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Genitourinary #2
| Question | Answer |
|---|---|
| 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) |
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