Week 2 - Management of Patients with Kidney Disorders
Examples of antihypertensive medications given for chronic kidney disease
- digoxin - dobutamine (Dobutrex) *also treated with fluid restrictions, low-sodium diets, diuretics and dialysis
Vascular access devices with hemodialysis
- double-lumen non-cuffed catheter into the subclavian, internal jugular or femoral vein (least common) - double-lumen, cuffed catheter into internal jugular vein (less risk for infection)
Signs & symptoms of fluid volume excess
- edema - crackles - SOB - decreased BUN - decreased hematocrit - distended neck veins
Risks with sodium/water retention in patients with chronic kidney disease
- edema - heart failure - hypertension - hypotension & hypovolemia - vomiting & diarrhea
Clinical manifestations of chronic kidney disease
- elevated creatinine levels - anemia - metabolic acidosis - fluid retention (edema & CHF) - hypertension - pain and discomfort - restless legs/burning feet
Healthy kidney functions
- filter the blood - acid-base balance - stimulates blood cell production - controls BP - maintains fluid & electrolyte balance - activates vitamin D
Describe erythropoietin
- give to patients to treat anemia r/t chronic kidney disease - helps to achieve hematocrit of 33-38% and hemoglobin of 12 - administered IV or sub-q 3x/week with ESKD - once given, it may take 2-6 weeks for the hematocrit to increase
Complications that can occur in patients receiving dialysis
- heart failure - coronary artery disease - angina - stroke - peripheral vascular disease - anemia - gastric ulcers - uremia - vomiting - hypertension - painful muscle cramping (due to fluid loss) - dysrhythmias - air embolism
Risks with vascular access devices
- hematoma - pneumothorax - infection - thrombosis of the subclavian vein - inadequate flow
Types of dialysis
- hemodialysis - peritoneal dialysis
When is acute/urgent dialysis indicated?
- high and increasing level of serum potassium, fluid overload or impending pulmonary edema - increasing acidosis - pericarditis - advanced uremia - may remove meds/toxins from the blood if non-responsive to other treatments
Adverse effects with erythropoietin therapy
- hypertension - increase clotting of vascular access site - seizures - depletion of body iron stores
Long-term complications of peritoneal dialysis
- hypertriglyceridemia - cardiovascular disease - abdominal hernias - low back pain - anorexia
Health conditions that can impair kidney function
- hypovolemia - hypotension - reduced cardiac output/heart failure - obstruction of the kidney or lower urinary tract (tumor, clot, stones) - bilateral obstruction of renal arteries/veins
Describe peritoneal dialysis
- may be treatment of choice for patients with CKD who are unable/unwilling to undergo hemodialysis or kidney transplant - done every day - patients experience fewer problems due to the slower rate of dialysis - often used for patients with diabetes or cardiovascular disease
Describe acidosis with chronic kidney disease
- occurs during ESKD because the kidneys are unable to excrete increased loads of acid - decreased acid secretion results from the inability of the kidney tubules to excrete ammonia & reabsorb sodium bicarbonate
Define an exchange
- occurs during peritoneal dialysis - is the entire cycle including the infusion, dwell and drainage of the dialysate
Clinical manifestations of acute kidney injury
- patient may be critically ill and lethargic - dry skin & mucous membranes - drowsiness - headache - muscle twitching - seizures
Acute complications of peritoneal dialysis
- peritonitis (most common) - leakage - bleeding
Nutritional therapy in patients with end-stage kidney disease
- regulation of protein intake - fluid intake of 500-600 mL more than the previous 24-hour urine output - eating carbohydrates and fat to prevent wasting - need vitamin supplementation - sodium and potassium restrictions
Most common complications with arteriovenous grafts
- stenosis - infection - thrombosis
Describe arteriovenous fistulas (AVF)
- the preferred method of permanent vascular access for dialysis - surgically created by joining an artery to a vein - arterial segment is used for arterial flow to the dialyzer - venous segment is used for reinfusion of the dialyzed blood - access site needs 2-3 months to "mature" before it can be used
Examples of medications that are nephrotoxic
- tobramycin - gentamycin - neomycin
Describe hemodialysis
- used for acutely ill patients requiring short-term dialysis or patients with advanced CKD and ESKD who require long term replacement therapy - prevents death but does NOT cure kidney disease - three times/week with 3-5 hours each time
What do the kidneys excrete?
