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Med-Surg Ch 28

Kidney Disorders

Kidneys Regulate Fluids, Acid-base (metabolic waste), Blood pressure, Electrolytes (Potassium and Sodium)
Age-related changes to Kidneys < Glomeruli = < GFR, Dehydration, Drug filter (“go low, go slow”, Elderly slogan), Glomerular function at 80 will be half of what it was at 30, < ability to concentrate urine & fluid/electrolyte regulation
Polycystic Kidney Disease Fluid filled cyst develop in nephrons , cluster of grapes, crowds other organs, infection, rupture, bleeding, < function, developed by 40, kidney failure by 60. Inherited: Autosomal recessive or Autosomal dominant, No prevention, Genetic counseling
Manifestations of Polycystic Kidney Disease Abdominal/flank pain, Hematuria, proteinuria, polyuria, Hypertension, Nocturia, > abdominal girth, Kidney stones, UTI
Polycystic Kidney Disease Diagnostic Assessment UA (Hematuria, proteinuria), BUN (5-25), Creatinine (0.5-1.5)(> as function <), Renal sonography, MRI, CT, Genetic Testing
Other things that go along with Polycystic Kidney Disease HTN, Renal failure (restrict sodium, daily weights, report gain of 2lbs/d or 3-5lbs/wk), prevent UTI, maintain intake 2500ml/day
Drug Therapy for Polycystic Kidney Disease Antihypertensive, diuretics (Amenoglycosides, -mycins), Avoid Nephrotoxic agents
Glomerular Disorder Leading cause of chronic renal failure in U.S., Affects structure/function of the glomerulus, 50 % require dialysis, Primary is idiopathinc (don’t know cause), Secondary is something I’ve done (know cause), Hematuria, proteinuria, and HTN are early signs
4 Types of Glomerular Disorders Acute glomerulonephritis, Rapidly progressive glomerulonephritis, Nephrotic syndrome, Chronic glomerulonephritis
Acute Glomerulonephritis Acute inflammation of the glomerular capillary membrane, 10-14 days after initial infection (group A beta-hemolytic streptococcus)
Acute Glomerulonephritis Manifestations Abrupt onset, Hematuria, Proteinuria, and Azotemia (nitrogenous waste) cola/tea colored urine, Periorbital & dependent edema, HTN, Fatigue, anorexia, N/V, headache, Prognosis is best for kids, 60% adults recover, may resolve spontaneously in 10-14 days
Nursing History for Glomerulonephritis: Ask about Infections (particularly skin or respiratory), Travel, Recent illnesses, Surgery or other invasive procedures (Body piercings), Systemic diseases (SLE)
Rapidly Progressive Glomerulonephritis Severe glomerular injury without known cause; Rrenal failure within months; Glomerular cells multiply, crescent-shaped lesions obliterate the Bowman’s capsule
Rapidly Progressive Glomerulonephritis Manifestations Flu-like symptoms ; Weakness, nausea, vomiting. Oliguria (<400ml/24hrs), abdominal/flank pain. Moderate HTN. Hematuria. Massive proteinuria.
Goodpasture’s syndrome – Rapid progressive glomerulonephritis Rare autoimmune disorder. Antibodies form in glomerular membrane, also damages alveoli in lungs & causes pulmonary hemorrhage. Manifestations: Renal/Respiratory
Nephrotic Syndrome Basics Not a specific disorder but group of findings, Increase glomerular circulation, Large molecules are able to pass thru membrane into urine, May progress to ESKD (end stage kidney disease) without treatment
Nephrotic Syndrome Causes Immune or inflammatory, Genetic, Alter liver function occurs = hyperlipidemia, Renal vein thrombus (Don’t know if it occurs with or causes)
Nephrotic Syndrome Manifestations Proteinuria >3.5 g in 24 hours, Low albumin (albumin is like gravity; not enough, fluid goes to other places rather than inside the cells), High lipids, Fatty urine, Edema, HTN, Increased coagulation, Renal insufficiency
Nephrotic Syndrome Complications Renal vein thrombosis, DVT (Pain swelling, edema, + homan’s sign), PE (Shortness of breath, chest pain), Implemented and complications (Fluids, blood thinners, immunosuppressant (steroids), diet, ACE inhibitors, diuretics)
Chronic Glomerulonephritis Chronic nephritic syndrome, Develops of 20-30 years or longer, Often unknown cause (Hypertension, infection,inflammation, poor blood flow to the kidneys), ALWAYS leads to renal failure
Diabetic Nephropathy Diabetes Mellitus:
Diabetic Nephropathy Education Avoid nephrotoxic agents (metfoman), Avoid dehydration, Explain relation between insulin and kidney execretion with decreased renal function (diabetes is not better, kidney function is worse)
Diabetic Nephropathy Diagnostics Throat cultures looking for strep, ASO titer also look for strep, ESR erythrocyte sedimentation rate, KUB (kidney, ureter, bladder x-ray), Kidney scan, Biopsy, BUN & Serum creatinine, Urine creatinine, Creatinine clearance, Serum electrolytes, UA
Medications for Glomerular disorders Antibiotics (Avoid nephrotoxic antibiotics), Immunosuppressive therapy (Prednisone, Cytoxan or Imuran), ACE inhibitors (reduce proteinuria, Protective effect in Diabetic nephropathy), Other antihypertensive
Glomerular Disorders Treatments Restricted activity, Low sodium diet, 1-2 grams, Low protein diet if azotemia is present, Plasmapheresis, Dialysis
With Glomerular Disorders Monitor for Fluid overload: crackles, rails, rhonchi, shortness of breath, chest pain, JVD, liver enlarged, acsities, blueish < O2Sat, pitted edema. Uremic symptoms: buildup of waste in blood, confusion, slurred speech, neurologic symptoms, ataxia, tremors, asterixis
Vascular Kidney HTN Result from kidney disorders (secondary HTN), or lead to kidney disorders. Malignant HTN: vascular changes that lead to renal ischemia, and infaction=renal failure. ACE inhibitors and Diuretics. < salt, < cholesterol, < fat, Exercise
Renal artery stenosis R/T atherosclerosis, Manifestations: Secondary HTN and Epigastric bruit. Diagnosed by Ultrasonography or MRI. ACE inhibitors, Antihypertensives, Diuretic, Angioplasty (Stint, clean out plaque)
Renal artery occlusion Acute occlusion, sudden, severe flank pain, N/V, fever, HTN, hematuria & oliguria. Labs: > WBC, > AST and LDH. Treat with Surgical intervention, Anticoagulation therapy (Coumadin), Antihypertensives and pain control
Renal vein occlusion Thrombus formation. Treat with TPA, streptokinase (clot busters), anticoagulation therapy, watch for S/S of PE.
Renal Vein Occlusion Risk Factors Nephritic syndrome, Pregnancy, Oral contraceptive use, Malignancies, Improvement in renal function noted with treatment
Renal Trauma Contusions, Lacerations, Breaks in renal artery or vein. Causes: Falls, Stabbings, gunshots, motor vehicle accident, Contact sports
Renal Trauma Manifestation Hematuria, Turner’s or Cullen’s Sign, Anuria, oliguria, Abdominal distention, Signs of shock
Renal Trauma Labs and Diagnostics H/H, UA, BUN, Creatinine, CBC w/dif. CT scan, Ultrasound
Renal Trauma Interventions Prevent/control bleeding: Clotting factors (Vit K, platelets). Restore circulation: Fluid replacement, Whole blood or PRBCs, Plasma expanders (albumin), Monitor for shock, Urine output hourly
