RENAL EXAM THEORY V Nursing
aldosterone
"salt-retaining hormone" which promotes the retention of Na+ by the kidneys. na+ retention promotes water retention, which promotes a higher blood volume and pressure
Complications of dialysis
-ASHD -disturbances of lipids worsened by dialysis -anemia and fatigue -gastric ulcers -renal osteodystrophy -sleep problems -hypotension -muscle cramps -dysrhythmias -dialysis equilibrium form cerebral fluid shifts.
Imaging in ESRD
-CT with contrast is ok -MRI with gadolinium is Not
Gerontologic Considerations
-GFR decreases following 40 years with a yearly decline of about 1 mL/min -renal reserve declines -multiple medications can result in toxic metabolites -diminished osmotic stimulation of thirst -incomplete emptying of bladder -urinary incontinence.
indications for Dialysis (AEIOU)
-acidosis -electrolytes -ingestions -overload -uremia
Access
-arteriovenous fistula (AVF) -graft -tunneled catheter
Imaging with CKD
-avoid contrast -if you have to prep (volume expansion: isotonic IVFs (3 cc/kgx1h before & 1cc/kgx 6h after) alkalinization: sodium bicarbonate, acetylcysteine, radiology can give you the protocol)
Creatinine Clearance .
-calculated measure of glomerular filtration rate. Is best indicator of overall kidney function. -Based on 24 hour urine collection -midway will obtain serum creatinine. Serum creatinine levels vary with age, gender and body muscle mass. -calculate: (volume of urine X urine creatinine) divided by serume creatinine.
What would cause increased creatinine levels
-gigantism -acromegaly -renal disease -rhabdomyolysis -congestive heart failure -dehydration -shock -hyperparathyroidism
Arteriovenous Fistula
-highest patency -lowest risk of infection -low risk of thrombus -maturation time 3-4 mo -steal syndrome (poor blood supply to the rest of the limb) -aneurysm formation
Risk factors for renal or urologic disorders
-htn -DM -Immobilization -Parkinson's disease -SLE -Gout -Sickle cell anemia, multiple myeloma -BPH -pregnancy -SCI
renal capsule vs renal cortex
-the kidneys are enclosed in the renal capsule -the renal cortex is the outer layer of the renal capsule, which contains blood-filtering mechanisms (glomeruli).
nephrons
-the nephrons are the functional units of the kideny -located within the parenchyma -composed of glomerulus and tubules -selectively secretes and reabsorbs ions and filtrates, including fluid, wastes, electrolytes, acids, and bases.
serum sodium
135-145 ref range -major cation of extracellular fluid -maintains osmotic pressure & acid base balance -assists in transmission of nerve impulses -absorbed in the small iintestine and excreted in urine
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1. Pouring warm water over the perineum 2. Ensuring the patency of the catheter 3. Removing the catheter within 24 hours 4. Cleaning the catheter insertion site
3. removing the catheter within 24 hours. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it.
creatine kinase
55-170 U/L -monitors muscle damage -can diagnose acute myocardial infarction, ischemia, muscular dystrophy. -creatine kinase enzyme is found inthe heart and skeletal muscle and to a lesser extent the brain. When damage is done to these types of tissue CK is released into the blood. There are three isoenzymes, and depending on which one is elevated this lab value can help determine timing, location, extent of damage. the theee isoenzymes are CK-MB (cardiac), CK-MM (skeletal), CK-BB (Brain)
Blood Urea Nitrogen (BUN)
7-20 indications: liver problems, renal problems, hydration -status, tumor lysis. -evaluate effects on drugs. -monitor effectiveness of hemodialysis -Blood Urea nitrogen measures the amount of urea in the blood. When protein is broken down ammonia is formed. Ammonia is converted to urea in the liver and eventually excreted in the kidneys.
Diagnostic tests used to measure kidney size of a client w/ kidney dysfunction? Select all that apply.a. cystoscopyb. cystographyc. radiographyd. cystourethrographye. computed tomography (CT)
A radiography and a computed tomography (CT) are diagnostic tests used to measure kidney size in clients with kidney dysfunction. A cystoscopy is used to identify abnormalities of the bladder wall in clients with kidney dysfunction. A cystography and a cystourethrography are used to examine the structure of the urethra and to detect backward flow of urine.