- wastes/toxins - medications - electrolytes *through urine
What problems should patients with CKD report to their primary provider?
- worsening signs/symptoms of kidney disease (nausea, vomiting, change in urine output, ammonia odor of breath) - signs/symptoms of hyperkalemia (muscle weakness, diarrhea, abdominal cramps) - signs/symptoms of access problems (clotted fistula or infection)
A patient has acute kidney injury (AKI) with a negative nitrogen balance. How much weight does the nurse expect the patient to lose?
0.5kg/day
A one kg weight gain is equal to _______________ of retained fluid
1,000 mL
Protein intake is usually restricted to ______________ per day for patients with CKD
1.2-1.3 g/kg
The goal for patients on hemodialysis is to keep their interdialytic weight gain under ____________
1.5 kg *interdialytic (between dialysis treatments)
Sodium intake is usually restricted to ______________ per day for patients with CKD
2-3 g/day
A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem?
Sore throat 2 weeks ago
Define creatinine clearance
a measure of the amount of creatinine the kidneys are able to clear in a 24-hour period
Define dialysate
a solution that circulates through the dialyzer, made up of all the electrolytes in their ideal extracellular concentrations
Define a dialyzer
a synthetic semipermeable membrane through which blood is filtered to remove uremic toxins and a desired amount of fluid *aka an artificial kidney *used during hemodialysis
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?
acute golmerulonephritis
A patient admitted with electrolyte imbalance has carpopedal spasm, ECG changes, and a positive Chvostek sign. What deficit does the nurse suspect the patient has?
calcium deficit
___________________ remains the leading cause of death in patients receiving dialysis
cardiovascular disease
When caring for the patient with acute glomerulonephritis, what assessment findings should the nurse anticipate?
cola-colored urine
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
dehydration
___________ is the primary cause of chronic kidney disease
diabetes
In hemodialysis, the toxins and wastes in the blood are removed by _____________
diffusion (area of higher concentration to area of lower concentration in the dialysate)
Define azotemia
excess nitrogenous wastes in the blood
Define uremia
excess of urea in the blood
____________ is an indicator of kidney transplant rejection
fever
Patients with kidney disorders commonly experience ______________________
fluid & electrolyte imbalances
Define nonoliguira
greater than 800 mL/day
Rejection of a transplanted kidney within 24 hours after transplant is termed:
hyperacute rejection
A client is diagnosed with polycystic kidney disease. What symptom would the nurse most likely assess?
hypertension
Chronic kidney disease describes:
kidney damage or decrease glomerular filtration rate lasting for 3 or more months
Define oliguria
less than 0.5 mL/kg/hr
Normal BUN to creatinine ratio
less than 15
Define anuria
less than 50 mL/day
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?
limiting fluid intake
Which of the following occurs late in chronic glomerulonephritis?
peripheral neuropathy
What is used to decrease potassium level seen in acute renal failure?
sodium polystyrene sulfonate. (Kayexalate)
Hyperkalemia is a serious side effect of acute renal failure. What electrocardiogram (ECG) tracing is diagnostic for hyperkalemia?
tall, peaked T waves
Define glomerular filtration rate (GFR)
the amount of plasma filtered through the glomeruli per unit of time *want >60
Define clearance during peritoneal dialysis
the movement of solute from the blood into the dialysate fluid
Goal of peritoneal dialysis
to remove toxic substances and metabolic wastes to reestablish normal fluid & electrolyte balance
When do we typically start dialysis in patients with chronic kidney disease?
when the patient cannot maintain a reasonable lifestyle with conservative treatment
When is chronic/maintenance dialysis indicated?
with chronic kidney disease & end-stage kidney disease
The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication?
with food
Causes of end-stage kidney disease in older adults
- diabetes - hypertension - chronic glomerulonephritis - interstitial nephritis - urinary tract obstruction
Describe anemia with chronic kidney disease
- develops due to inadequate erythropoietin production, shortened lifespan of RBC's, nutritional deficiencies and patient's tendency to bleed - erythropoietin stimulates bone marrow to produce RBC's - results in fatigue, angina and SOB
If the dialysis solution is too cold, what can occur?
