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Test 4

AKI/ CKD/ ESKD/Dialysis/ Kidney Transplant/ Cirrhosis

Acute Kidney Injury is... Sudden onset- rapid kidney loss demonstrated by a ↑ in creat & or ↓ UOP proteinuria 3 Phases: Pre-renal, Intra-renal, and Post-renal COMMON CAUSE: Acute Tubular Necrosis COMMON CAUSE OF DEATH: Infection * Potentially reversible
Risks of developing ATN are... Major surgery, shock, sepsis, transfusion reaction, muscle injury, prolonged hypotension
R.I.F.L.E. Risk: <0.5ml/kg/hr > 6hrs Injury: <0.5 >12hrs Failure <0.3 >24hrs (oliguria <400ml/day) Loss: Persistent >4weeks Kidney Function LOss End-Stage: Complete loss >3 months aka CKD
How does AKI progress? Oliguric phase to diuretic, then recovery. If not CKD results requires dialysis & transplant.
Prerenal is.... Caused by external factors: burns, shock, dehydration, MI, ↓CO, renal thrombosis, cirrhosis fluid shift ↓ circulation ↓ UOP (oliguria or <.3ml/kg/hr for 24hrs) ↓ renal perfusion ↓ GFR
Are kidneys damaged during Prerenal? NO
Prerenal Azotemia ↓ excretion in sodium = ↑NA/H2O Retention =↓ UOP
Intrarenal is.... Caused by direct dmg to kidney tissue impairing nephrons- prolonged ischemia, nephrotoxins, sepsis, allergic reactions, AGN, SLE ATN most common cause Nephrotoxicity causes blockage of tubules *potentially reversable
Nephrotoxic agents Contrast, mycins, glycosides, antibiotics, sporins, NSAIDs, amphotericin, crush injury, chemical exposure to lead/ethanol/arsenic
Postrenal is.... Caused: BPH, prostate or bladder cancer, trauma to pelvis region, extrarenal tumors, calculi, spinal cord disease Bilateral ureter obstruction leads to hydronephrosis- if relieved w/48hrs poss recovery Prolonged obstruction irreversible
Oliguric Phase is defined as... <400ml/day 1-7 days post surgery, lasts 2wks Urine: casts, rbcs, wbcs, spec gravity stationary 1.010, urine osmo 300, Proteinuria may be present if renal failure is related to glomerular membrane dysfunction. Fluid retention causes heart failure, edema,
Best indicator of AKI is.. ↑ creat> 0.6-1.2
Urea and creatinine is... the end product of protein metabolism in kidneys
Diuretic Phase is Caused by High Urea and GFR- Kideneys can excrete nut not concentrate Lasts 1-3wks 1-5L daily in UOP ML for ML replaced bun/creat normalize at the end
Diuretic phase complications Hyponatremia, hypokalemia, & dehydration
AKI diagnostics Thorough PMH Serum creat urinalysis- casts, rbcs, wbcs, specific gravity 1.010, urine osmo 300 Kidney US Renal Scan CT w/o contrast Renal Biopsy
Hyperkalemia in AKI treatment Tx: Insulin and sodium bi-carb Calcium gluconate Kayexelate HD Dietary restriction
First step in treating AKI is Determine if adequate intravascular vol & CO to perfuse kidneys bc diuretic therapy may be used if AKI is not established loop diuretics lasix bumex mannitol
Fluid restriction in AKI 600ml + previous 24hr loss = intake restriction for the day
Never give kayexalate to Paralytic illeus
AKI risks Nephrotoxic drugs age trauma surgery burns heart failure sepsis ob complications pelvic trauma pre-existing ckd
Azotemia is ↑ bun and- urea- creat in blood
AKI nutrition Protein 1gm, K+ restriction, NA restriction, Phos restriction, Calcium supps or Phos binders, ↑Fat, 30-35kcal, cal 1000-1500mg, carbs
Nursing assessment of AKI Fluid intake and output Daily weight UOP color, glucose, gravity,protein,blood,casts skin color edema JVD bruising inflammation LOC crackles murmurs ecg for dysrythmias
Treatment of CAN Contrast assoc neuropathy- reversed by hydration plus bicarb or sodium chloride and mucomyst
Loss of 1kg is equal to 1000ml
Leading cause of death in aki is Infection
CKD is Progressive, irreversible loss of kidney function GFR <60ml/min/1.73 >3 months
CKD stages 1- >90 GFR/ 2- Mild GFR 60-89/ 3- Mod GFR 30-59/ 4- 15-29/ 5- <15 dialysis w/uremia present (uremia <10)
Uremia indicated by GFR<10ml/min
