N2100 renal lecture spring 2014 voice over

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Nursing Lecture N2100 Renal Unit

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N2100 renal lecture spring 2014 voice over

  1. 1.       Homeostasis: acidbase, BP Excrete urea, toxins, water Produce Erythropoetin (hormone that stimulates RBC production) Produce Renin (reninangiotensin system regulates BP) Convert Vitamin D into useable form Think about the nursing implications of each!
  2. 2. Two thirds of all chronic kidney disease is related to other chronic illnesses. Diabetes (43%) Hypertension (23%) 1) Why and how do each of these conditions damage the kidney? 2) What can be done to prevent or manage these underlying conditions?
  3. 3.    Nephrotoxic Drugs: -Aminoglycosides: Ex. gentamycin, tobramycin, amikacin, neomycin -Amphotericin B -Vancomycin Chronic use of NSAIDS (especially cardiac patients and patients with cirrhosis) Patients with Creat > 2.0 who receive radiopaque contrast dye
  4. 4.    Glomerular filtration rate (GFR) is a test used to check how well the kidneys are working. Specifically, it estimates how much blood passes through the tiny filters in the kidneys, called glomeruli, each minute. The GFR test measures how well your kidneys are filtering a waste called creatinine, which is produced by the muscles.  When the kidneys aren't working well, creatinine builds up in the blood.  Normal results range from 90 - 120 mL/min/1.73 m2
  5. 5.  Lab values – Measuring kidney function  Serum Creatinine ◦ Creatinine is a product of creatine metabolism from muscle  dependent of muscle mass ◦ Creatinine is eliminated primarily by glomerular filtration (GFR). As GFR , serum creatinine . ◦ Doubling of creatinine suggests a 50% drop in GFR (estimated).
  6. 6.    Acute/Chronic Postinfection causes - Group A betahemolytic strep infection of throat Nursing Management
  7. 7.    Characteristic of glomerular injury from diabetets, infections, renal toxins, immune disorders. Excretion of 3.5 g or more of protein in the urine per day. Loss of serum proteins and sodium retention
  8. 8.    Glomerular capillaries are damaged  Leads to increased permeability to proteins Decreased osmotic pressure  leads to proteinuria, hypoalbuminemia, and edema. MAY LEAD TO RENAL FAILURE…..PREVENTION OF CAUSES IS CRITICAL!!!
  9. 9.   Progressive loss of renal function Associated with systemic disease such as hypertension, diabetes mellitus, intrinsic kidney disease.  Diabetes (40%), Hypertension (25%), and Glomerulonephritis (10%)  Kidney damage as GFR less than 60 ml/min/1.73m2 for 3 months or more.
  10. 10.     Altered fluid status and electrolytes Nutritional abnormalities Anemia Secondary hyperparathyroidism
  11. 11. Management and goals:    Restrict dietary protein Intensive insulin therapy if needed Optimize BP control (tight regulation) ◦ Goal for CKD – BP 130/85 ◦ Goal for Proteinuria – BP 125/75  Manage hyperlipidemia ◦ Goal of LDL - <100
  12. 12. Stage 1: Kidney damage but normal GFR (>90), “At risk” Stage 2: Kidney damage with mild decrease in GFR (60-89), “Chronic Renal Insufficiency” or CRI Stage 3: Moderate decrease in GFR (30-59), CRI or CRF (“Chronic Renal Failure”) Stage 4: Severe decrease in GFR (15-29), CHF Stage 5: Kidney Failure, GFR < 15, more than 90% of nephrons have lost function, ESRD “End Stage Renal Disease”, dialysis or transplant required to survive.
  13. 13. Rapid loss of renal function, progressive azotemia (accumulation of nitrogenous waste products such as BUN) and increasing serum creatinine.  Uremia (literally “urine in the blood”) is a condition in which renal function declines to the point that symptoms develop in multiple body systems.  Often associated with Oliguria (output less than 400 ml/day)  In 30% of cases there is a normal or increased urinary output  Oliguric patients have a higher mortality rate  Develops over hours or days with progressive elevation of BUN, creatinine, and K+.  ARF follows severe, prolonged hypotension or hypovolemia or exposure to a nephrotoxic agent, also can be due to obstruction of urine outflow. THINK PREVENTION!!!
  14. 14. 1. PRERENAL Impaired renal perfusion (shock, hypovolemia, volume shifts, CO, PVR, renal artery obstruction) 2. INTRARENAL Involves parenchymal changes (renal trauma, acute tubular necrosis, infectious diseases, glomerulonephritis) 3. POSTRENAL Obstruction to urinary tract prostate disease, obstruction, spinal cord injury, pelvic trauma)
  15. 15. 1. INITIATING PHASE  Begins at time of insult until S&S seen (hours to days) 2. OLIGURIC or ANURIC PHASE  Oliguria caused by GFR decrease  Begins 1-7 days after insult depending on cause  Usually lasts usually 10-14 days (may last up to 8 weeks)  Longer the phase, poorer prognosis of renal recovery  Manifestations are changes in UOP, fluid & electrolyte balances, & uremia   in serum levels of urea, creatinine, uric acid, K+ & Mg
