Renal Replacement Therapy

Acute Transplant Complications: Occurs ___ week to ___ years after transplant Presents with ________ or ________, ________, fluid volume ________, and ________ at transplant site.

1, 2 oliguria, anuria, hypertension, excess, pain

CRRT is performed continuously and slowly for ___ hours or more, avoiding complications associated with rapid changes in composition of the ECF.

12

The AV graft heals in ___ - ___ weeks.

2, 4

Number the steps of CAPD: - The PD catheter in the abdomen is connected to a plastic bag of new dialysate. - When empty, the plastic bag is removed and thrown away. - Current dialysate is drained from the abdomen through the PD catheter into another plastic bag. - The plastic bag is raised to shoulder level allowing gravity to pull the dialysate into the abdomen. - The dialysate stays in the abdomen for several hours for the "exchange" process to occur.

2, 4, 1, 3, 5

HD sessions are usually ___ times a week for ___ - ___ hours

3 3, 4

How many times per day should CAPD be done? What setting should PD be done in?

3-5 any clean environment (home, work, traveling, etc.)

The AV fistula heals (matures) in ___ - ___ weeks. It is typically not used until ___ months following placement.

4, 6 3

Hyperacute Transplant Complications: Occurs within ___ hours of transplant. Presents with ________, ________ at transplant site, and ________.

48 fever, pain, hypertension

How many steps are there in CAPD?

5

What is an automated process that uses a machine called a "cycler" to perform your exchanges?

Automated Peritoneal Dialysis (APD)

Which RRT is preferred for hemodynamic instability?

CRRT

What type of dialysis is performed continuously, without a machine, each day?

Continuous Ambulatory PD (CAPD)

What RRT is performed when clients are unable to tolerate HD or rapid fluid removal d/t hemodynamic instability?

Continuous Renal Replacement Therapy (CRRT)

List the common symptoms of DDS (10) Memory Trick: Think of a kidney vending machine - you're doing Dialysis while you VEND for a MATCH D VEND MATCH

Disorientation Visual disturbances Emesis Nausea Dizziness Muscle cramps Agitation Tremors Confusion Headache

Which RRT's primary side effect is hypotension?

HD

Which RRTs require vascular access?

HD, CRRT

What RRTs can be performed at home?

HD, PD

Which RRTs require special training (nurse or client) to be performed?

HD, PD, CRRT

What are 4 primary options that are considered RRT?

Hemodialysis (HD) Peritoneal Dialysis (PD) Continuous Renal Replacement Therapy (CRRT) Kidney Transplant

Which RRT yields the greatest flexibility for travel?

PD

List the common signs of DDS (5) Memory Trick: Think of the signs as a sad drop, or SAD CC

Seizures Asterixis (flappy hand tremor) Death Coma Changed mental status

Pre-transplant nursing care: Administer prophylactic ________ and ________ medications

antibiotics, immunosuppressive

What are 2 common anti-rejection immunosuppressants used in conjunction with corticosteroids following a kidney transplant?

azathioprine mycophenolate

Nurses should avoid ________ ________ and ________ ________ on the arm with AV fistulas or grafts. We should educate clients not to do what 2 things?

blood pressure, needle sticks lift heavy objects, sleep on the side (that has the fistula / graft)

Can APD be done as a long single session while you sleep, or as multiple shorter sessions during the day or night, or both? Can the client choose when / where the dialysis will be done?

both yes

What 4 aspects of the dialysate should be documented in the EMR? Document these for ________ exchange.

color clarity amount drained amount filled every

Name the primary, potent immunosuppressive drug administered after a kidney transplant? What does it prevent? How long does the client take this medication?

cyclosporine rejection for life

What 4 assessments should be made before initiating PD?

daily weight intake & output vital signs catheter site

Name the phase of PD: The saturated solution inside the abdomen, containing waste and excess fluid, is drained.

drain

List the 3 phases of PD

drain, fill, dwell (then repeat)

Name the phase of PD: The dialysis solution stays in the peritoneal cavity where the process of dialysis occurs.

dwell

In HD, the dialyzer is like an "external kidney" that follows the process of diffusion to remove ________, and ________ ________. It uses ultrafiltration to remove ________ ________ from the body.

electrolytes, waste products excess water

Although dialysis compensates for lost renal elimination functions, it does not replace lost ________ production. Therefore ________ is a continuing problem for the patient receiving dialysis.

erythropoietin, anemia

For PD, you should adhere to the ________ ________ ordered by the provider.

exchange schedule

Which short-term vascular access site carries the greatest risk for infection? What other risk is posed with this site if the client ambulates and aggravates the site?

femoral bleeding

Does an AV fistula pose a risk for fewer, or greater complications than an AV graft?

fewer

Name the phase of PD: After the abdomen is drained of the old solution, new dialysis solution is put in through the catheter to fill up the peritoneal cavity.

fill

What AV access is formed through a surgical anastomosis of an artery and vein (usually the radial artery and cephalic vein)?

fistula

When establishing long-term access for HD, what are the two forms of atherovenus (AV) access?

