renal part 2 (fluid and e- changes) - exam 3
Systemic Alterations
- Cardiovascular - Pulmonary - Hematologic - Immune - Neurologic - Gastrointestinal - Endocrine and reproduction - Integumentary
Theories on Enuresis
- Organic causes (DM?) - Factors that increase urine production - Maturational lag - Genetic factors - Sleep patterns - Psychosocial theories
synthetic erythropoeitin
Epogen
The nurse is explaining the physiologic reasons for taking vitamin D and calcium supplements to a client with renal failure. Which statement made by the nurse is appropriate?
"There will be a decrease in the active metabolite of vitamin D in your body." can't absorb calcium without vitamin D kidney failure = no vit D calcium = cant clear phosphate
The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?
1.Elevated creatinine level - T 2.Decreased hemoglobin level - T 3.Decreased red blood cell count - T 4.Increased white blood cells in the urine - F (this would be a UTI)
A nurse writes a goal of preventing renal calculi in a care plan for a client with paraplegia. Which information most likely caused the nurse to write this goal?
Accelerated bone demineralization (no weight bearing exercise = important for bone strength = bone gets soft)
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?
Acute kidney injury *** creatinine = should be .6-1.2 *** BUN = should be 10x creatinine know BUN/CR values/ranges!!!!!!
cont.
Calcium, phosphate, bone can't excrete phosphate = hyperphosphatemia = hypocalcemia give pt. calcium supps block absorption of phosphate = Phosphate binders!!!!! = take with food so phosphate from diet isnt absorbed + calcium supps given to pt. (+ vit. D = need kidneys to activate vit. D)
Acute Post-Streptococcal Glomerulonephritis
Glomerulonephritis in a 7 y/o versus an adult exact same disease process! had strep infection = cola colored urine, edema, high BP, less urine output
The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure?
Decrease in erythropoietin
The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder, if noted on the client's record, should the nurse identify as a risk factor for this disorder?
Diabetes mellitus
A client is admitted to the hospital with severe renal colic caused by a ureteral calculus. Later that evening the client's urinary output is much less than the intake. When it is confirmed that the bladder is not distended, what should the nurse suspect developed?
Hydroureter - urine stuck in ureter = above bladder - if stuck in bladder = urethral obstruction - only been a few hours = not kidney failure yet
A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client?
Hypertension pt doesn't pee = oliguria = and edema (fluid overload!!!!!!)
Hypoplastic or dysplastic kidneys
Hypoplastic = really small dysplastic = weird shape both = congenital
A client presents to the emergency department with shortness of breath, bloody sputum, weight gain, generalized edema, and a blood pressure of 150/110. The nurse reviews the client's laboratory results and determines that the client has impaired renal function. Which diagnosis will the nurse most likely observe written in the client's electronic medical record?
Nephrotic syndrome (fluid overload)
A client with chronic kidney disease (CKD) is prescribed aluminum hydroxide. Which information should the nurse include while instructing the client regarding the action of this medication?
It combines with phosphorus and helps eliminate phosphates from the body aluminum hydroxide = phosphorus = phosphate binder
A client with a femoral fracture associated with osteomyelitis is immobilized for 3 weeks. The nurse assesses for the development of renal calculi. What is the rationale for the nurse's assessment?
Lack of weight-bearing activity promotes bone demineralization bone demineralization = also at risk for kidney stones
normal hemoglobin levels
Male: 14-18 g/100mL Female: 12-16 g/100mL stop at 10 for anemic/kid. failure pt. !!!!!!!!!!!!!!! = don't want too much RBC to make blood viscous
Incontinence / Enuresis
Primary enuresis - The child has never been continent (potty trained around age 3) (ie. 10 y/o can't control urine) Secondary enuresis - used to be continent and now they aren't (ie. from psychological trauma = parent divorce = nighttime enuresis) Daytime enuresis - Nighttime enuresis - bed wetting (common til age 9/10 = sleeping so deeply that having to pee doesn't wake them) - common in kids til 8/9 y/o
CKD Diagnostics
Proteinuria and uremia - Due to glomerular hyperfiltration - Damages interstitial tissue of kidney via inflammation Creatinine and urea clearance - GFR falls - Plasma creatinine increases
Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation?