Promotes sodium reabsorption of water in the kidney and produces a concentrated urine
ADH
The nurse is educating a couple concerning the process of fertilization. The nurse explains to the couple that which component stimulates the release of estrogen and progesterone after fertilization?
HCG After fertilization, human chorionic gonadotropin (hCG) stimulates the corpus luteum to produce estrogen and progesterone. Inhibin is a hormone produced by the ovarian follicles;
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy?
It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion. -Diffusion [1] [2] moves particles from an area of greater concentration to an area of lesser concentration; osmosis moves fluid from an area of lesser to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen.
which hormone is secondary to angiotensin and aldosterone?
Renin
RAAS
Renin is released by kidneys in response to decreased blood volume; causes angiotensinogen to split & produce angiotensin I; lungs convert angiotensin I to angiotensin II; angiotensin II stimulates adrenal gland to release aldosterone & causes an increase in peripheral vasoconstriction
Chronic kidney disease and GFR
Stage 1 - GFR 90-130 Stage 2 - GFR 60-90 Stage 3 - GFR 30-60 Stage 4 - GFR 15-30 Stage 5 ESRD - GFR <15
A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?
Take vital signs and notify the primary healthcare provider
Dialysis Rx
Time: 2-5 hours -bath -blood flow rate: 400-450 cc/min -dialysate flow rate: 500-800 cc/min -anticoagulant -additives (anemia (EPO, blood) (bone metabolism- vit D, calcitriol, etc) (meds- abx)
renin
a hormone released in response to decreased renal perfusion. this hormone is responsible for regulating blood pressure.
A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. What should be the nurse's initial intervention? -strain all urine output -increase oral fluids -obtain urine specimen for culture -administer the prescribed analgesic
administer the prescribed analgesic. -Pain of renal colic may be excruciating; unless relief is obtained, the client will be unable to cooperate with other therapy.
Promotes sodium reabsorption and potassium secretion in distal collecting tubules
aldosterone
uremia
urine in the blood
renal medulla
-inner region, which contains the renal pyramids and renal tubules. -together, the renal cortex, pyramids, and medulla constitute the parenchyma.
Prostate gland
-the prostate gland surrounds the male urethra -the prostate gland contains a duct that opens into the prostatic portion of the urethra and secretes the alkaline portion of seminal fluid, which protects sperm.
which hormone is crucial in maintaining the implanted egg
progesterone
Renal function tests
urine osmolality creatinine serum creatinine urea nitrogen
Common Admissions
-complications of missed HD *SOB from fluid overload *HTN crisis *hyperkalemia -Line infections -access issues
determination of serum creatinine levels
-creatinine levels reflects the glomerular filtration rate -kidney disease is the only pathological condition that increases the serum creatinine level -serum creatinine level increases only when at least 50% of renal function is lost
Tunneled Catheter
-immediate use -bridge to AVF/AVG -Poor flow (decreased HD efficiency) -high infection risk -venous stenosis -thrombosis
renin
hormone secreted by the kidney; it raises blood pressure by influencing vasoconstriction (narrowing of blood vessels)
Adrenal Glands
one adrenal gland is on top of each kidney the adrenal glands influence BP and sodium and water retention
The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney?
papilla Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid
creatinine clearance
tests clearance of creatinine in one min. Relects GFR
Which hormone is released in response to low serum levels of calcium?
Parathyroid hormone -If serum calcium levels decline, the parathyroid gland releases parathyroid hormone to maintain calcium homeostasis
Angiotensin II
increases blood pressure by stimulating kidneys to reabsorb more water and by releasing aldosterone
Serum creatinine
measures effectiveness of renal function. 0.6 to 1.2 mg/dL
cause tubular secretion of sodium. release from cardiac atria and brain
natriuretic hormones
Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? Calcium of 9.5 mg/dL (2.375 mmol/L) Potassium of 7.02 mEq/L (7.02 mmol/L) Bicarbonate of 22.8 mEq/L (22.8 mmol/L) Phosphorus of 4.1 mg/dL (1.3243 mmol/L)
potassium of 7.02 mEq/L (7.02 mmol/L) -The normal level of serum potassium is between 3.5-5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum phosphorus are between 2.4-4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum calcium are usually between 8.6-10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum bicarbonate is between 22 and 26 mEq/L or mmol/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. Which urinary finding should the nurse conclude needs to be reported to the primary healthcare provider?
presence of large proteins -The glomeruli are not permeable to large proteins such as albumin or red blood cells (RBCs), and it is abnormal if albumin or RBCs are identified in the urine;
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI?
prevent the development of clots in the bladder.