Renal Trauma Surgical Interventions Nephrectomy or partial, Bench surgery (Fix it on the table, put it back)
Renal Trauma Prevention Wear a seat belt, Safe walking habits to prevent falls, Caution with ride bicycles, motorcycles, Protective equipment with contact sports, Avoid all contact sports if only one kidney
Renal Cell Carcinoma 2:1 Male/Female ratio. Increased risk in tobacco use, obesity, chronic irritation, renal calculi (kidney stones), genetics
Renal Cell Carcinoma Manifestations Flank pain, Hematuria, Palpable kidney mass, Fever /s infection, Fatigue, Anemia (Kidney send erytropoetin, tells bone marrow make RBCs), Paraneoplastic syndromes, Darkening nipples, hyperglycemia, HTN, hypercalcemia, < appetite = < weight, wasting
Renal Cell Carcinoma Surgical Interventions Nephrectomy (Blood loss is major concern), Monitor for: Hemorrhage, infection, Adrenal insufficiency, Renal function, Pain, Prevent complications, No contact sports for 1 year
Renal Failure Kidneys can not remove metabolites from the blood, Acute vs. Chronic (slow, silent), End-stage renal disease (ESRD) : Undergoing kidney dialysis, Often waiting for a kidney transplant, Very expensive, effects on quality of life
Acute Renal Failure Rapid decline, Azotemia (nitrogenous waste), Fluid and electrolyte imbalances
Causes of Acute Renal Failure Ischemia, Nephrotoxins
Acute Renal Failure Risk Factors Trauma, Infection, Surgery, HTN
3 Stages of Acute Renal Failure Prerenal ARF, Intrinsic (Intrarenal) ARF, Postrenal ARF
Prerenal ARF Conditions that affect renal blood flow and perfusion, Rapidly reversed when blood flow restored, If not reversed lead to Intrarenal stage
Prerenal ARF Causes Hypovolemia, Shock, Heart failure, Anaphylaxis, Massive PE, Sepsi, Low cardiac output
Intrinsic (Intrarenal) ARF Acute damage to renal parenchyma and nephrons
Intrinsic (Intrarenal) ARF Causes Acute tubular necrosis, Glomerulonephritis, HTN, Occlusion, Unreversed prerenal stage, Drugs (Aminoglycoside antibiotics, NSAIDs), Tumors, Inflammation of glomeruli, Vasculitis, Obstruction
Postrenal ARF Obstructive problems: BPH, calculi, tumors
Postrenal ARF Causes Caused from obstruction anywhere in renal/urinary system, Tumors, Stones, Bladder atony, Prostatic hyperplasia, Stricture
Acute tubular necrosis (ATN) Destruction of tubular epithelial cells, Abrupt and progressive decline in renal function, Ischemia >2 hrs=severe and irrevisible damage
Risk Factors for Acute Tubular Necrosis (ATN) major surgery, Severe hypovolemia, Sepsis, Trauma, Burns
3 ARF phases Due to ATN (Acute Tubular Necrosis) Initiation: hrs-days, event caused, ends /c tubular injury. Maintenance: <GFR, tubular necrosis, <kidney = azotemia, edema, HTN, electrolyte imbalances, metabolic acidosis, anemia, <immune system. Recovery: function improves, tubular repair, dieresis
ARF Diagnostic Tests UA, BUN & Creatinine, eGFR, Serum electrolytes, ABG, CBC, Renal ultrasound, CT, IVP, Renal biopsy
Medications for ARF IVF & blood vol expanders. Intropin, >kidney function. Loop diuretic: Lasix, Demadex, expel waste and potassium. Osmotic diuretics: Osmitrol and Isotol, >risk of GI bleed (Treat with antacids, H2 receptor antagonist, PPI).
More Medications for ARF No Nephrotoxic drugs. Antihypertensive /c toxemia, pregnancy HTN. Hyperkalemia treatment: Kayexalate (klean-up,), Calcium chloride, Bicarb, Insulin and glucose. Amphojel, Antacid, controls hyperphosphatemia with ARF, Adjust all meds excreted in kidneys
ARF Treatment Limited Fluid intake: 500ml average loss from breath/sweat. Accurate DAILY WEIGHTS! Monitor serum Na. Special diet: Limited proteins – select complete proteins, 0.6 per kg of body weight per day, Increase carbohydrates, Parental nutrition if needed
Dialysis Removes wastes & excess fluids. Early dialysis gives better prognosis. Does not replace erythropoiten, must take Procrit injection, 1/wk
Types of dialysis Hemodialysis, Peritoneal dialysis, Continuous renal replacement therapy (CRRT)
Hemodialysis Blood passes through a semipermeable membrane filter outside the body. Dialysate is a solution like extracellular fluid used on the other side of semipermeable membrane, filters BUN and creatinine. Can add electrolytes like calcium.
Hemodialysis Complications Hypotension (Osmolarity changes, Rapid removal of fluid, Vasodilation), Bleeding (Altered platelet function, Heprin therapy to keep lines and tubing open), Infection (invasive, MRSA of vascular access site, Higher incidence of hepatitis B & C, HIV, CMV)
Continuous Renal Replacement Hemofiltration /c more gradual fluid and solute removal. Solutes drain in collection device. Fluid replaced with NS or electrolyte solution. Continuous blood circulation thru highly porous hemofilter for 8-12 hours. ICU or speciality nephrology unit.
Vascular Access Acute or temporary access. Double lumen catheter. Inserted in subclavian, jugular, or femoral veins.
Arteriovenous (AV) fistula Longer term access. Anastomosis of the vein & artery. Must wait till site matures before use (1 month). Palpable pulse and bruit on auscultation. No venipunctures or BP allowed on fistula arm.
Arteriovenous graft Gor-Tex implanted to connect artery and vein
Complications of Vascular Access Infection, Septicemia, Clotting/Thrombosis, Aneurysm, Graft Failure (Depression, Low self-esteem)
Dialysis Nursing Care VS, Weight (before and after), Assess Vascular Site, Monitor Labs (before and after), Watch for Disequilibrium Syndrome (headache, N/V, LOC, HTN), Dehydration, N/V, muscle cramps, Seizures, Bleeding
Peritoneal Dialysis Warm sterile dialysate instilled into the peritoneal cavity. Dwell Time. Fluid drained by gravity into a sterile bag. Will repeat at Rx intervals.
Peritoneal Dialysis Nursing Care VS, Weight, Labs, Abdominal Girth. Empty Bladder before catheter insertion. Warm dialysate solution, infuse over 10 min. Strict aseptic technique.
Chronic Renal Failure (CRF) Progressive renal tissue damage & loss of renal function. DM and HTN major causes. Final stage: Oliguria, Uremia: urine in the blood (Early S&S – nausea, weakness, fatigue, flu-like symptoms)
CRF Diagnostic tests same as ARF
CRF Effects Fluid and Electrolytes. Cardiovascular (
CRF Medications No Nephrotoxic drugs: Most drugs are excreted primarily by kidneys, NO Demerol or Glucophage. Loop diuretics. ACE inhibitors. Oral phosphate binding medications. Vit D (for renal rickets). Folic acid & iron supplements. Multivitamin.
Dietary/Fluid Managment for CRF Restrict protein. Increase Carbohydrates. Sodium restriction 2 g per day. Water intake 1-2 liters. DAILY WEIGHT!!! Stage 4-5 limited K and Phosphorus intake (Eggs, dairy products, & meat, Salt substitutes)
Kidney Transplant Most common and successful transplant procedure. Can come from cadavers or live donors. Prevent Rejection: Immunosuppresive drugs, Antihypertensive agents, Antibiotics.
Renal Transplant Not considered a cure. 97,000 waiting for transplant.
Transplant Criteria Free of medical problems. No advanced, uncorrectable cardiac disease. No metastatic cancer. No chronic infection. No severe psychological problems. DM will be closely monitored, limit complications.
Hyperacute Kidney Transplant Rejection Onset within 48 hrs. Malaise, high fever. Graft tenderness. Organ must be removed to < S/S.
Acute Kidney Transplant Rejection 1wk-2yrs. Oliguria, Anuria. > 100F temp. >BP. Flank tenderness. Lethargy. >BUN, K and Creatinine. Fluid Retention.
Chronic Kidney Transplant Rejection Gradual over months to years. >BUN, Creatinine. Imbalances in Proteinuria and Electrolytes. Fatigue.
Nursing Diagnoses for Transplant Risk for Ineffective renal perfusion. Imbalanced Nutrition: less than body req. Risk for Infection. Disturbed body image.
Created by: nimeggs
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