Clinical manifestations CKD Fatigue EARLY polyuria at night fixed gravity 1.010 Anuria UOP ↓40ml/24hrs Uremic pleuritis Hypertensive retinopathy encephalopathy amenorrhea or vaginal bleeding anemia osteo paresthesias scaly, flaky skin
Metabolic Distrurbances ↑ trig levels hyperinsulinemia stimulates
As GFR decreases... BUN and Creat increase
Most common cause of death in CKD Cardiovascular Disease
Fatal dysrhythmias can occur when K is.. 7-8
Anemia in CKD occurs bc Kidneys produce a hormone EPO, prompts bone marrow to make RBCs so when dmg occurs so does anemia Tx: Iron, erythropoietin epogen, folic acid 1mg/day, bleeding tendencies
CKD Infection Leukocytosis ↓ WBC ↑ Glucose- hyperglycemia- susceptible to infection trauma av/g site infection
You can feel a Thrill
You can hear a Bruit upon auscultation
Asterixis High ammonia levels cause hepatic encephalapathy and flapping of the hands when extended- also seen in renal
Diagnostics of CKD Persistent proteinuria 1+ 300mg/albumin/gm creat = CKD rbcs, wbcs, protein, casts, glucose
Drug therapy for CKD Statins- ↓LDL and Trig to <200 CCB (not diabetics), Aces&ARBS (ok diabetics), Anti HTN Phos Binder: PhosLo Calcium Acetate, Caltrate (cal carbonate), Renagel (sevlamer) Calcitrol IV (phos must be ↓first) Epogen,iron,folic, no transfusions
CKD nutrition is K Restricted NA Restricted 2-4g/day Protein Restricted ↓ Phos 1000mg Low Fat ↑carbs No salt subs 600ml+prev 24hr loss+ intake restriction
Drug therapy complications CKD Digoxin, Antibiotics, Demerol, NSAIDS, Fluid volume overload, Electrolyte imbalances
Early signs of CKD GFR<15ml >3months FATIGUE, lethargy, proteinuria, pruritus, HTN
Nursing Mgt CKD Daily weight Constant BP's Fluid overload monitoring Hyperkalemia (n/v, fatigue, paresthesias, brady) Strict Dietary Med Teaching HD & PD avail for home
Calories allowed HD 30-35/kcal/kg PD 25-35 kcal/kg/day (includes glucose fm dialysate)
CRRT Hemodynamically unstable clients- 24hr round the clock dialysis thru cannulation of artery or vein- much slower fluid pull than HD
Indications for RRT are... Volume overload hyperkalemia Metabolic Acidosis Bun >120 ↓LOC Pericarditis Peri-effusion Cardiac Tamponade
Hemodialysis is.. 4hrs daily or every other day 3-4x wk Used when rapid changes are needed in short time Req special staff, heparin, and close hypotension monitoring, weight monitoring pre and post dialysis
Hypovolemia.. Can exacerbate all forms of AKI
Metabolic Acidosis Kidneys cant synthesize ammonia, bicarb ↓acidic, and pt may develop kussmaul's
Peritoneal Dialysis Manual PD 30-50min- Auto 1-2 hrs Less invasive then HD Preferred in diabetic issue infection/perotonitis temporary cath
Complications of PD Site infection Peritonitis Hernias Atelectasis, pneumonia, bronchitis displacement of tube protein loss 10-20g/day or .5g/l exchanged lower back problems bleeding
PD pros and cons are.. Fewer dietary restrictions Greater mobility Great for pt w/bad vascular access Diabetics bc insulin can be given intraperitoneal Heparin not required
CAPD Continuous Ambulatory Peritoneal Dialysis 1.5L-3L removed 4xday Manual w/4hr dwell times
Foods high in phospherus Meat, milk, icecream, cheese, yogurt, dairy in general, pudding, chicken, fish, nuts, beans
Food high in salt Cured/processed meat, pickled, canned soup, canned veggies, stews, hot dogs, soy sauce, salad dressing
Foods high in Potassium Oranges, Bananas, melon, tomato, prune/raisin, deep green leafy veggies except kale, yellow veggies, white and sweet potato, beans, legumes, chocolate, granola, milk, PB, mushrooms, carrots, salt subs, salt-free broth
Why does hypocalcemia occur GI tract unable to absorb calcium in absence of VIT D. Phosphate binders can help. Phoslo admin w/ea meal- may need stool softener Vit-d <30- supplement cholecalciferol needed
Osmosis Movement of fluid to LESSER to GREATER of solutes
Diffusion Movement fm GREATER to LESSER concentrate.