Dialysate concentrations
sodium 135-155 potassium 0 -4 calcium 1.25 to 1.75 (2.5 to 3.5 meq/L) magnesium 0-0.75 (0-1.5 meq/L) chloride 87 to 120 bicarbonate 25-40 glucose 0 to 0.20
A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should:
swab the drainage directly from the urethra to obtain a specimen
Arteriovenous Graft
type of surgically created vascular access for dialysis by which a piece of biologic, semibiologic, or synthetic graft material connects the patient's artery to a vein -easier to create -Maturation time 3-6 weeks -Poor patency (often requires thrombectomy or angioplasty) -infection -aneurysms -steal syndrome
erythropoietin
released by the kidneys in response to poor blood flow to the kidneys; it stimulates the production of red blood cells.
A nurse is caring for a client after surgical creation of a conduit diversion (ileal conduit). Which information will the nurse consider when planning care for this client?
urine continuously drains from it
determination of Blood Urea Nitrogen
-Bun levels indicate the extent of renal clearance of urea nitrogenous waste products -an elevation does not always mean that renal disease is present -Some factors that can elevate the BUN level include dehydration poor renal perfusion, intake of a high-protein diet, infection, stress, corticosteroid use, gastrointestinal GI bleeding, and factors that cause muscle breakdown
The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client's condition? -Potassium 8 mEq/L -Hemoglobin 10 g/dL -Phosphorous 7 mg/dL -Bicarbonate 1 mEq/L
-bicarbonate 15 mEq/L an increased rate and depth of breathing is called kussmaul respiration and occurs due to metabolic acidosis in clients with kidney disease. The serum bicarbonate level decreases in metabolic acidosis. normal range of serum bicarbonate is 20-30.
Homeostasis of potassium
-increase in the serum potassium level stimulate the secretion of aldosterone -Aldosterone stimulates the distal convoluted tubules to secrete potassium; this action returns the serum potassium concentration to normal.
Functions of kidneys
-maintain acid-base balance -excrete end products of body metabolism -control fluid and electrolyte balance -excrete bacterial toxins, water-soluble medications, and medication metabolites -Secrete renin to regulate the blood pressure and erythropoietin to stimulate the bone marrow to produce red blood cells -Synthesize vitamin D for calcium absorption and regulation of the parathyroid hormones
what would cause increased levels of creatine kinase?
-muscle damage -rhabdomyolysis -muscular dystrophy -heart attack -exercise -kennedy's disease -stroke
kidney anatomy
-one kidney is attached to the left abdominal wall at the level of the last thoracic and first 3 lumbar vertebrae, the other is on the right -the kidneys are enclosed in the renal capsule
Peritoneal Dialysis
-peritoneal membrane = partially permeable membrane -dextrose dialysate -diffusion and osmosis until equilibrium -3-10 dwells per night with 2-2.5 L per dwell.
functions of the Kidney
-regulation of water excretion -regulation of electrolyte function -regulation of acid-base balance-retain HCO3-and excrete acid in Urine -regulation of blood pressure--RAAS -Regulation of RBC's -vitamin D synthesis -secretion of prostaglandin E and prostacyclin which cause vasodilation, important in maintain renal blood flow -Excretion of waste products-body's main excretory organ. urea, creatinine, phosphatase, uric acid and sulfates. Durg metabolites
what would cause decreased levels of creatinine clearance
-renal disease -congestive heart failure -obstruction within kidney -dehydration
what causes increased BUN levels
-renal failure -congestive heart fialure -myocardial infarction -kidney disease -shock -dehydration -excessive protein intake -diabetes mellitus (DM) -GI bleed -urinary tract obstruction
hormones that influence renal function
-renin- raises BP -Bradykinins- increase blood flow and vascular permeability -erythropoietin -ADH -Aldosterone-promotes sodium reabsorption and potassium excretion -natriuretic hormones- released from the cardiac atria and brain.
Complications of peritoneal dialysis
-respiratory difficulties -hypotension -infection: peritonitis; see cloud or opaque dialysate outflow (effluent). fever, abdominal tenderness, pain malaise, N&V. -hypo-albuminemia -bowel perforation -bladder perforation -catheter may get clogged.
A client is diagnosed as having invasive cancer of the bladder, and brachytherapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of this therapy? -decrease in urine output -increase in pulse strength -shrinkage of the tumor on scanning -increase in the quantity of WBC
-shrinkage of the tumor on scanning Brachytherapy, in which isotope seeds are implanted in the tumor, interferes with cell multiplication, which should control the growth and metastasis of cancerous tumors.
Bladder
-the bladder detrusor muscle, composed of smooth muscle, distends during bladder filing and contracts during bladder emptying -the ureterovesical sphincter prevents reflux of urine from the bladder to the ureter -the total bladder capacity is 1:; normal adult urine output is 1500 mL/day.
kidney Tubules
-the tubules include the PCT, the loop of henle, and the distal convoluted tubule (DCT) -The PCT receives filtrate form the glomerular capsule and reabsorbs water and electrolytes through active and passive transport. -The descending loop of henle passively reabsorbs water from the filtrate -the ascending loop of henle passively rabsorbs sodium and chloride from the filtrate and helps to maintain osmolality -The DCT actively and passively removes sodium and water -the filtered fluid is converted to urine in the tubules, and then the urine moves to the pelvis of the kidney -the urine flows form the pelvis of the kidneys through the ureters and empties into the bladder.
Bowman's capsule
-thin double-walled capsule that surrounds the glomerulus -fluid and particles from the blood such as electrolytes, glucose, amino acids, and metabolic waste (glomerular filtrate) are filtered through the glomerular membrane into a fluid-filled space in Bowman's capsule (bowman's space) and then enter the proximal convoluted tubule (PCT)
GFR
-volume of fluid filtered from renal glomerular capillaries into Bowman's capsule per unit of time. -Generally expressed in ml/minute -Normal GFR generally is 125mL/minute
A nurse is caring for a client who is scheduled for cystoscopy. What should the nurse include in the client's postcystoscopy teaching plan? 1.Remain flat in bed for the first 24 hours 2.Increase fluid intake for three to four days postoperatively 3.Notify the nurse if there is any drainage on the dressing 4.Bear down when attempting to void during the first six hours
increase fluid intake for 3 to 4 days postoperatively -flushes the bladder internally and helps decrease the risk of infection and reduce the burning sensation upon urination. Remaining flat in bed for the first 24 hours is unnecessary after a cystoscopy. A cystoscopy is performed through the urethra; a dressing is not necessary. Bearing down increases pressure in the pelvic and perineal area and should be avoided.
What are the functions of antidiuretic hormone (ADH)? Select all that apply. 1. Controlling calcium balance 2. Increasing arteriole constriction 3. Increasing tubular permeability to water 4. Stimulating the bone marrow to make red blood cells 5. Promoting the reabsorption of sodium in the distal convoluted tubule (DCT)
increasing arteriole constriction, and increasing tubular permeability to water. -Antidiuretic hormone (ADH), also known as vasopressin, is a hormone released from the posterior pituitary gland. ADH increases arteriole constriction and tubular permeability to water. Calcium balance is controlled by blood levels of calcitonin and the parathyroid hormone (PTH). Erythropoietin stimulates the bone marrow to make red blood cells. Aldosterone promotes the reabsorption of sodium in the distal convoluted tubule (DCT).
BUN extra info
liver must function properly to produce urea nitrogen. BUN levels indicate the extent of renal clearance of this nitrogenous waste product. -may see elevation of BUN with bleeding into tissues or from rapid cell destruction from infection/steroids.