*vasoconstriction of the vessels - may cause pain, cramping and reduced clearance
Side effects of ACE inhibitors
- A: angiotension - C: cough - E: elevated potassium
Stage 5 of chronic kidney disease
- GFR < 15 mL/min - end-stage kidney disease or chronic kidney disease
Stage 1 of chronic kidney disease
- GFR > 90 mL/min - kidney damage is with normal or increased GFT
Stage 4 of chronic kidney disease
- GFR: 15-29 mL/min - severe decrease in GFR
Stage 3 of chronic kidney disease
- GFR: 30-59 mL/min - moderate decrease in GFR
Stage 2 of chronic kidney disease
- GFR: 60-89 mL/min - mild decrease in BFR
Examples of anticonvulsant agents given for chronic kidney disease
- IV diazepam (Valium) - phenytoin *happens because of neurologic abnormalities due to decreased perfusion to the brain *should also have side rails up & padded to protect patient
Describe acute kidney injury
- a rapid loss of renal function due to damage to the kidneys - may result in potentially life-threatening metabolic complications (metabolic acidosis, fluid & electrolyte imbalances) - treatment is aimed at replacing renal function temporarily
Nursing management with erythropoietin therapy
- administer heparin to prevent clotting of lines during hemodialysis - monitor hemoglobin and hematocrit - assess serum iron & transferase levels - administer iron supplement if indicated - assess serum potassium
Complications of end stage kidney disease
- anemia - bone disease - hyperkalemia - hypertension - pericarditis, pericardial effusion or pericardial tamponade
Pathophysiology of chronic kidney disease
- as renal function declines, the end products of protein metabolism accumulate in the blood - uremia develops & effects all systems in the body - the greater the buildup, the more symptoms produced - disease progresses more rapidly in those with high amounts of protein or elevated BP
Nursing interventions to protect vascular access
- assess for patency - listen for bruit over site at least every shift - observe for signs/symptoms of infection (redness, swelling, drainage, fever, chills) - do dressing changes as needed - no IV or blood pressure taken on extremity with access - no tight clothing/compression of the site
Signs & symptoms of end-stage renal disease
- asterixis - confusion - disorientation - seizures - ecchymosis - pericardial friction rub/effusion/tamponade - pitting edema - ammonia odor to breath - bleeding from GI tract - mouth ulcerations and bleeding - anemia - amenorrhea - decreased libido/infertility - bone fractures/pain - loss of muscle strength
Describe at home dialysis
- available for highly motivated patients who are willing to take responsibility for the procedure and are able to adjust each treatment to meet the body's changing needs - may need a caregiver - must be the decision of the family and patient - patient/family must be trained to: prepare, operate & disassemble the machine, maintain & clean the equipment, administer medications into the machine and handl emergency problems
Medications given with end stage kidney disease
- calcium & phosphate binders - antihypertensive meds - anticonvulsant agents - erythropoietin
Examples of calcium & phosphate binders
- calcium carbonate - calcium acetate - sevelamer hydrochloride (Renagel - phosphate binder)** *take with food to increase absorption
Describe arteriovenous grafts
- can be created by subcutaneously interposing a biologic or synthetic graft material between an artery and a vein - usually created when a patient's vessels are not suitable for creating an AVF - locations: arm (most common), thigh, chest wall
Risk factors for chronic kidney disease
- cardiovascular disease - diabetes - hypertension - obesity
Nursing interventions to prevent drainage during dialysis
- checking patency of catheters (check for kinks, closed clamps or air locks) - monitor for peritonitis, bleeding or respiratory difficulty - measure abdominal girth to determine if patient is retaining fluid - frequent turning
Signs & symptoms of peritonitis
- cloudy dialysate - abdominal pain - rebound tenderness - hypotension *given antibiotics for 10-14 days
Chronic kidney disease is associated with:
- decreased quality of life - increased healthcare expenditures - premature death
Signs & symptoms of fluid volume deficit
- decreased skin turgor - dry mucous membranes - oliguria/anuria - increased hematocrit - BUN increased - hypothermia
Medical management of chronic kidney disease
- decreasing BP - renal replacement therapies - treat hyperglycemia - manage anemia - smoking cessation - weight loss - exercise programs - reduction of salt & alcohol intake
The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take?
Hold the medications until after dialysis
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage