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Genitourinary #2

QuestionAnswer
What is renal failure? Inability of the kidneys to excrete metabolic waste products and water-leads to fluid/electrolyte/acid-base imbalances.
What is acute renal failure (ARF)? Abrupt onset of increased BUN and creatinine and inability of kidneys to regulate fluid and electrolytes.
What is BUN and its normal range? Blood urea nitrogen (urea is from protein breakdown). Normal range is 10-20 mg/dL
What is creatinine and its normal range? Nitrogenous waste from muscle metabolism-reflects GFR. Normal is 0.6-1.2 for men, 0.5-1.1 mg/dL for females.
What is the best indicator of renal failure and why? Creatinine! It is not affected by any other condition.
Describe the categories of ARF. (Hint: there's 3) Prerenal-caused by decreased blood flow (before kidneys). Intrarenal-caused by disease process (in kidneys). Postrenal-caused by any condition that obstructs urine flow (past kidneys).
What causes ARF? Prolonged renal ischemia (low blood flow) or nephrotoxic injury. BOTH lead to acute tubular necrosis (ATN)
What are the stages of ARF? Onset, oliguric, diuretic, and recovery. (OODR)
Describe the onset phase. Begins at time of insult and continues until s/s are apparent. Lasts hrs-days.
Describe the oliguric phase. Oliguria <400 mL urine OP in 24 hrs. High BUN, creatinine, potassium, phosphate, magnesium. Low calcium & pH (metabolic acidosis)
Describe the diuretic phase. May reach up to 10 L/d of dilute urine. Lab values stop increasing and eventually decrease-normal tubular function re-established.
Describe the recovery phase. Complete recovery may take up to 12 months. SOME never recover and progress to chronic renal failure.
What are the s/s of ARF r/t urinary changes? Urinary OP < 400 mL in 24 hrs, altered specific gravity (< 1.010 if intrarenal- >1.030 if prerenal), sediment in urine, proteinuria (if glomerular damage)
What are the s/s of ARF r/t fluid volume excess? Fluid retention, JVD, bounding pulses, edema, HTN, crackles. Can lead to CHF, pulmonary edema, or pericardial/pleural effusion
What are the s/s of ARF r/t metabolic acidosis? Kussmaul respirations (labored, heaving breathing) progressing to lethargy and stupor if no tx.
What are the s/s of ARF r/t sodium balance and potassium excess? Sodium levels can be normal or low (diluted)-should be avoided to prevent fluid retention. Potassium levels increase (worsened in crushing injury and acidosis) and may cause arrhythmias. K level of 6.0 or higher requires immediate tx.
What are the s/s of ARF r/t hypocalcemia and hyperphosphatemia? Low Ca (d/t decreased absorption d/t inactivated vit D) causes parathyroid to secrete PTH & release Ca from bones. Phosphate high anyway-bones release more.
What are the s/s of ARF r/t hematologic disorders? Anemia (d/t impaired erythropoietin production) compounded with platelet abnormalities can lead to abnormal bleeding. WBCs altered causing immunodeficiency. Infection = major cause of death in ARF!
What are the s/s of ARF r/t waste product accumulation and neurologic disorders? BUN & creatinine increased. Nitrogenous waste products accumulate in brain/nervous tissue causing mild fatigue, difficulty concentrating => seizures and even coma.
What are the diagnostic studies for ARF? Thorough hx (tx causative factors), urinalysis, CBC, CMP, x-rays, renal ultrasound (blood flow), CT scan & MRI (masses/vascular anomalities), intraveneous pyelogram (IVP), and renal biopsy
What medications are given for ARF? IV fluids/blood volume expanders, dopamine at renal dose, loop diuretics (given with dopamine), ACE inhibitors (for HTN), H2R blockers (prevent GI bleed), and aluminum hydroxide (lowers phosphate)
What medications should be d/c or adjusted if renal failure? (chronic or acute) D/c any nephrotoxic meds! May need to adjust other meds excreted by kidneys (esp. Digoxin-potentiated with hypokalemia)
Describe collaborative care for ARF. Monitor I&O/labs, monitor for hyperkalemia, limit protein (unless on dialysis), restrict sodium/potassium/phosphorus food intake, increase carbs.
What is the tx for hyperkalemia? Regular insulin IV with glucose, sodium bicarb (moves K intracellular), calcium gluconate, kayexelate (exchanges Na for K), or dialysis if severe (normal within 30 min-2 hrs)
What are the indications for dialysis in ARF? Volume overload compromising cardiac/pulmonary status, hyperkalemia with ECG changes, metabolic acidosis (bicarb <15 mEq/L), BUN > 120, altered mental status, or pericarditis/pericardial effusion/cardiac tamponade.
Is dialysis for ARF temporary or permanent? Usually temporary
List important nursing interventions for ARF pt with fluid volume excess. Hourly I&O, daily wt, edema (esp. periorbital), monitor LOC, lung sounds, heart sounds and ECGs, and lab values: K-heart, Na-neuro, P-tingling/tetany, Ca-tetany/Trousseau
List important nursing interventions for ARF pt at risk for infection. Sterile technique, avoid indwelling catheters, monitor for s/s of infection (redness, edema, fever, drainage, elevated WBCs), and assess dialysis access site for infection/patency (feel the thrill and hear the bruit!)
List important nursing interventions for ARF pt with imbalanced nutrition: less than body requirements. Provide frequent small meals and between meal snacks, engage pt in planning, admin antiemetics, weigh daily, and dietary consult
List gerontologic considerations for ARF. Elderly more susceptible d/t less functioning nephrons, impaired function of other organs, aging kidney less able to compensate for changes. Common causes are dehydration, hypotension, diuretics, obstructive d/o, sx, infection, or radioactive agents.
What is chronic renal failure (CRF)? Progressive, irreversible damage of nephrons. End stage renal failure (ESRF) involves every body organ and requires dialysis or kidney transplant. GRF is < 15 mL/min.
What are the common causes of CRF? Uncontrolled DM or HTN most common! May also be chronic glomerulonephritis, systemic lupus, or polycystic kidney disease.
What are the s/s of CRF r/t the urinary system? Polyuria -> oliguria -> anuria (<40 mL/day), nocturia, specific gravity fixed at 1.010
What are the s/s of CRF r/t the cardiovascular system? Hypertension (worsened by Na/fluid retention and increased renin production) and/or CHF with peripheral edema, left ventricular hypertrophy -> pulmonary edema
What are the s/s of CRF r/t metabolic disturbances? Waste product accumulation (s/s: low GFR, high BUN & creatinine, n/v, lethargy, ammonia breath/uremic fetor, uremic frost) and hyperlipidemia which increasis risk for atherosclerosis and cannot be decreased with dialysis-must take oral meds ('statins')
What are the s/s of CRF r/t electrolye/acid-base imbalances? Hyperkalemia, hyponatremia (still restrict!), hyperphosphatemia/hypocalcemia (may cause renal osteodystrophy), hypermagnesemia (no reflexes), and metabolic acidosis
What is renal osteodytrophy? Occurs with hyperphosphatemia-excess P complexes/combines leading to calcifications deposited throughout body (ex. uremic red eye = irritation from calcium deposited in eye)
What are the s/s of CRF r/t the hematologic system? Anemia (d/t decreased production of erythropoietin, nutrition deficiency, bleeding, or hemolysis), defective platelet function, altered immune response (leads to infection), increased incidence of cancer.
What are the s/s of CRF r/t the respiratory and GI systems? Pulmonary edema, fluid overload, uremic lung (interstitial edema on x-ray). GI inflammation, mucosal ulcerations -> risk for GI bleed
What are the s/s of CRF r/t the neurologic system? Lethargy, apathy, decrease in concentration, fatigue, irritability, seizures, coma, and peripheral neuropathy (tx Neurontin). Altered mental status = start dialysis.
What is dialysis encephalopathy? Progressive neurologic impairment associated with aluminum toxicity-very uncommon.
What are the s/s of CRF r/t the integumentary system? Gray-bronze discoloration, pallor, decreased perspiration, pruritis, uremic frost (BAD!)
What are the s/s of CRF r/t the reproductive and endocrine system? Infertility and decreased libido. S/s of hypothyroidism (low T3 and T4).