Ultrafiltration Water & fluid removal- osmotic pressure gradient
Dialysis Solution 1-2L w/glucose 1.5/2.5/4.25% Similar to plasma Warmed to body temp High levels of peritoneal absorption lead to obesity , ↑trig, ↑BG
PD Inflow Phase 2L infused over 10min, flow rate can be ↓ for pain, close clamp after infused.
PD Dwell phase AKA Equilibrium Diffusion and osmosis b/t pt's blood & solution in perotoneal cavity 20min-8hrs (avg 4)
PD Drain phase Lasts 15-30 min may be facilitated w/gentle massaging or changing position
APD Automatic cycler times and controls equilibrium so pt can dialize while sleeping
CAPD Manual 1.5-3L exchanges x4day 7 12 5 10 risk for peritonitis
AV fistula forearm anastomosis of radial & cephalic vein 2lg needles used bruit you hear thrill you feel 3 months prior to HD not good for HTN, Vascular problems, DM
AV graft Bridge b/t brachial artery & vein antecubital 2-4 wks healing 2 lg needles used can't take bp, sticks, in that arm
Steal syndrome distal ischemia too much blood being shunted, pain, paresthesias, poor cap refill
Temp Vascular Access Jugular, femoral- preferred over sub only 1-3 weeks use ICU setting
Dialyzer Long plastic cartridge w/hollow tubes & filters - blood pumped into top fibers-dialysate pumped through bottom- clean blood then returns to pt
HD procedure 2 needles placed into fistula/graft one pulls blood to HD other returns it Heparin added to blood Diasilate warmed Alarms for air or blood leaks, temp, bp changes At the end, dialyzer is flushed with saline at the end,gentle pressure to site.
HD nursing fluid status, site, temp, skin, WEIGHT, lungs pre and post weight no more than 1-1.5kg gain b/t tx hypotension vs q30-60min HOLD MEDS PRIOR TO HD
HD complication hypotension d/t rapid removal hypovolemia, ↓CO, ↓vascular resistance, s/s: dizziness, vision changes, chest pain tx: ↓volume of fluids removed, increase saline 100-300ml
HD complication Muscle cramps d/t rapid removal of NA and H2O tx: reduce rate and infuse hypertonic or NS bolus
HD complication Blood Loss Blood incompletely rinsed, separation of tube, membrane rupture, bleeding site, too much heparin tx: rinse back blood, monitor pt/inr heparin
HD complication Hepatitis Blood transfusions lack of precautions or blood screening for hep c
Diff between CVVH and CVVHD CVVH doesn't require dialysate
Kidney transplant Less than 25% ppl receive one Eliminates need for dialysis Pre-emptive if living donor avail Persons <70 yr, that dont smoke, drugs, refractory CV diseases, chronic pulm, cancer that is wide spread
Procedures that may be required prior to tx refractory HTN- bilateral nephrectomy Polycystic Kidney Disease CABG or stent cholecystectomy in general both kidneys in recipient are usually not removed.
Histocompatibility Testing for HLA antigens for both donor and recipient ABO - O universal donor Test recipient for antigens- if negative that good match
Kidney transplant donor sources deceased w/compatibility blood relatives emotionally related donors paired organ donation
Expired donor fm relatively healthy person who suffered irreversible brain damage
Live donor Min Cold time- immediate organ avail Labs: 24hr clearance, creat, t protein, cbc, eletrolyte, aids/hep nephrectomy- donor goes first 1-2hrs, kidneys flushed, takes 3hrs, lap r illiac fossa preferred in recepient placed extraperotonealy
Post-op KT care Fluid Balance- prefusion- UOP HCT watch for fall >3pts Creat >1.4 maintain Fluid replaced ml for ml 12-24hrs cvp 8-15 Sudden decrease in UOP ATN can occur and dialysis may be needed
Sudden drop in UOP KT May be due to dehydration, rejection, urileaks, or obstruction
Nrsg Mgt KT Pre-op discuss immunosupps, ecg, cxr, labs, prevent infection
Immunosuppressive Drugs Tacrolimus, Cyclosporine - nephrotoxic Mycophenolate- thrombocytopenia, Prednisone/solumedrol- corticosteroids Sirolimus- leukopenia, Imuran- Anemia, Cyclophosphamide- neutropenia
S/E Immuno drugs peptic ulcers, HTN, Na/H2O retention, easy bruising, joint pain, delayed healing
