 1st before obtaining culture.
osmosis
Diffusion of water through a selectively permeable membrane.
inotropic agents for HF in ESKD
Digoxin (Lanoxin) ->Watch for toxicity->Bradycardia, dig levels. Dobutamine (Dobutrex).
what intermittent hemodialysis requires
Direct access into the vascular system. Mechanism to transport the blood to & from the dialyzer. A dialyzer.
MRSA- ABOUT
Direct contact with hands, droplets or by sharing items. Lives for days on environmental surfaces & clothing(On hands for 3 hours!).
carbapenems
Doripenem (Doribax); merropenem (Merrem); ertapenem (Invanz). Broadest ATB action of any ATB.
Tetracyclines: examples
Doxycycline (Vibramycin); tetracycline (sumycin); Tigecycline (Tigacil) -Injection only{Glycylcyclines}.
management in the catabolic process in AKI
Early nutritional consult. Restrict K+, Phos, Na+. Limit protein intake. Increase carbohydrates, fats and essential amino acids. Fluid restriction. Daily weight, protein, albumin levels, Assess BMs. Assess mental status q shift.
entended-spectrum beta-lactamases (ESBL)
Enzymes produced by certain types of bacteria. These enzymes can break down the active ingredients in many common antibiotics, making them ineffective.
intrarenal prevention with medical management for AKI
Evaluate meds in elderly, hypertensive, or diabetic patients and adjust accordingly. Alter dosage of antibiotics- FOLLOW LEVELS. Caution with procedures involving dye. Monitor electrolyte balances. May start a protein restricted diet.
US and or CT scan
Evaluate size, shape and position of the kidneys, detects hydronephrosis, tumors, cystic disease.
patient education in AKI
Explain diet and fluid restrictions. Provide handouts for the patient and family. Demonstrate how to check BP, pulse, respirs and weight. Discuss personal hygiene and how to avoid infections. Describe the medications and adverse effects.
Anti-Fungals: examples
Fluconazole (Diflucan); Amphotericin B deoxycholate (Fungizone)~ "Shake N Bake" "Amphoterrible"; Capsofungin (Cancidas); Nystatin (Mycostatin).
the care of patients with AKI, assessment and diagnosis
Fluid & Electrolyte Balance. Nutritional status. Patient knowledge. Activity tolerance. Self-esteem. Potential complications.
treatment of the initiation phase of AKI
Fluid challenges-NS bolus. Mannitol IV. Furosemide (Lasix) or bumetanide (Bumex) IV (If diuresis occurs may repeat dose). Fenoldopam mesylate (Corlopam). If U.O. < 30 mL/hr -ATN . Packed RBC's and NS if hemorrhage is cause. Acute Glomerulonephritis: glucocorticosteroids.
performing the exchange; drain
Fluid is drained out of the body by gravity. Open clamp at end of dwell time. Monitor outflow(effluent) for color and clarity. Should be clear, straw yellow. Never bloody or cloudy.
Acinetobactor baumannii
Found in soil, mucous membranes, skin.
diuretics for AKI: loop
Furosemide (Lasix), Bumetanide (Bumex).
macrolides:: SE
GI discomfort; hepatotoxicity; QT prolongation; blood dyscrasias.
Aminoglycosides: examples
Gentamicin (garamycin); Amikacin (Amikin); tobramycin (Nebicin); Neomycin.
insufficient flow of dialysate: reasons: catheter migration
Get X-ray to check placement.
AKI effects on cardiovascular
HTP. edema. CAD. dysrhythmias. pericarditis. pericardial effusion. pericarditis. HF. cerebrovascular disease.
disequilibrium syndrome
Headache, decreased LOC, restlessness ,N/V, seizures. Anticonvulsants and barbiturates may be needed. More common in AKI or extreme BUN level (150mg/dL).
cause of MRSA
Healthcare-Associated- VAP, Bacteremia associated with central lines. Community acquired - causes soft tissue infections. Today, 50% of hospital - acquired S. aureus are Methicillin resistant (HA-MRSA).
Hemodynamic monitoring and fluid balance in AKI
Hemodynamic monitoring. Daily weight~ what is their "Dry weight"?. Physical assessment.
Anti-Fungals: SE
Hepatotoxicity, Hypokalemia, hypocalcemia, Hypomagnesemia, nephrotoxicity, HPTN, myalgia, fever, chills. especailly ampho B.
fluid balance in AKI
Hourly outputs. Hemodynamic monitoring. Daily weights. Assess for s/s of fluid overload lung and heart sounds. Interventions focus on preventing fluid excess by: Fluid restriction-strict I/O. Diuretic therapy (w/ some kidney function). Renal Replacement Therapies.
complicatiosn of ESKD
Hyperkalemia. Pericarditis. Hypertension. Anemia. Bone Disease.
Collaborative Problems and Complications of AKI
Hyperkalemia. Pericarditis. Pericardial effusion. Pericardial tamponade. Hypertension. Anemia. Bone disease and metastatic calcifications.
complicatiosn for hemodialysis watch for
Hypotension, exsanguination. N/V, Muscle Cramps. Headaches, dizziness, malaise. Chest pain, dysrhythmias. Infectious Diseases like Hepatitis B/C, HIV. Avoid invasive procedures for 4-6 hours after hemo. Hemorrhage.
B12-cyanocobalamin (anemia)
IM q Month. Both are important co-factors in RBC production. Assess Iron, Folic Acid, B12 levels before and during.
Most at Risk Patients: Healthcare-Associated (HA-MRSA)
IMMUNOSUPPRESSED. Skin Barrier Breaks. Invasive Devices. Extended Stay Hospitalized Patients / ICU. Pre-hospital.
antibiogram
Identifies antibiotic -> organism is sensitive or resistant.
high risk if: VRE
Immunosuppressed/critically ill. Previous exposure to IV Vancomycin, 3rd generation Cephalosporins. Prolonged antibiotic therapy. Elderly. Foley or IV cath. Repeated hospital admissions. Enterococcal Bacteremia - endocarditis. Lives on surfaces for weeks. Only killed by antiseptic soap - chlorhexidine. No ETOH based hand foam.
causes of resistance
Inappropriate prescribing of antibiotics. Not matching the drug to the bug!!. Patients that do not complete regimen (Sub- therapeutic). Vets inappropriately prescribe antibiotics for animals.
infectious complications of patients with AKI
Infection is the major cause of death from AKI due to immunocompromised status. Minimal use of invasive lines and tubes is crucial. Prompt removal is essential. Aggressive pulmonary hygiene. Assess for s/s of infection->Increased WBCs, fever, cultures. ATB dosages require adjustments according to the severity renal dysfunction.
initiation phase of AKI
Initial phase of injury to the kidney. Lasts about hours to several days. Ends either when oliguric/anuric stage begins or when azotemia does in absence of an oliguric/anuric stage. Reversal or prevention of kidney dysfunction is possible. at this stage by early intervention.
the three types of renal replacement therapy
Intermittent Hemodialysis (IHD). Peritoneal Dialysis. Continuous Renal Replacement Therapy (CRRT).
renal replacement therapies
Intermittent Hemodialysis . Peritoneal Dialysis. CRRT. Renal Transplant.
6 Steps to Prevention of C. Diff: step 3
Isolate patients with C. difficile immediately..
reasons for intrarenal
Kidney ischemia (advanced stage of prerenal-blood wasnt able to get to the kidney tissue). Endogenous toxins (rhabdomyolysis, tumor lysis syndrome). Infection (acute GN, interstitial nephritis).
foods high in phosphorus
Limit milk, cheese, colas, meat, poultry, fish, broccoli, carrots, whole grain cereals, chocolate, beer, peanut butter.
CDC guidelines for VRE
Limit use of Vancomycin. VRE lasts long on inanimate objects. Wash hands. Environmental cleaning needed. Dedicated equipment in patient rooms. Contact isolation.
Oxazolidinones: examples
Linezolid (Zyvox)
Oxazolidinones: nursing interventions
Linezolid is a weak MAOI; avoid eating foods containing tyramine during use-> HTN. Monitor CBC, LFT's, Platelets.
goals in the plans of care of patients with AKI
Maintaining of IBW without excess fluid. Maintenance of adequate nutritional intake. Increased knowledge. Participation of activity within tolerance. Improved self-esteem. Absence of complications.
Prerenal Kidney Injury~ Medical Management: prevention is major tx
Maintenance of fluid volume before, during, and after surgery. Treat Hypotension- give fluids, medications, or low dose dopamine 2-3 mcg/kg/min.
Vancomycin-Resistant Enterococci (VRE). Enterococci normal flora of GI tract.
Major pathogen- E. Faecalis, E. Faecium. Urinary tract most common infection site. Blood or wounds. Spread by direct contact. VRE occurs at higher rates in patients with MRSA.
Anatomic location
Make sure site is correctly identified.
recombinant human erythropoietin (EPO, epogen, procrit)
May be given IV or SQ 3x /week. Increases energy & Hct, decreases need for blood transfusions; Thrombotic events if Hgb>= 12. Watch BP- may cause HTN.
Darbepoetin Alfa (Aranesp).
May be given IV or SQ weekly. Side effects- cardiac arrhythmias, CHF, sepsis, vascular access thrombosis, seizures, MI, stroke. Watch Hgb levels- hold dose if > than 12.
renal biopsy
May help w/ diagnosis; gold standard to diagnose the specific type of kidney disease.
Nitroimidazole: SE
Metallic - bitter taste, furry tongue, SEIZURES, may darken(deep red) urine.
Nitroimidazole: example
Metronidazole (flagyl)
disulfiram like reaction
Metronidazole SE if given with alcohol. avoid during tx. after and before.
colonization
Microorganisms present without host interference or interaction. Not sick - but if get sick & immune system breaks down - could get sick. Can transmit organism to susceptible patient. Anterior nares most common site. Normally, do not decolonize = leads to further resistance.
Fibrin/clot formation in PD
Milk tubing. Heparin.
preventing anemia in AKI
Minimize blood draws. Stress ulcer prophylaxis. Test stool, NG, emesis for OB. epoetin alfa (Epogen, Procrit), darbepoetin (Aranesp).
sulfonamides: nursing interventions/patient education
Monitor CBC, liver, renal panels. Instruct patient to use sunscreen; Increase fluid intake to 2-3 L/day. Contraindicated in women who are pregnant near term, breast feeding mothers & infants under 2 months.
cephalosporins; nursing interventions/patient education
Monitor CBC. Use barrier method of birth control while on cephalosporin.
Cyclic Lipopeptide: nursing interv
Monitor CPK levels weekly throughout therapy. Especially with statin use. Renal impairment-> dosage reduction required. Do not mix with Dextrose -only NS or LR.
Aminoglycosides: nursing interventions
Monitor I/O; BUN/Cr/GFR. Monitor serum levels. Increase fluids if not contraindicated; Assess CN VIII. Do not mix with PCN-> PCN will inactivate aminoglycosides.
nursing management during CRRt
Monitor VS frequently. Monitor hemodynamic and perfusion status q 2 hours. Monitor for signs of clotting. Monitor for signs and symptoms of infection. Monitor for hypothermia. Monitor electrolyte ,acid- base levels, and fluid balance.
tx for diuretic phase of AKI
Monitor daily weight. Orthostatic BP & P. Strict I/O. Monitor electrolytes. Fluid and electrolyte replacement. Monitor EKG rhythm.
electrolytes/acid/base imbalance with AKI
Monitor electrolytes & ABG levels. Assess for s/s of electrolyte imbalances. Medications for electrolyte imbalances. Dialysis. Assess for pruritus. Monitor ABGs. could be on bicarb tablets.
nursing management c diff.
Monitor for electrolyte imbalances & dehydration. Administer rehydration therapy (assess for hypovolemic shock). Clean environment with bleach. Spores survive up to 70 days in the environment. Wash hands with soap & water only. ETOH based hand sanitizers do NOT kill spore forming bacteria. Contact Isolation.
nursing management of vascular access
Monitor for infection. Aseptic technique. Assess for bleeding at site and connections.
Tetracyclines: nuring interventions
Monitor liver, renal, CBC . Avoid use in pregnant women . Contraindicated in children under 8 -> discolors teeth. Use sunscreen and protective clothing. Barrier method to prevent pregnancy. Avoid taking with antacids, milk, or calcium products -> if necessary wait at least 1 hr before and 2 hr after administration of tetracycline.
diffusion
Movement of molecules from an area of higher concentration to an area of lower concentration.
types of PC: tenckhoff catheter
Must wait 2 weeks to use.
airborne precautions
N95 respirator
meds that are toxic to the kidneys
NSAIDS, Motrin, vancomycin, ace, aminoglycosides.
ATN
Necrosis (death) of renal tubule tissue. Renal tissue ischemia caused by inadequate blood supply or by nephrotoxic agents. Tissue ischemia occurs when mean arterial BP (MAP) falls below 50-60 mmHg for > than 25 minutes. High Incidence of permanent renal damage.
dialysis diseqilibrium syndrome
Neurologic complication. Cause is unknown but may be due to rapid decrease in BUN levels and rapid osmolar fluid shifts during Hemodialysis. Change in urea levels can cause cerebral edema, which leads to ICP.
Digoxin toxicity s/s
Normal 0.5-2 ng/mL. Yellow-tinged vision, Halos. Vomiting. Headaches. Fatigue. heart block 1st degree. bradycardia.
STAPHLOCOCCUS AUREUS (mrsa)
Normally lives on skin (hands), mucous membranes of nasopharynx, large intestine & vagina. 30% of population - Colonized with staph /10% with MRSA = silent carriers Usually anterior nares. Only decolonize if massive outbreak in close living arrangements. mupirocin [Bactroban).
Quinolones: nursing interventions
Not recommended for under 18 yrs of age or pregnancy. Do not administer with antacids or dairy products (separate at least 1 hr before or after). Avoid concurrent use with amiodarone-> Prolongs QT. Use sunscreen or protective clothing.
nursing priorities for peritoneal dialysis
Observe for s/s of infection. Monitor fluid volume status. Infusing dialysate. Observe outflow (effluent). Preventing complications of PD.
reasons for postrenal
Obstruction (urethra, prostate, bladder). Rare as a cause in ICU.
Usually effect skin or soft tissues - accompanied by fever, swelling, pain, purulent drainage, or warmth.
Often mistaken for spider or bug bite. Boils, abscesses, furuncles, folliculitis cellulitis.
nursing management of vascular access: things to remember
Only trained persons to access catheters. Sterile technique only. Staph aureus (most common pathogen) during cannulation. Heparin is instilled after dialysis to prevent thrombosis- (most common complication w/ AV access). Watch for bleeding-PTT levels. Monitor the patient's hemodynamic status. Provide patient education.
Tricyclic Glycopeptides; SE
Ototoxicity, HPTN, nephrotoxicity, Red Man Syndrome.
Aminoglycosides: SE
Ototoxicity; nephrotoxicity; muscle paralysis.
folic acid (vitamin B9) anemia
P.O /SQ/IM/IV. Side effects- slight flushing.
vancomycin in c. diff should only be given
PO.
nursing management for long term vascular access
PROTECT the Catheter!! Aseptic technique. Do not use for anything else. Protect the catheter. Assess for infection. Instill with heparin to prevent clotting. Assess for bleeding at site or connections.
sensitivity testing
Performed after isolating microorganism in culture. Determines the effects of various antibiotics on that particular organism. Organisms killed by acceptable levels of antibiotic are considered sensitive to that drug (S). Organisms that are not killed by tolerable levels of an antibiotic are considered resistant to that drug (R). Preliminary results usually take 24-48 hours / Final results take 72 hours. ***Antibiotic therapy should not begin until after culture specimen has been obtained***
Sevelamer Hydrochloride (RenaGel) bone disease
Phosphate binder. Give other meds 1 hour before or 3 hours after Renagel.
calcium acetate (phos-low) bone disease)
Phosphate binding agent. Take with meals, snacks.
sulfonamides: SE
Photosensitivity; Steven-Johnson Syndrome; blood dyscrasias; crystalluria; jaundice
nursing care for steal syndrome
Place hand in dependent position. Keep hand warm- wrap in towel, glove.
reverse isolation
Precaution used for individuals who are immune-compromised to protect THEM from harmful organisms that may be brought in from outside. Everyone who enters room wears gown, gloves & mask. All equipment entering room needs to be disinfected.
6 Steps to Prevention of C. Diff: step 1
Prescribe and use antibiotics carefully. About 50% of all antibiotics given are not needed, unnecessarily raising the risk of C. difficile infections.
reasons for prerenal
Prolonged HPTN (Sepsis, vasodilation). Prolonged decreased cardiac output (HF, cardiogenic shock). Prolonged volume depletion ( dehydration, hemorrhage). Reno vascular thrombosis.
nursing management of hospitalized patients on dialysis
Protect vascular access; assess site for patency and signs of potential infection, and do not use it for blood pressure or blood draws. Monitor fluid balance indicators and monitor IV therapy carefully; keep accurate I&O and IV administration pump records. DAILY Weights! Weights pre and post treatment. Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data. Monitor cardiac and respiratory status carefully. Monitor blood pressure; anti-HTN agents must be held prior to dialysis to avoid hypotension- give after treatment is completed!. Monitor all medications and medication dosages carefully; avoid medications containing potassium and magnesium. Address pain and discomfort . Implement stringent infection control measures; Provide CAPD catheter care. Monitor dietary sodium, potassium, protein, and fluid; address individual nutritional needs. Provide skin care: prevent pruritus; keep skin clean and well moisturized; trim nails and avoid scratching.
the 6'p's
Pulslessness. Pallor. Pain. Parasthesia. Paralysis. Pollor
contrast induced nephrotoxic injury and AKI
Radiopaque contrast. Prevention-Promote hydration and avoid dehydration. Medications~ Bicarb.
mycobacterium tuberculosis
Require Treatment with combo of 3 or 4 antibiotics for at least 6 months. Must use culture & sensitivity or resistance occurs quickly.
oliguria/auric phase: hyperkalemia
Requires emergent treatment!. Monitor pH, K, Bicarb levels. Monitor EKG; neuromuscular symptoms. 50 mL 50 % Dextrose with 5-10 units of Regular Insulin IV, bicarb; Calcium chloride/gluconate. Kayexalate PO/ enema; Nebulized albuterol. Dialysis.