List important nursing management for CRF. Restrict potassium/sodium/fluid/phosphate. Give anti-hypertensives/diuretics/phosphate binders (Tums or Renagel)/vitamin D/erythropoietin/iron supplements. Avoid blood transfusions-suppresses erythropoiesis.
What are the complications of drug therapy in CRF? Drug toxicity from accumulation. Extreme caution with digoxin, NSAIDs, and aminoglycosides. NEVER give Demerol!!
What is dialysis? Movement of fluid and molecules across a semipermeable membrane from one compartment to another. Used to correct fluid/electrolyte imbalances and remove waste products.
What are the 3 types of dialysis? Hemodialysis, peritoneal dialysis (PD), and continuous renal replacement therapies (CRRT)
What is an arteriovenous fistula? Surgical connection of an artery and vein in the forearm. Takes 4-6 wks to heal. Best patency rates and east amt of complications.
What is an arteriovenous graft? Surgically anastomosed between artery and vein-made of synthetic materials (Teflon). Heals in 2-4 wks. Higher risk of infection and thrombosis.
Describe temporary vascular access. VAS-CATH: used for immediate access-temp or permanent. Inserted in large vein (jugular best). Red lumen-artery, blue lumen-vein. NO MEDS in this!
Describe long-term catheters. Temporary to await for fistula placement/long-term when other access methods fail. In upper chest wall and tunneled SQ to jugular vein, cath tip in right atrium. Dacron cuff = no sutures or infection.
List important nursing interventions for hemodialysis. Assess fluid stats before and compare difference after treatment. Assess condition of vascular access device. Monitor v/s q 15 or 30 min. Have heparin antidote-protamine sulfate. May add K to dialysate if hypokalemic
What are possible complications of hemodialysis? Hypotension (withhold bp meds before tx), muscle cramps, blood loss, hepatitis, and sepsis
What is disequilibrium syndrome? Cerebral edema caused by solutes being removed from blood faster than it can be removed from CSF and brain. May result in seizures, coma, or death.
What are the s/s of disequilibrium syndrome? Nausea/vomiting, confusion, restlessness, headache, twitching, jerking, muscle cramps, seizures, and hypotension.
Who is at risk for disequilibrium syndrome? Pt just starting dialysis, elderly, pediatric, severe metabolic acidosis, or pt with existing CNS disorders.
What is peritoneal dialysis (PD)? Permanent insertion of catheter into the peritoneal cavity-anchored by fibrous growth into Dacron cuffs. Must wait 7-14 days before use.
List advantages of PD. More independence, greater motility, and fewer dietary restrictions.
List contraindications for PD. Multiple abd surgeries, abd disorders, excessive obesity, chronic back problems, and COPD.
List possible complications from PD. Peritonitis (cloudy effluent)! Infection, referred pain, hernias, bleeding (new or prolonged bloody effluent) atelectasis/pneumonia/bronchitis, intestinal obstruction or strangulation, electrolyte imbalances, or cardiac dysrhythmias.
When is kidney surgery needed? Remove obstructions, insert tube for drainage, or to remove kidney.
List pre-op care for kidney surgery. Fluids, report abnormal lab values, discuss expectations.
List post-op care for kidney surgery. Monitor for s/s of shock or hemorrhage. Assess urine OP, color, catheter. Note placement/status/drainage of ureteral catheters/nephrostomy tubes/drains.
Describe pre-op care for kidney transplant. Normal metabolic state, complete physical/psychological exam, and help pt deal with concerns.
Describe post-op care for kidney transplant. Monitor urine OP (may take 2-3 wks if cadaver donation), strict I&O first 24 hrs, may need dialysis several days-weeks, and prevent/monitor for rejection or infection (WBCs differentiate).
What are the s/s of rejection and how are they prevented? Oliguria, edema, increased blood pressure, fever, wt gain, swelling/tenderness over kidney, or creatinine level > 20% rise. Prevent with immunosuppressive meds (cyclosporine-DOC) for rest of their life.
What are the possible complications of cyclosporine? Infection (teach s/s to pt), cancer, congenital abnormalities, or peptic ulcer disease (PUD)
Created by: 541787602