A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client's ability to deep breathe and cough postoperatively?
location of surgical incision
What would cause decreased creatinine levels
loss of muscle mass muscular dystrophy inadequate protein intake pregnancy liver disease
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1 Low purine 2 Low calcium 3 High phosphorus 4 High alkaline ash
low calcium Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout. Foods high in phosphorus must be avoided.
Treatment of calciphylaxis
low phosphorous diet, normalizing calcium and phosphate with non-calcium based phosphate binders and low-calcium dialysate. Sodium thiosulphate 25g VI over 30 minutes three treatments per weeks has been shown to improve lesions and should be continued for 2 months beyond the resolution of lesions.
Which hormone elevations indicate Turner syndrome? Select all that apply.
lutropin, follitropin -Elevation of lutropin and follitropin indicates Turner syndrome. Elevation of prolactin indicates possible galactorrhea, pituitary tumor, disease of hypothalamus or pituitary gland,
A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure?
macula densa- the macula densa is a part of the distal convoluted tubule and consists of cells that sense changes in the volume and pressure of blood calices are cup-like structures, present at the end of each papilla that collect urine.
what is the action of vasopressin?
reabsorbs water into the capillaries. -Vasopressin is also known as an antidiuretic hormone (ADH). It helps in the reabsorption of water into the capillaries. Aldosterone promotes sodium reabsorption. Natriuretic hormones promote tubular secretion of sodium. Erythropoietin stimulates bone marrow to make red blood cells (RBCs).
To prepare for hemodialysis, a client with end-stage kidney disease is scheduled for surgery, specifically for the creation of an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm. When considering care for these sites, which difference will the nurse consider?
the graft is more subject to hemorrhage, clotting, and infection that the fistula is -The external shunt may come apart with possible hemorrhage; clotting is a potential hazard. Frequent handling increases risk of infection. Blood pressure readings should not be obtained in the extremity that has a shunt or fistula because of the pressure exerted on the circulatory system during the procedure. IVs should not be infused in the extremity with the shunt or the fistula to avoid pressure from the tourniquet and to lessen the chance of phlebitis. The ends of the shunt cannula should be left exposed for rapid reconnection in the event of disruption.
Types of Dialysis
hemodialysis (HD) Continuous Veno-venous hemofiltration (CVVH) Peritoneal dialysis
The client diagnosed with a fistula between the bowel and urinary bladder reports passing air and bubbles during urination. What does the nurse anticipate the client's condition to be?
pneumaturia -The occurrence of gas along with urination is called pneumaturia and could result from the formation of a fistula between the bowel and urinary bladder.
describe juxtaglomerular cells
secret renin, renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure
renal disease is the only common pathological condition that increases what serum level
serum creatinine. does not increase until at least 50% of renal function is lost
Dialysate Bath
solution that contains water and electrolytes that passes through the artificial kidney to remove excess fluids and wastes from the blood. concentrations of dialysate components used in hemodialysis
BUN/creatinine ratio
The BUN level is divided y the creatinine level to obtain the ratio. -when the BUN and serum creatinine levels increase at the same rate, the ratio of BUN to creatinine remains constant. -elevated serum creatinine and BUN levels suggest renal dysfunction -a decreased BUN/Creatinine ratio occurs with fluid volume deficit, obstructive uropathy, catabolic state, and high-protein diet -an increased ratio occurs with fluid volume excess.
Which statement is true regarding the functions of kidney hormones?
renin raises blood pressure because of angiotensin and aldosterone secretion
kidney hormones
renin, bradykinin, and erythropoietin
albumin levels in urine
men 2-20 women 2.8-28. higher levels indicate microalbuminuria. can also be determined by a 24 h specimen
which hormone influences kidney function?
aldosterone -Released from the adrenal cortex, aldosterone influences kidney function.
which hormone increases blood flow and vascular permeability
Bradykinnins
ASHD
arteriosclerotic heart disease
epo
erythropoietin; promotes growth of red blood cells
homeostasis of water through the kidneys
-ADH is primarily responsible for the reabsorption of water by the kidneys -ADH is produced by the hypothalamus and secreted from the posterior lobe of the pituitary gland -secretion of ADH is stimulated by dehydration or high sodium intake and by a decrease in blood volume. -ADH makes the distal convoluted tubules and collecting duct permeable to water -water is drawn out of the tubules by osmosis and returns to the blood; concentrated urine remains in the tubule to be excreted -when ADH is lacking, the client develops diabetes insipidus
Homeostasis of acidity (pH)
-Blood pH is controlled by maintaining the concentration of buffer systems -carbonic acid and sodium bicarbonate form the most important buffers for neutralizing acids in the plasma. -the concentration of carbonic acid is controlled by thee respiratory system -the concentration of sodium bicarbonate is controlled by the kidneys. -normal arterial pH is 7.35-7.45, maintained by keeping the ratio of concentrations of sodium bicarbonate to carbon dioxide constant at 20:1 -strong acids are neutralized by sodium bicarbonate to produce carbonic acid and the sodium salts of the strong acid; this process quickly restores the ratio adn thus blood pH. -the carbonic acid dissociates into carbon dioxide and water; because the concentration of carbon dioxide is maintained at a constant level by the respiratory system, the excess carbonic acid is rapidly excreted. -Sodium combined with the strong acid is actively reabsorbed in the distal convoluted tubules in exchange for hydrogen or potassium ions. the strong acid is neutralized by ammonia and is excreted as ammonia or potassium salts.
Homeostasis of sodium
-When sodium increases, extra water is retained to preserve osmotic pressure -increase in sodium and water produces an increase in blood volume and BP -when BP increases, glomerular filtration increases, and extra water and sodium are lost; blood volume is reduced, returning the BP to normal. -reabsorption of sodium in the distal convoluted tubules is controlled by the renin-angiotensin system -Renin, an enzyme is released from the nephron when the BP or fluid concentration in the distal convoluted tubule is low -renin catalyzes the splitting of angiotensin I from angiotensinogen; angiotensin I converts to angiotensin II as blood flows through the lung. Angiotensin II, a potent Vocontrictor, stimulates the secretion of aldosterone. Aldosterone, stimulates the distal convoluted tubules to reabsorb sodium and secrete potassium -the additional sodium increases water reabsorption and increases blood volume and BP, returning the BP to normal; the stimulus for the secretion of renin then is removed.
Access with CKD
-avoid PICC/midlines in CKD stage 4-5 -try to preserve access -try for feet or EJ -but if needed order a midline.
CVVH
Continuous venovenous hemofiltration -highly permeable membrane -fluid and solute removal via ultrafiltration -filtrate is dicarded -replacement fluid is infused similar to plasma (but no K, urea, Cr, PO4) -used in ICU, runs 12-24h, through double lumen catheter -less drastic fluids shifts.
Medications in ESRD
ABX- renally dose, loading dose, then maintenance No lovenox dvt PPX, use heparin no morphine - hepatic metabolism but active metabolites. limit other opioids (dilaudid: hepatic metabolism but metabolites cause neuroexcitiation) constipation/GERD: avoid magnesium/phosphate containing agents
On assessment, the nurse notes that a client with acute kidney injury (AKI) has developed fine crackles in the lung bases bilaterally. what should the nurse do?
AKI is the sudden loss of kidney function caused by renal cell damage form ischemia or toxic substances. It occurs abruptly and can be reversible. AKI leads to hypoperfusion, cell death, and decompensation in renal function. With this disorder, the nurse should monitor for complications such as fluid overload, ascites, pulmonary edema and heart failure. If fine crackles in the lung bases develop bilaterally, the nurse should notify the health care provider because this could be a sign of one of these complications.
steal syndrome
blood entering the limb is drawn into the fistula and returned to the general circulation without entering the limb's capillaries. this results in cold extremities of that limb, cramping pains, and if severe, tissue damage; vasculature that supplies the rest of the limb is poor.
24 hour urine collection
check with lab about specific instruction -instruct the client about the urine collection -at the start time, instruct the client to void and discard that sample. -collect ll urine for the prescribed time (24 hours) -keep the urine specimen on ice or refrigerated and check with the laboratory regarding adding a preservative to the specimen during collection. -at the end of the prescribed time, instruct the client to empty the bladder and add that urine to the collection container.
Which component of the client's nephron acts as a receptor site for the antidiuretic hormone and regulates water balance?
collecting ducts -The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone. The Bowman's capsule collects glomerular filtrate and funnels it into the tubule. The distal convoluted tubule acts as a site for additional water and electrolyte reabsorption
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. Which diagnosis will the nurse most likely observe written in the client's medical record?
cystitisCystitis is an inflammation of the bladder that causes frequency and urgency of urination, pain on micturition, and hematuria. Chronic glomerulonephritis is a disease of the kidney that is associated with manifestations of systemic circulatory overload. Nephrotic syndrome is a condition of increased glomerular permeability characterized by severe proteinuria. Pyelonephritis is a diffuse, pyogenic infection of the pelvis and parenchyma of the kidney that causes flank pain, chills, fever, and weakness.
Which urodynamic study provides information on bladder capacity, bladder pressure, and voiding reflexes? 1-Radiography 2-Renal arteriography 3-Electromyography (EMG) 4-Cystometrography (CMG)
cystometrography -Cystometrography (CMG) is an urodynamic study that provides information on bladder capacity, bladder pressure, and voiding reflexes.
what would cause increased levels of creatinine clearance
diabetes mellitus exercise pregnancy high protein diets
what would cause decreased levels of creatine kinase?
early pregnancy and small stature
A client has been diagnosed with anemia. Which decreased hormone level may be the cause?
erythropoietin -Erythropoietin stimulates the production of red blood cells (RBCs) in the bone marrow. Deficiency of erythropoietin causes a decrease in RBCs, thereby resulting in anemia. Bradykinin increases blood flow and vascular permeability. Prostaglandins regulate kidney perfusion. Activated vitamin D promotes the absorption of calcium in the gastrointestinal (GI) tract.
A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply. -fever -oliguria -jaundice -polydipsia -weight gain
fever, oliguria, and weight gain. -Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria or anuria occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy; this response must be assessed further.
what would cause decreased bun levels
-liver failure -overhydration -inadequate protein intake -pregnancy
What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen?
urinate small amount, stop flow, fill half of cup.
Calciphylaxis
-calcifation of the small vessels of the dermis and subcutaneous tissues occurs. This leads to vessel thrombosis, tissue infarction and skin necrosis -1-4% of dialysis patients -risk factors include hyperparathyroidism, and elevated calcium-phosphate product (>70 mg/dl), DM, female sex, obesity, warfarin use, and protein C or S deficiency. -1 year survival after dx of caliphylaxis is about 50%. -very painfulviolaceous reticulated plaques that are well defined and deep. develop into deep non-healing ulcers that can become gangrenous. Sepsis is the most common cause of mortality.
Dialysis Disequilibrium Syndrome
-caused by rapid decrease in fluid volume and blood urea nitrogen levels during HD -Change in urea levels can cause cerebral edema and increased ICP -Neurologic complications include: HA, vomiting, restlessness, decreased LOC, Seizures, coma or death -can be prevented by starting HD for short periods and low blood flows.
Glomerulus
-each nephron contains tufts of capillaries which filter large plasma proteins and blood cells -Blood flows into the glomerular capillaries from the afferent arteriole and flows out of the glomerular capillaries into the efferent arteriole.
Labs in ESRD
-get labs before or 4 hours after hemodialysis -only the h/h is accurate -floor RNs can't use HD lines -can ask to have cultures drawn at HD from the line.
Serum Creatinine
0.6-1.3 mg/dL ref range -creatinine is a specific indicator of renal function -increased levels of creatinine indicate a slowing of the glomerular filtration rate. -prior to draw, have Pt avoid excessive exercise for 8 hours and excessive red meat for 24 hours
Creatinine (CR)
0.7-1.4 mg/dL indications- identify muscular disorders and renal disease -creatinine is a byproduct of creatine metabolism and it is excreted by the kidneys. Creatinine is created in proportion to muscle mass and usually stays stable.
serum potassium
3.5-5.0 mEq/L ref range -major intracellular cation -regulates water balance, electrical conduction in muscle cells, and acid base balance -the body obtains potassium through diet -the kidneys preserve or excrete K. depending on cellular need -K levels are used to evaluate cardiac function, renal function, GI function, & need for IV therapy (clients with elevated WBC & PLT count may have false + K levels.
BUN
7-20 range -urea nitrogen is the nitrogen portion of urea, a substance formed in the liver through an enzymatic protein breakdown process -urea is normally freely filtered through the renal glomeruli, with a small amount reabsorbed in the tubules and the remainder excreted in teh urine -elevated levels indicate a slowing of glomeruli filtration rate
Creatinine Clearance
85 to 125 mL/min used to determine: kidney damage in renal disease, glomerular function, effectiveness of treatment -Creatinine is a byproduct of creatine metabolism and is excreted in the kineys. Creatinine is created in proportion to muscle mass and usually stays stable. urine and blood levels are compared to determine creatinine clearance from the blood. any disease that affects the kidneys ability to clear waste products will increase blood creatinine levels and decrease creatinine clearance levels.
Angiotensin
A normal blood protein produced by the liver, angiotensin is converted to angiotensim I by renin (secreted by kidney when blood pressur falls). Angiotensin I si further onverted to angiotensim II by ACE (angiotensin converting enzyme). Angiotensin II is a powerful systemic vasocontrictor ans stimulator of aldosterone relase, both of which result in an increase in blood pressure.
A healthcare provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan?1 Maintaining a supine position during the procedure2 Consuming a diet low in fat for three days before the procedure3 Emptying the bladder immediately before the procedure4 Staying on a liquid diet for 24 hours after the procedure
Ans: 3The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.
A nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation?
Prolactin
Calcinosis cutis
refers to calcium deposition in the skin and is a subtype of calcinosis, a condition describing calcification in vessels and organs -painless flexural infiltrating plaques at periarticular sites. -size and number of plaques correlate with degree of hyperphosphatemia does not cause skin necrosis
Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item?
apples- low in phosphate, fresh fruit is low in phosphorus. Chocolate contains more phosphate than apples. Rye bread contains more phosphate than apples. Cheese is made with milk, which contains phosphate and should be avoided.
The blood urea nitrogen (BUN)/creatinine ratio of a client is 3. Which condition does the nurse suspect in the client?
fluid volume excess -The normal range of the blood urea nitrogen (BUN)/creatinine ratio is from 6 to 25. A decrease in the BUN/creatinine ratio indicates fluid volume excess. An increase in the BUN/creatinine ratio indicates obstructive uropathy. A decrease in the levels of blood urea nitrogen (BUN) indicates severe hepatic damage. An increase in the levels of blood urea nitrogen (BUN) indicates gastrointestinal (GI) bleeding.
A client is diagnosed with condyloma acuminatum. Which finding in the client supports the diagnosis?
genital warts. -moist, fleshy projectionson the penis
24 hour collection
have patient void first and do not add to collection device. -then start time -follow agencies policy on cooling of urine -Post signs to ensure all urine is collected.
BUN/Creatinine Ratios
high ratios 20:1 typically indicate low flow to kidneys, i.e. dehydration or CHF. -Low ratios 10:1 can be seen with liver failure patients.
A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the primary healthcare provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis?
hyperkalemia -Protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause a cardiac dysrhythmia and standstill. The failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis.
Which test helps to identify fibroids, tumors, and fistulas while performing a reproductive tract examination?
hysterosalpingography -A hysterosalpingogram is an X-ray used to evaluate tubal anatomy and patency and used to identify uterine problems such as fibroids, tumors, and fistulas.
urine osmolality
indication of concentrating ability, changes seen early in disease processes
Urea nitrogen
indicator of renal function. 7-18 mg/dL. measures renal excretion of urea nitrogen, a byproduct of protein metabolism. Is not always elevated with kidney disease. Not best indicator of renal function.
describe the glomerulus
is the initial part of the nephron, which filters blood to make urine
Hemodialysis
the process by which waste products are filtered directly from the patient's blood
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do? -Drink a glass of water -Turn from side to side -Deep breathe and cough -Rotate the catheter periodically
turn from side to side -Turning from side to side will change the position of the catheter, thereby freeing the drainage holes of the tubing, which may be obstructed.