Vets inappropriately prescribe antibiotics for animals
Resistance passed on to humans through food contamination. Milk, meat, eggs.
New strains of multi drug-resistant M. tuberculosis (MDR-TB) are spreading
Resistant Isoniazid and rifampin. Consider starting 5-7 drugs before susceptibility is known. Continue treatment for 12-24 months after cultures negative.
intrarenal AKI - rhabdomyolysis
Resulting from a variety of diseases, trauma, or toxic insult to skeletal muscle. Breakdown of muscle fibers with leakage of potentially toxic cellular contents in the circulation->myoglobin.
oliguric/anuria phase: metabolic acidosis fix
Results from kidneys inability to excrete H ions and loss of renal bicarbonate buffering capabilities. pH < 7.35, anion gap. Lungs attempt to compensate by excreting more CO2 (Kussmaul respirs). Unable to totally compensate for increased acid load. IV Bicarb drip. Dialysis.
steal syndrome
Results from vascular insufficiency after creation of a fistula. "Steals" blood from palmar arteries. S/S: C/O pain distal to the fistula Pallor, diminished pulse distal to fistula. Necrosis and gangrene if not treated. Nursing Care: Place hand in dependent position. Keep hand warm- wrap in towel, glove. Thrombosis. Carpal Tunnel Syndrome. Infection.
peritoneal dialysis procedure
Review order for # exchanges (cycles), type and amount of dialysate, additives needed. Close patient door, have visitors leave/ or mask family member that may be assisting the patient at home. Disinfect work surface, wash hands!! Mask for all people in the exchange area. Open and set up equipment. Solution should be warmed to body temp (heating pad). Check strength, clarity, amount, leaks, expiration date.
nursing care for AVG
Same as AVF. More prone to thrombosis infection, and stenosis. No BP, IV, venipuncture in that arm.
intermittent hemodialysis description
Shunting of the blood from the body through a dialyzer in which diffusion and ultrafiltration occur and then back to the body.
continuous renal replacement therapy: (CRRT)
Slow and continuous removal of fluids and solutes-- lasting 12 hours -> several days. Used in critical care setting for those clinically unstable for traditional HD. Those who can not tolerate Hemodialysis. Slow blood pump flow (100-200 mL/min).
meds for hyperkalemia in AKI
Sodium Polystyrene sulfonate (Kayexelate). Hemodynamically unstable. Regular Insulin IV, 50% dextrose IV, calcium IV.
clostridium difficile
Spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A & B. Colonizes in human intestinal tract only after normal flora have been altered by antibiotic therapy. Antibiotic associated colitis. Most diarrhea associated with antibiotics is unrelated to C. Diff ATB reduce the ability of intestinal microflora to break down unabsorbed carbohydrate. Accumulate in colon - increases osmotic pressure and causes movement of water from extracellular fluid into intestinal lumen = diarrhea.
dx for C.diff
Stool sent for C. diff toxins A & B. 3 samples sent to rule out if 1st is negative.
insufficient flow of dialysate: reasons: constipation
Stool softeners; high fiber diet.
tx for C diff
Stop causative ATB, if possible. Metronidazole hydrochloride [Flagyl]. Vancomycin [Vancocin] (PO) or linezolid [Zyvox]. If no response to Flagyl, allergic to Flagyl, or pregnant. Donor stool transplants ??????. NO ANTIDIARRHEALS.
Patients that do not complete regimen (Sub- therapeutic)
Stop when feel well. Don't follow dosing schedule. Hoard meds and give to others.
acute kidney injury: about
Sudden onset set of kidney disorders that can range from mild impairment-> Failure. Severe AKI->sudden decline in GFR. Urine output is usually < than 40 mL/hr (oliguria) but may be normal or increased. Most frequent causes->Sepsis and cardiac surgery. Co-existing nonkidney conditions increase susceptibility. Most types of AKI are reversible if treated early!!!
post-renal AKI medical tx
Surgery. Suprapubic catheter to relieve bladder (completely bipass the obstruction). Stents to open ureters. Dialysis. Monitor for rapid fluid loss after obstruction relieved.
ferrous sulfate (feosol, slow fe)
Take on empty stomach if possible. Do not give with antacids. Side effects- black stools, nausea, constipation. Add stool softeners/ Laxatives.
Lanthanum carbonate (Fosrenol) bone disease
Take with meals. Binds with phosphorus in the intestinal tract.
promoting home and community based care
Teach home blood pressure and weight measurement . Teach client to avoid magnesium containing antacids. Encourage client to obtain yearly influenza vaccine and to get pneumococcal vaccine. Encourage diet, exercise, and medication control~ Nutrition consult. Teach home care of dialysis access site. Refer to community resource or support groups.
6 Steps to Prevention of C. Diff: step 2
Test for C. difficile when patients have diarrhea while on antibiotics or within several months of taking them.
ultrafiltration
The process where small molecules are forced from the blood out of the capillaries of the glomerulus, under high pressure, into the Bowman's capsule.
Oxazolidinones; SE
Thrombocytopenia, lactic acidosis, COLITIS, increased LFT's.
at risk patients; community associated (CA-MRSA)
Transmitted via direct physical contact. Children in daycare. Group homes /Nursing homes. Amateur & professional athletes. IV drug users. Homosexual men. Prisoners.
acinetobactor baumanni tx
Treat w/ Carbapenems; Tigecycline [Tigacil].
Control of MRSA in Healthcare Facilities: not as serious infection
Trimethoprim - sulfamethoxazole DS [Bactrim DS] Intranasal mupirocin [Bactroban].
sulfonamides: example
Trimethoprim/Sulfamethoxazole (Bactrim); co-trimoxazole (Septra).
tx for disequilibrium syndrome
Try slowing the blood flow rate to avoid rapid changes in plasma composition. Shorter dialysis time. Anticonvulsants and barbiturates may be needed.
insufficient flow of dialysate: reasons: kinked or clamped connection
Try to reposition patient; low fowler's position. Ensure drainage bag is below abdomen.
fluid restriction in chronic kidney disease
U.O + 500-600ml (insensible loss)
oliguria/auric phase; fluid restriction
U.O.+ insensible water loss (800-1500 mL/day)- we dont calculate, but we educate our patients. Accurate I/O essential. Daily weights. (dry weights better be known).
at risk disease states and AKI
Underlying chronic kidney disease (CKD). Older age and AKI. Heart failure and AKI~ Cardiorenal syndromes. Respiratory failure and AKI~. Positive pressure ventilators. Sepsis and AKI~ causes 50% of AKI cases. Trauma and AKI: (Trauma admissions. Rhabdomyolysis). contrast induced nephrotox, CAUTI. and hemodynamic monitoring and fluid balance.
tests for rhabdomyolysis
Urinalysis- positive for blood. Urine myoglobin is positive. CPK- very high (thousands). Hyperkalemia. Increased Phos, BUN, Cr.
Beta-Lactam Antibiotics: Penicillins: nursing interventions/patient education
Use barrier method when taking oral contraceptives. Separate from aminoglycoside use 1-2 hours. Monitor BUN/Cr/GFR, e-lytes. Monitor for allergic reaction; watch for cross allergy to cephalosporin.
carbapenems: nursing interventions/patient education
Use cautiously in renal impairment -> check BUN/CR/GFR.
how long c-diff lasts
Usually 5-10 days after antibiotic therapy has begun - up to 10 weeks after stopping.
MRSA S&S
Usually effect skin or soft tissues - accompanied by fever, swelling, pain, purulent drainage, or warmth. Often mistaken for spider or bug bite. Boils, abscesses, furuncles, folliculitis cellulitis.
diuretic phase of AKI
Usually occurs 2-6 weeks after onset of oliguric and continues until BUN levels ceases to rise; Lasts 1-2 weeks. Begins when U.O.> 400 mL/day. Renal tubules are beginning to heal, regaining integrity. U.O. may be up to 4-5 L/24 hours due to kidneys inability to concentrate urine and diuretic affect of BUN. Later in the diuretic phase the BUN starts to fall and continues to do so until normal levels are reached. Fluid and electrolyte levels difficult to manage.
Oxazolidinones: treats
VRE, MRSA of skin. Reserved for treatment of serious bacterial infections when other antibiotics have failed.
Anti-Fungals: nursing interventions
VS q 15 min during test does q 30 min 2-4 hrs. Monitor renal, LFT's, e-Lytes . Ampho B->Need to pre-medicate with anti-emetics, antipyretics, anti-histamine, and steroids to minimize infusion -related reactions.
Tricyclic Glycopeptides: nursing intervent
Vanc levels must be monitored. Monitor for s/s of Ototoxicity; may be permanent. Use with caution if already have a hearing impairment. Monitor for nephrotoxicity. Caution if have kidney disease
Tricyclic Glycopeptides; example
Vancomycin [Vancocin] .
Control of MRSA in Healthcare Facilities: serious infection
Vancomycin(Vancocin): Resistance is an up-coming problem Linezolid(Zyvox) Cefaroline (Teflaro) {5th generation cephalosporin}.
calcitriol (Calcijex, Rocatrol); calcifediol (Calderol) (bone disease)
Vitamin D analog. 3x/week at the end of dialysis.
6 Steps to Prevention of C. Diff: step 4
Wear gloves and gowns when treating patients with C. difficile, even during short visits. Hand sanitizer does not kill C. difficile, and hand washing may not be sufficient.
perotineal dialysis: after the procedure
Weigh or measure the drainage. Record- time, amount, solution, UF for I/O.
6 Steps to Prevention of C. Diff: step 6
When a patient transfers, notify the new facility if the patient has a C. difficile infection.
According to the CDC, Carbapenem-Resistant Enterobacteriaceae are
a very serious developing threat
TB under a microscope
acid fast basil
uses for intermittent hemodialysis
acute poisoning. acute/chronic renal failure. transfusion reaction. hepatic coma.
S&S C. diff
acute, foul-smelling, watery diarrhea with lower abdominal pain, low grade fever, leukocytosis. Severe cases: diarrhea w/ mucus and blood. Usually 5-10 days after antibiotic therapy has begun - up to 10 weeks after stopping. Many are asymptomatic carriers that continue to shed toxic organisms - contamination of environment.
contraindications for perioneal dialysis
adhesions of the peritoneum of abdomen. peritonitis. recent abdominal surgery.
Eosinophils
allergic reactions and parasitic infections.
E. coli. gram negative
aminoglycoside. and imipenem.
arteriovenous graft (AVG)
anastamosing of a piece of tubular, synthetic material to an artery, tunneling through the soft tissue and finally anastamosing to a vein. Can not use for at least 10 days. Alternative for those whose vessels are inadequate for fistula formation
Interpreting a Microbiology Report.
anatomic location. gram stain report. antibiogram. organisms.
temporary vascular devices take form the vein
and put back in the vein
AKI effects on hematological
anemia. imapired clotting.
AKI effects on GI
anorexia, N/V. gastroenteritis, hiccups, abdominal pain, uremia, peptic ulcer, GI bleeding.
most common site of colonization
anterior nares
ampho B needs to be premedicated with
antiemetics, antipyyretic, antihistamines, and steroids.
VRE on surfaces only killed by
antiseptic soap- chlorhexidine. not alcohol based hand foam.
influenza tx
antivirals (neuraminidase inhibitors: Recommended to treat as early as possible for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness; who require hospitalization; or who are at greater risk for influenza-related complications (CDC) Oseltamivir (Tamiflu) Zanamivir (Relenza®)- 7 yr or older Peramivir (Rapivab®) - 18 yr or older.
AKI effects on neurologic
apathy, lethargic, headache, impaired cognition. insominna. restless leg, gait disturbances, paresthesias, seizures, decreased LOC. coma.
tetracyclines administration
avoid taking with calcium products like milk, or antiacids,. if you have to, wait an 1 hr before and 2 hours after administration of this ATB.
monitor hypothermia in CRRT
because there is more fluid out of the body then in the body.
weights in dialysis should be done
before and after treatment
Tissue ischemia occurs when mean arterial BP (MAP) falls
below 50-60 mmHg for > than 25 minutes.
obstruction in postrenal need to be
bilateral, in order for both to go into AKI.
watch for clotting in CRRT because
blood is going much slower, and there is a chance for blood to sit.
blue port (venous side)
brings back filtered blood into the body
hear a
bruit
frequent oral hygiene for fluid restriction
brushing teeth, hard candies, wont be taking fluid. need to keep mouth moist.
patient on PD dialysis are chronic patients
but they can still work. will one day probably have to start HD.
if a med comes back Resistance
call the doc and find out what to try next.
acute on chronic kidney injury, if tx
can only return to baseline of kidney function.
Commonly used medications to treat ESBL-involved infections include:
carbapenems (imipenem, meropenem, and doripenem) cephamycins (cefoxitin and cefotetan) beta-lactamase inhibitors (clavulanic acid, tazobactam, or sulbactam) non-beta-lactamases colistin, if all other medications have failed.
calcium gluconate in hyperkalemia for
cardio-protective.
macrolides should be avoided during administration of
cardizem, verapamil. and HIV protease inhibitors, could cause tachycardia, and possible cardiac arrest.
Pseudomembranous colitis
causes horrible diarrhea, but is not c.diff
First generation cephalosporins
cefazolin, cephalexin (Keflex) good for surgery. removes all of the gram positives on the skin.
changes in urea levels in dialysis disequilibrium can cause
cerebral edema. which could lead to increased intercranial pressure.
should never use a microwave to warm solution in filling peritoneal dialysis
chances of hot spots! use heating pads.
diuretic AKI: thiazide
chlorothiazide (Diuril); metolazone(Zaroxolyn).
Rifle criteria
classification of chronic kidney failure. Risk. Injury. Failure. Loss. ESRD
contraindications of intermittent hemodialysis.
coagulopathy. age extremes (young or old). hemodynamic instability.
acute kidney injury, if introduced to tx if
completely reversible
biggest complication of AVF+AVG
compression, and or obstruction/clot. closing off.
vaptans diuretic for AKI
conivaptan( Vaprisol) (if making urine) used in hyponatremia w/ hypervolemia...inhibits ADH.
radial or brachial artery connected
connected to the cephalic vein
organism not killed by acceptable levels of ATB are
considered resistant, to the drug and marked with an (R).
organism killed by acceptable levels of ATB are
considered sensitive. and marked with an (S).
tx for Mycobacterium lasts
continoue to tx for 12-24 months after culture is negative.
after TB culture comes back negative
continue treatment for 12 -24 months after
amount dialysis in hemodialysis
could be many liter in mere minutes
if outflow is less than inflow
count as intake in peritoneal dialysis
Cyclic Lipopeptide: example
daptomycin (Cubicin).
leading cause of CKD
diabetes mellitus
common causes of chronic kidney disease.
diabetes mellitus (leading cause). hypertension (second leading cause). disease may start in the tubules due to (systemic disease, autoimmune reaction and transplatn and rejection, harmful actions of drug and or toxins, infection, mechanical damage. ischemia. obstruction of the urinary tract.
hyperphosatemia in AKI
dietary-phosphorus binders. aredia. take with food to bind out.
fenoldopam mesylate (corlopam)
dilator that increases the perfusion to the kidney's during the initiation phase of AKI. but it also causes a drop in BP. ugh. . . .
Heparin may be added to prevent fibrin clot formation in the catheter or tubing. Antibiotics, Insulin, additional lytes can be added.
dilysate additives
AKI effects on immune system
diminshed leukocytes counts. increased susceptibility to infection.
intrarenal AKI
direct damage to the kidneys by inflammation, toxins, drugs, infection or reduced blood supply. damage to the actual kidney's themselves. hardest to treat due to being inside the kidneys. prolonged ischemia.
watch orthostatic hypotension in
diuretic phase due to all of the electrolytes shifts, and fluid lost, and fluid restoration.
quinolone: administration
dont give with dairy products or antiacids.. if have to, wait at least 1 hour before or after eating.
when degree of renal damage should be assessed
during the recovery phase
culture from sterile body fluids are
dx of a infection/anything.
biggest concern in c.diff
elctrolytes and fluid imbalance from all of the diarrhea. dehydration.
1st dx for AKI
electrolytes and fluid balance. nutrition coming in in second.
creatinine and bun in CKD.
elevated as CKD progresses, with cr a more reliable indictor or renal function.
patients on continuous CRRT should be assessed
every 2 hours
electrolytes and acid/base should be check when on CRRT
every 4-6h. because of the continuous changes in fluid and balance.
neutrophils
first cell to respond to bacterial infection. if increased, it indicates that this is indeed a bacterial infection. increase in bands (shift to the left). absolute neutrophil count (ANC) (actual number).
patients on dialysis in the hospital should avoid
foods that contain potassium, and magnesium. these electrolytes are high, and there is no way to excrete besides dialysis. so don't be given these patients milk of mag or salt substitutes.
avoid invasive procedures for
for 4-6 hours after hemodialysis. just used heparin, and might want to check labs as well.
main reason for doing an AVG rather than a AVF
for those who have vascular issues.
before heading over for dialysis, nurse should check
for uremia, and electrolyte imbalance.
how long VRE lives on surfaces
for weeks.
if patient complains that bag in PD has changed postitions
get x-ray right away. might have migrated.
CDC recommends this as the first step and most important step in protecting against the flu
getting the influenza vaccination.
ATN tx
give steroids. decrease the inflammation.
if acute glomerlononephrititis in initiation phase
given gluxoxorticosteriods.
gram negative
hardest bacteria to tx
indictions of peritoneal dialysis
hemodynamic instability. severe cardiovascular disease. hemodialysis not availble. less rapid treatment appriopreite inadequte vascular access.
Tetracyclines; SE
hepatotoxicity; photosensitivity; superinfection; tooth discoloration
initiation phase: time frame
hours to days.
acid-base in CKD.
hydrogen ion excretion and bicardonate reabsorption in the early stage progresses to metabolic acidosis in later stages.
AKI effects on endocrine
hyperparathyoidism. glucose intolance.
second leading cause of CKD
hypertension
anti-tensive drugs held before dialysis due to
if have decreased BP due to the drugs, and then take off a bunch of fluid, you will drop the patient's BP way done. hypovolemia, and hypotension. but if come out, hypertensive, give them the anti-hypertensives.
give RBC/blood or NS
if hemorrhaging in the reason a patient started the initiation phase of AKI. reverse it now!
always want to be checking the connection on dialysis.
if something comes apart, could extravagate your patient. death.
differential shows the percent of
if this is an viral infection. bacterial, allergic or parasitic.
infection is a major cause of death from AkI due to
immunocompromised status
not matching the drug to the bug happens a lot
in ER where they take a culture and start a broad spectrum ATB, but doesn't match.
CRRT only done
in ICU. monitor very closely.
azotemia
increased BUN and creatinine and waste.
can have inflammation without
infection.
complications of continous renal therapy.
infection. bleeding. infiltration. air embolism.
complications of intermittent hemodialysis
infection. decreased cardiac output. cardiac arrhythmias. disequlbruim syndrome. air embolism. disconnection hemorrhage.
complications of peritoneal dialysis
infection. decreased cardiac output. fluid overload. hyperglycemia. metabolic alkalosis. respiratory insufficiency. abdominal pain.
cant have infection without
inflammation.
arteriovenous fistular (AVF) native
internal anastamosis of an artery to a vein (preferred method). Radial or brachial artery. Cephalic vein. Can not use for at least minimum of 14 days- needs to "mature". Requires 2 needles - one for pulling out blood (arterial) and one for returning it (venous).
4.5% dex
is a high concentration. used to pull off a lot in peritoneal dialysis.
renal replacement therapy: objective
is to extract toxic nitrogenous substances from the blood and to remove excess fluid: Diffusion, osmosis, and ultrafiltration. Does not correct renal dysfunction. Controls acid-base imbalances. Can be used in AKI & CRF.
most diarrhea associated with antibiotics is
is unrelated to C. diff
peritoneal dialysis: description
is used as the dialyzing membrane and substitutes for kidney function during failure. Works by diffusion and osmosis. Can be continuous or intermittent. Never used as 1st line acute treatment.
multiple organ infections should be
isolated.
a lot of ATB cause diarrhea. doesn't mean
it is c.diff for sure. need to culture to know for sure.
stage 1 of CKD
kidney damage with normal or increased GFR. GFR greater then 90ml/min/1.73m2
stage 5 of CkD
kidney failure. GFR- less than 15 or dialysis.
KUB
kidneys, ureters, bladder. Evaluate for obstruction, stones, masses in these places.
if a patient has MRSA and VRE place them on
linezolid (zyvox) one of the best. saved for occasions such as these.
Antidiarrheal agents
loperamide (1 brand name: Imodium) bismuth subsalicylate(2 brand names: Kaopectate, Pepto-Bismol).
diuretic in AKI: osmotic
mannitol
droplet precautions
mask, gloves, gown
red man syndrome in vancomycin
massive histamine reaction. means your given way too fast. slow it down. will see effects nipple line up.
MRSA only decolonizes if
massive outbreak in close living arrangement. give mupirocin (Bactrim).
potassium in CKD
may be at or near normal levels as tubular secretions is increased, as CKD progresses and oliguria occurs, hyperkalemia is a principle feature and may be life-threatening.
sodium in CKD
may be reduced as normal tubular reabsorption is reduced and urine excretion is increased, as CKD progresses, hypernatremia often predominates.
culture from nonsterile site (wound drainage)
may signify colonization. or pathogen without the actual infection.
stage 2 of CKD
mild reduction in GFR. GFR is 60-89ml/min/1.73m2.
stage 3 of CKD.
moderate reduction in GFR. GFR 30-59ml/min/1.73m2
if outflow in peritoneal dialysis is bloody
monitor for pulse, BP. may be small amounts at first, and menstruating may have some effects.
uses for continous renal therapy.
multiple organ dysfunction. sepsis. acute renal failure. inability to tolerate hemodialysis or perironeal dialysis
contact precautions
need gloves, gown.
no antidiarrheals in C-diff
need to get it out!
if giving ampho B
need to premedicate with anti-emetics, antipyretic, anti-histamine, and steroids to minimize infusion related reaction.
anemia- iron for ESKD
needed with EPO administration.
whenever there is an obstruction of either the prerenal/postrenal
needs to be bilateral
creatinine has such a small range
needs to be reported if it increases like 0.2. to be like 1.2
Daptomycin (Cubicin): mixes
never mix with dextrose. only NS, or LR.
contraindications for continous renal therapy.
no absolute contraindiations. not therapy of choice if rapid removal or fluid or substance is needed.
enterococci about
normal flora of the GI tract. E. Faecalis, E. Faecium.
about staph.
normally lives on hands, skin, mucous memebranes of the nasopharynx, and large intestines, vagina.
only use vancomycin in C diff if patient is
not responding to flagyl, or allergic to flagyl, or pregnant.
Calciphylaxis
now known as calcific uremic arteriolopathy greatest risk with a serum calcium of greater than 60 mg/dl tx with IV sodium thiosulfate
calciphylaxis
now known as calcific uremic arteriolopathy greatest risk with a serum calcium of greater than 60 mg/dl tx with IV sodium thiosulfate
flagly: given
on an empty stomach, or small amounts of food.
AKI effects on musculoskeletal
osteodystrophy. bone pain, spontaneous fractures.
nonsterile sites signify colonization as in
our skin has natural bacteria on it, like staph and strep.
if patient is on coumadin with a vascular device, always be checking
pT, INR. watch for bleeding
diuretic phase starts and oliguria/anuria end when
patient pees out more then 400mL/day.
neutrophils define if
patient should go into reverse isolation.
macrolides are great for
patient who are allergic to penicillin products, but you will have a horrible stomach ache.
reason TB has become so resistant
patient's compliance. they stop taking because there is 5-7 drugs a day. for months
VRE occurs at higher rates in
patients with MRSA
aminoglycoside shouldn't be mixed with
penicillin. will inactive the ATB.
VRE and MRSA safety
place them always in contact isolation.
AKI effects on urinary
porteinuria, hematuria, fixed specific gravity. nocturia, oliguria, anuria.
carbapenems: SE
possible cross-sensitivity to PCN or cephalosporin; Suprainfection; drug induced seizures, pseudomembranous colitis.
negative cultures are as important as
postive
uremic frost
precipitation of renal urea and nitrogen waste products through sweat onto the skin.
provide skin care for dialysis patients.
prevent pruritus, keep skin clean and well moisturized. trim nails, and avoid scratching.
Catheter-associated urinary tract infection (CAUTI)
prevent. if you dont need a catheter, get it out!
hypokalemia ECG
prolonged PR interval, flattened T wave, and prominent U wave
red port (arterial side)
pull blood out of the body, puts it into the dialyzer.
AKI effects on respiratory
pulmonary edema. pleuritis. kuzzmauls breathing.
main vessels used for AVF
radial artery and cephalic vein
calcium and phosphate in CKD
reducion renal excretion of phosphate and decreased kidney synthesis of the active form of vitamin D. reduced vitamin D and elevated phosphate levels bind free clacium, causing hypocalemia and resulting in hyperparathyroid activity and bone loss.
Beta-Lactam Antibiotics: Penicillins: SE
renal impairment; urticaria, pruritus, angioedema; hyperkalemia (PCN G); superinfection; anemia.
disadvantages of continous renal therapy.
requires vascular access and antigoagulates. slow process. restricts activity level. risk for contaminination.
disadvantages of intermittent hemodialysis
requires vascular access and heparin. restricts activity level.
endogenous toxins that effect the intrarenal
rhabdo and tumor lysis syndrome.
if patient kuzzmals breathing dont
sedate. this is compensation. sedating them would stop them from being able to breath and compensate.
main complication of long term vascular access
sepsis and blockage
most frequent cause of AKI
sepsis and cardiac surgery where there is a decreased purfusion.
stage 4 of CKD
severe reduction of GFR. GFR 15-29.
tetracyclines and children
should be avoid- discoloreration of teeth.
sticks when there is a fistula or graft (AVF/AVG)
should be in different places so as to prevent leaks or weakening of the vessel.
glucose in AKI
should be negative. but will be postive in AKI.
quinolone: children warning
shouldnt be given for 18yrs and under. not for pregnant women.
quinolone: mixes
shouldnt be mixed with amindarone. will prolong the QT.
diuretics given in the initiation phase of AKI is given to
slap the kidneys awake and see if they will make urine the way they are suppose to.
ways to prevent dialysis disequilibrium syndrome
slow the blood flow rate to avoid rapid fluid changes in plasma, and shorter dialysis time at first as the patient becomes more tolerant.
diadvantages of peritoneal dialysis
slower than hemodialysis. abdominal discomfort. decreased mobility. risk for peritonitis.
1.5% dex
small amount of concentration. used when there is very little required to be pulled off in peritoneal .
only trained patient can access vascular device. like a
specialty dialysis nurse
AKI diuretic: potassium sparring
spironolactone (aldactone)
most common pathogen during cannulation in dialysis
staph aureus.
donor transplant of stool
stool from someone who matches is condensed, and then put down a NG tube in order to flow down the GI tract.
prerenal AKI
sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or illness. the arteries supplying the blood is less then what it should be. normally bilateral . decreased perfusion.
postrenal AKI
sudden obstruction of the urine floow due to enlarged prostate, kidney stones, bladder tumor, or injury. easiest to fix. bilateral obstructs the way out
if outflow is brown in peritoneal dialysis
suspect a bowel perforation, and get a abdominal x-ray.
diseases that may have started in the tubules, but now CKF
systemic disease like diabetes, hypertension, autoimmune reactions and transplant rejection. harmful drugs or toxins. infections, mechanical damage. ischemia.
hyperkalemia ECG
tall tented T waves, prolonged PR interval and QRS duration, absent P waves, ST depression.
Quinolones: SE
tendon rupture; tendonitis; increased AST and ALT; photosensitivity.
if you see nafcillin sensitive
that patient goes into contact isolation hands down! staph aurous
the thing that depends on the assessment in peritoneal dialysis.
the % of the dex required.
check the 6-p's below
the fistula in AVF
reasoning that dependent position, gloved hand works in the steal syndrome fixes
the vessels in the hand vasodilate
reason we don't mix aminoglycosides and penicillin
they inactivate each other if given together. if have to, make sure it is an hour apart at least.
restrict K, phos, NA, limit protein, fluids,
things that need restricted in AKI.
feel a
thrill
most common complication of AV access
thrombosis
when culturing something always make sure
to clean the open wound first, and then obtain the culture.
when pateitn has an access the goal is
to protect the access
Mupirocin (Bactroban)
topical antibiotic. only decolonize if massive outbreak in close living arrangements
Cyclic Lipopeptide: treats
tx MRSA, VRE
amount of fluids used in rhabdomyolysis
up to 20L/24hrs.
normal NA diet and fluid intake in CKF based on. and should be
uremia. non-dialysis patient on 1-3 g of NA.
most common infection site for VRE
urinary tract
most common type of VRE
urinary tract infection - especially for women, things are very close in location. spreads.
might given norepi/dopamine in order to
vasodilate the renal arteries in order to allow more blood flow.
Lymphocytes
viral infections
because VRE last longer on inanimate objects. we should
wash hands, environmental cleanning is needed, and dedicated equipment in patients rooms with. and contact isolaion.
we put some patient in isolation because
we are trying to rule out a bug
dry weight
weight that patient is at baseline. this tells the doctors how much to take off during dialysis and tells how much the kidneys have retained.
diuretic phase comes to an end when
when BUN, creatinine, electrolytes, and GFR start to return to normal.
initiation phase ends
when either oliguria/anuria start, or when azotemia occur in the absence of oliguria/anuria stage.
Tamiflu should be given
within 2-3 days.
if daptomycin and statins mix
worry about rhabdo. monitor CPK.
should never use access port unless
you talk to doc, or are special trained. but never for anything else. unless have to.