fistula, graft

Post-transplant nursing care: •Monitor ________ status •Monitor for early signs of transplant ________ including ________, ________, ________ especially within the first ___ hours. •Monitor for s/s of ________ •Assess surgical dressing for ________ drainage •Educate client and family on ______-______ care

fluid rejection, hypertension, fever, pain, 24 infection bloody post-transplant

Dialysis Disequilibrium Syndrome (DDS) results from too rapid a decrease of BUN and circulating _________ volume. It can result in ________ edema and increased ________ pressure.

fluid, cerebral, intracranial

What class of drug is administered for long-term immunosuppression and treatment of acute rejection? What is a common drug in this class?

glucocorticoids prednisone

What AV access is formed by a tubular bridge (made of Gore-Tex) being surgically implanted to connect the artery and the vein?

graft

Does catheter access pose a risk for fewer, or greater complications than AV access?

greater

What is a contraindication to receiving hemodialysis? Which RRT would be done instead?

hemodynamic instability (such as hypotension, low CO) CRRT

What medication is administered during HD? What risk is associated with the medication? What should be avoided for 4-6 hours following HD due to this risk? What should be accessible to reverse this medication in an emergency?

heparin bleeding surgeries (invasive procedures) protamine sulfate

Before HD: If available, follow facility policy on what medications to _________ and what medications to ___________ pre-HD. If no policy for medications before HD, contact ______________ for orders.

hold, give provider

Name the 3 categories of transplant complications?

hyperacute acute chronic

What is the most common complication during and/or after hemodialysis? What are other common complications?

hypotension bleeding at access site clotting of access site headaches, muscle cramps, fatigue (after HD) Dialysis Disequilibrium Syndrome (DDS)

List some conditions that contribute to hemodynamic instability, making CRRT the appropriate RRT?

hypovolemic shock septic shock cardiogenic shock major trauma or burn severe heart failure

What is the treatment for hyperacute transplant complications?

immediate removal of the kidney

What is the treatment for acute transplant complications?

increase doses of immunosuppressive therapy

What is the primary concern for patients taking immunosuppressants?

infection

Other than peritonitis, what 3 complications are common with PD?

infection at catheter site protein loss poor dialysate inflow or outflow

What are the 2 greatest risks posed by AV fistulas / grafts?

infection, clotting

Before HD: Verify an ____________ ____________ is on the chart. Assess patency of vascular access by palpating the site for a ________ and auscultating the site for a ________. Avoid _________, _________, and _________ on arm with access site.

informed consent thrill, bruit BP, IV, venipunctures

What is the best option for a client with ESRD?

kidney transplant (live is better)

What causes infection of the PD catheter site? What can this lead to?

leakage of dialysate peritonitis

What is the treatment for chronic transplant complications?

monitor until need for dialysis

Chronic Transplant Complications Occurs gradually over ________ to ________ Slow return of ________, fluid volume ________, and ________ imbalance.

months, years azotemia, excess, electrolyte

What are 5 causes for poor inflow or outflow of dialysate?

obstruction or twisted tubing constipation positioning fibrin clot catheter displacement

Symptoms of peritonitis include abdominal ________, ________, or ________. Drainage of fluid will appear _______. What vital sign is commonly abnormal?

pain, tenderness, distention cloudy temperature (fever)

In Peritoneal Dialysis (PD), dialysis is performed in the ________ cavity.

peritoneal (or abdominal)

What is the most common complication associated with PD? What is this usually due to?

peritonitis bacterial or fungal infection

What macronutrient should be increased in the diet of the patient undergoing PD? What blood test should be monitored?

protein (serum) albumin

What is a contraindication to initiating PD?

recent abdominal surgery

When uremia is no longer manageable and organ dysfunction occurs because of the accumulated metabolic wastes, what is the only option to sustain life?

renal replacement therapy (RRT)

What is a serious, life-threatening complication that can result from peritonitis?

sepsis

What should be complications should we watch for during PD? If pulmonary complications are observed, what should you do?

shortness of breath (pulmonary complications) nausea, vomiting, abdominal pain (GI complications) STOP

To treat DDS: ________ the dialysate rate. Administer an osmotic agent such as ________ or a ________ saline. This will pull fluid out of cells through the process of ________, thus reducing ________ ________.

slow mannitol hypertonic osmosis cerebral edema

Acute or short-tem vascular access for HD or CRRT usually is gained by inserting a double-lumen catheter into the ________, ________, or ________ vein. This site is used if emergency access is needed, or while the long-term access site heals.

subclavian, jugular, femoral

Hemodialysis (HD) uses a ________ access device. Blood is shunted from the body through a ________, then returned to circulation.

vascular, dialyzer

After HD: Monitor ________ ________ and ________ ________

vital signs, access site

During the dwell phase, the solution is collecting the ________ and excess ________ from your body.

waste, fluid

Before HD: Make sure pre-HD ____________ and ________ ________ have been performed and recorded.

weight, vital signs

Is home HD an option?

yes