Urination is not painful Phenazopyridine = urinary analgesic side effect = reddish orange urine
Hematologic
anemic
Immunoglobulin A (IgA) Nephropathy
antigen-antibody complex = immune system problem = beurger's disease NOT FROM STREP = autoimmune disease problem!!!!!!!!!
renal failure
apparent within first couple of days = occluding glomeruli = kidneys cant work
kidney pt.
at risk for osteoporosis w/ low calcium levels parathyroid gland pulls calcium out of bones and puts it blood ie. old lady fall = pathologic fractures!! = bone snaps just from walking
Exstrophy of the bladder
bladder outside of skin = corrected surgically = sometimes combo defect with exstrophy of bladder AND hypo/epispadias
hyperkalemia
cause (brady)dysrhythmias = but pt. heart eventually get used to it normal value (3.5-5) (ie. see catalano before dialysis pt. bc dialysis pt. used to it)
chronic kidney disease pt.
compensated metabolic acidosis = used to it
rhonchi
deeper and louder = smokers cough = mucus = clears with coughing
HUS treatment
dialysis (pulls out BUN/CR - nitrogenous waste)while treating pt, plasamapharesis (clean out dead RBC = help spleen), no antibiotics
Nephroblastoma / Wilms Tumor
embryonal cancers = manifest in cells before age 5/6 = from embryonic layer 4 stages = 5 stages if in both kidneys parent usually finds it when bathing child = lump in belly
polycystic kidney disease (PKD)
genetic disorder (WATCH MINI NARRATION - cat. sent info)
Victoria develops hematuria, proteinuria, and oliguria with peripheral edema approximately 2 days after an upper respiratory infection. She asks you whether she needs to go to the clinic. What do you tell her and why?
glomerulonephritis = check history if they've had strep + upper resp. infection = and protein in urine
erythropoietin
hormone that affects anemia stimulates blood cell production by the bone marrow = if kidnes fail = this hormone isnt made + they dont filter blood
Hemolytic Uremic Syndrome (HUS)
how kids get renal failure usually see E. coli involved (produce dangerous toxins = damage RBC = filtered thru kidneys = toxins get stuck in glomeruli = glom. clotted off = eventually spleen recycles them = lose RBC = anemia) anemia = low RBC = if hemolytic = something has destroyed them = in this case, its from the E. coli toxins = spleen recycles the used RBC = hemolytic anemia from E. coli + damaged kidneys (from damaged/stuck RBC in glom.) = kidneys aren't working = uremia (buildup of waste products in blood) SUPER DANGEROUS
Ureteropelvic junction obstruction (UPJ)
in a baby its not a kidney stone = probably a ureteral stricture = takes awhile to figure out bc other kidney working fine = still producing pee
renal agenesis
kidney didn't form = born with one kidney = not allowed to play contact sports Unilateral or bilateral (Potter syndrome = no kidneys= dialysis til kidney transplant surgery)
Immune
kidneys don't clear waste products = alterations in immunity = high WBC count = prone to infection
Horseshoe kidney
kidneys fused at the lower poles must be surgically separated
acid/base balance
kidneys make bicarb !!!! (base) - metabolic acidosis occurs renal failure = all in metabolic acidosis compensate by breathing heavier to get rid of CO2
anemia
lethargy, dizziness, and low hematocrit are common may have a cardiac event = not enough hemoglobin to carry O2 to tissues give synthetic erythropoeitin (epogen) = until hemoglobin level hits 10!!!!!!!!!!!!!!!!
Fluid & Elyte Changes with CKD
losing sodium and water when kidneys - give kidneys lots of fluids
Endocrine and reproduction
most pt. are older = if they're younger, they won't have infertility issues?
Gastrointestinal
nausea, no appetite, vomiting
Integumentary
nitrogenous waste products (uremia = waste products in blood) makes skin itchy and dry = crystallizes on the skin
Nephrotic Syndrome
not usually a chronic illness in kids like it is for adults, very rare for kids (more likely to get glomerulonephritis) lots of edema (orbital edema), protein in urine (not in blood), lipids in blood (high cholesterol)
Neurologic
numbness, tingling in feet, some neurologic effects are from preexisting conditions (ie. renal failure from being diabetic = diabetes kills kidneys and nerves = nerves meaning neuropathy)
Bryan is a 6-year-old with hemolytic uremic syndrome. He will be your patient today. What signs and symptoms do you expect to see when you go to care for him? What assessments do you need to make, and what are some of your priorities for his care?
pale, bruises all over body, lethargic, bloody stool, nauseous/puking = needs dialysis
Adam is a 3-year-old admitted with primary nephrotic syndrome. What signs and symptoms would you expect to see, and what is the underlying cause of those?
pale, swollen face/eyes = primary problem is peeing out protien
kidney pt needs =
phosphate binders + calcium supps ** don't need phosphate binders if pt. is not eating tho NPO pt = no phosphate binders needed
cont
potassium - at beginning of kidney failure = kidneys cant hold onto it as GFR + urine output dec = we start retaining potassium HYPERKALEMIA! K levels are always high - put pt on low potassium diet (ie. dark greens, bananas, fruit - oranges, potatoes/tomatoes, salt substitutes)
Pulmonary
pulmonary edema from fluid = hear crackles in lungs pleurisy, dyspnea on exercise
Pauline comes to the clinic with fever, chills, lower back and flank pain, frequency and urgency, and dysuria. What assessment could help you in determining the reason for these signs and symptoms?
pyelonephritis = infection in kidneys = fever, chills, flank pain urinalysis lab, and check for CVA tenderness (costovertebral angle = between rib cage and spine = put hand there and punch hand on back = CVA positive if there's pain)
CVA tenderness
sign of pyelonephritis
Bladder outlet obstruction
something wrong w bladder itself = kink in urethra = could be a structure that can be opened up = emergent = baby not peeing = put catheter in and see if you meet obstruction = then a scope
Hypospadias
sometimes comes with chordee = penis is kind of bent bc urethra is pulling on it downwards
Olivia is 10 years old and missed school one week ago for a severe sore throat and fever. Today, she is sick again and her mother brings her to the clinic with a recurrent fever, headache, irritability, and new onset hematuria. During the initial examination, you discover that she has flank pain. What disorder do you suspect that she may have? What other kinds of assessments will be done?
sore throat/fever = glomerulonephritis = post strep
kidney pt (renal failure) =
takes multivitamin (nephrocap) = with iron in it = bc they need iron
John develops oliguria the day after he has a CT scan with contrast to aid in diagnosis of abdominal pain. What would you suspect has caused this reduction in urine production? What are your priorities for John's care?
the dye = must be flushed out = nephrotoxic = give him IV fluids to get dye out of system = acute kidney injury recovery phase = oliguria to diuresis!!!
HUS Manifestations
tired (no RBC), bruised, pale, anemia, GI issues (naseau, vomit, diarrhea), blood in stool, possibly seizures
Cardiovascular
too. much retained urine/fluid = inc BP dont get thirsty tho = bc they arent hypovolemic mouth care, ice chips, etc
UTIs in kids
tub baths, wiping front to back, cant become acute and chronic pyelonephritis repeated kidney infections = insert dye = check for Vesicoureteral Reflux (VUR)
never give pt K
until you know they're peeing
Hypospadias + Epispadias
urethra opening located on upper or lower pole of penis = only in boy babies = not dangerous = can be surgically corrected
Structural Abnormalities (next slides are examples...)
usually know about it in utero while fetus is developing ...
Vesicoureteral Reflux (VUR)
very severe = DO A SCAN! (where ureter inserts and how much of ureter is inside bladder) voiding cystourethrogram (VCUG) = put dye in and have kid pee while watching on screen to see if there's a backflow + where ureter is insterting gradually becomes worse = causes massive UTIs, pyelonephritis = chronic ureter not really inside bladder/ureter far down on bladder = reflex seen
Cody is a 4-year-old whose mother detects a firm, smooth mass in his abdomen while bathing him. He has no pain when she touches the mass. She brings him to the ER to find out what this is and how it needs to be managed. What will she likely be told about the diagnosis?
wilm's tumor = cut it out = take kidney out
Glomerular Disorders
•Glomerulonephritis •Immunoglobulin A (IgA) nephropathy •Nephrotic syndrome •Hemolytic uremic syndrome
