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.