KT infections CMV most common candida, cryptococcus, aspergillus, epstein-barr, hsv, utis pneumocystis- occurs first month
KT CV complications ↑atheroscerosis immunosupps ↑htn ↑hyperlipidemia Adhere to diet, htn meds, weight, dm, dash diet
Most common malignancies in KT Basal cell carcinoma- sunscreen avoid sun Lymphoma
Recurrence of Renal Disease in KT Glomerulonephritis IgA nephropathy DM Focal segmental Sclerosis
Corticoid related complications aseptic necrosis hips, joints peptic ulcer DM dylipidemia cataracts ↑ cancer ↑infection
Hyperacute rejection minutes to hours sudden ↑ BP
Acute rejection is days to months 3mo T cells attack, ↑bun, ↑creat, ↑temp, ↑BP, dec UOP
Chronic Rejection is Over months to years is irreversible proteinuria, ↑creat
Cirrhosis in general Chronic, slow progressive disease- abnormal re-shaping of the liver with fibrous tissue impedes blood flow, 8th leading cause of death
Two types of Cirrhosis are Biliary obstructive and cardiac from long standing right sided heart failure
Cirrhosis S/S Jaundice, thrombocytopenia, leukopenia, asteresis, edema/ascites, spider angiomas, palmar erythema, lesions, esophageal varices, libido, gynocomasteia, ammenorrhea, dec b12, dec folic
Causes of Cirrhosis EARLY sign: Fatigue, thrombocytopenia, hyperaldosterone Causes: alcohol, chronic hep c, protein malnutrition, environment, chronic inflammation
Decompensated cirrhosis is When the complications occur: portal htn, varices, ascites, hepatic encephalopathy, hepatorenal syndrome
Portal HTN ↑venous pressure splenomegaly large collateral veins in esophagus, abdomen, try to reduce ↑plasma load HTN varices
Cirrhosis Labs ↑AST ↑ALT ↓Stool bilirubin, ↓plt, ↓wbc, ↓alb/protein, ↑BUN ↑CREAT ↑Serum Bilirubin ↑ Urine Bilirubin ↑PT bleeding time
Hepatorenal Syndrome Renal failure w/Azotemia, oliguria, intractable ascites No structural dmg of kidneys Portal HTN leads to vasodilation leads to renal constriction Tx: transplant
Hepatic Encepalapathy Neurotoxic effect of ammonia CHange in LOC impaired asterexsis fetor hepaticus Tx: lactulose, rifaximin, antibiotic, prevent constipation, control gi bleeds
Cirrhosis diet w/o complication ↑Cal 3000-cal/day ↑Carb mod-low fat ↑Protein ↓NA (pts with edema)
Ascites 3rd spacing belly tx: NA restriction, albumin, potassium sparing aldactone amilodrine, tolvaptan, paracentesis, TIPS, vasopressor samsca
Esophageal varices Prevent bleeding, airway, blood products, baloon tamponade deflate 5 min q8-12 tips- non surgical transjugglar hepatoshunt ligation band sclera vitamin k PPI, lactulose, surgical: portocaval & distal spleen shunt with severe bleeding
Cirrhosis nursing rest, relief, teaching, nutrition assess jaundice, ascites, loc, labs relive pruitis monitor stool, urine girth measurement
Paracentesis void prior to procedure high fowlers sitting position monitor bp post procedure
Mgt of esophageal varices monitor for pettichiae, electric razor, soft bristle toothbrush, oral care, refractory bleeding may need shunt or tips, balloon tamponade, aspiration, scissors bedside for emergency
More s/s AKI Hypotension early, htn after fluid overload,memory impairment, anemia, dec plt, proteinuria, casts, rbcs, specific gravity 1.010, osmo 300, pulm edema, kussmaul, hypocalcemia, dysrhythmias, leukocytosis
Iron supplements are only given if Epogen/erythropoietin is being given
AKI Diet can have 1gm protein, fat, 30-35 kcal, carbs
PD diet can have K, phos 1.2g, protein, 25-35kcal
HD diet can have carbs, low fat, water restriciton
CKD diet can have carbs, low fat, water restriction
KT diet can have high protein, high fiber, fresh fruit and veggies cleaned and peeled, low fat low sodium low dairy
Cirrhosis diet can have High calorie 3000/day, high carb, 1500-2000, enteral protein nutrition prefferred
Hepatotoxic statins, beta blockers, tylenol, cillins, myacins, thiazides
High ammonia levels cause confusion
Created by: matthew0116