  16. 16. Acute Renal Failure Stages 3. DIURETIC PHASE -Gradual increase of UOP can reach 1-2 (or more) L per day. Nephrons are still not fully functional -Caused by osmotic diuresis and inability of tubules to concentrate. -Recovered ability to excrete wastes, but not concentrate. -Monitor for hypokalemia, hyponatremia & dehydration -Hypovolemia and hypotension can occur Lasts 1-3 weeks -Acid-base, electrolyte and waste product levels begin to normalize.
  17. 17. 4. RECOVERY PHASE Begins when GFR increases allowing BUN and creatinine to reach a plateau and decrease May still have glycosuria and decreased ability to concentrate urine Major improvements first 1-2 weeks but may take 12 months to stabilize.
  18. 18.  May excrete as much as 2L/day  Urine dilute and iso-osmolar  Hypertension and tachypnea and symptoms of fluid overload are usually seen  Can see orthostatic hypotension and dry mucous membranes  Associated with less morbidity and mortality
  19. 19.   Urinalysis hemoglobin + in pylonephritis, protein + in diabetic nephropathy, glomerulonephritis, WBC (pyuria) + in infection •Specific gravity of urine 1.001-1.035 •Sodium levels -serum: 135-145 mmol/L -urine (usually 24 hour collection): 27-287mmol/d Hematocrit •Serum Creatinine .6-1.2 mg/dL •BUN 8-21, 10-31 if older than 90 •Urine Creatinine & Creatinine Clearance: Determines extent of nephron damage (decreased when 50% of nephrons lost)
  20. 20. -Treat cause -Maintain fluid and electrolyte balance -Prevent infection -Monitor for arrhythmias (related to K+and other electrolyte imbalances) -Maintain nutritional status  Adequate protein (or restriction) depending on catabolism  Restriction of K+, phosphate, magnesium, and/or sodium  Dietary fat 30-40% total calories  If necessary, use TPN and/or Ca supplements, phosphate-binders
  21. 21.      Protein: limit protein pre-dialysis (this slows progression of renal failure). During dialysis, protein is lost so patient will require more protein. Concentrate on high value protein (dairy and meat). Potassium: limit due to hyperkalemia, especially if on dialysis. Salt: restrict use of salt due to renal damage from ongoing hypertension. (canned goods, processed foods, “fast foods,”, table salt). Make sure salt substitute does not contain potassium. Phosphorus: elevated in patients with renal disease. (dairy products, yogurt, eggs) Fluid restriction: carefully follow restrictions
  22. 22. ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Fluid and electrolyte imbalance Susceptibility to secondary infections Anemia Platelet dysfunction Gastrointestinal (GI) complications Uremic encephalopathy Impaired wound healing Alteration in urine output Consider the role of the nurse in the prevention and management of each of these!
  23. 23.       Fluid volume deficit r/t (name cause or causes) Fluid volume excess r/t inability of kidneys to produce urine Risk for infection Disturbed thought processes Fatigue Anxiety
  24. 24. Monitor intake & output Assess vital signs Daily weights Evaluate skin turgor, mucous membranes ◦ Monitor dialysis site ◦ Monitor lab values (UA, ◦ ◦ ◦ ◦ Specific gravity, Sodium levels, BUN, & Serum creatinine*) (*best indicator of renal function, not altered by other temporary factors) ◦ Monitor urine (amount, color, specific gravity, glucose, protein, sediment, blood) ◦ Monitor for pain, bleeding, and neuro status/seizures ◦ Monitor for murmurs & dysrhythmias ◦ Prevent infection ◦ Frequent oral care ◦ Monitor lung sounds, pulmonary toilet ◦ Restrict fluids ◦ Education!
  25. 25. • The last stage of kidney failure where GFR is <15. Dialysis or transplantation required to survive. •80% of GFR may be lost with few overt changes in body. •Can survive without dialysis until almost 90% of nephrons are lost •Remaining nephrons hypertrophy and compensate. •When creatinine clearance <15 ml/min (normal 85-135) need transplant or dialysis to survive. •ESRD patients are eligible for Medicare Disability.
  26. 26. Initially, polyuria (mostly at night) due to inability to concentrate urine Later, anuria=< 40ml/day BUN rises (causing nausea, vomiting, lethargy, fatigue impaired thought process, headaches.) Serum creatinine rises, less so for older person Altered carbohydrate metabolism due to insulin resistance. Insulin is also dependent on kidneys for excretion Elevated triglycerides: hyperinsulinemia stimulates hepatic production of triglycerides. Atherosclerotic changes may worsen
  27. 27.       Hyperkalemia can cause fatal arrhythmias if >7.0-8.0 Metabolic acidosis Anemia Worsening hypertension Anorexia, nausea, vomiting Uremic breath     Neurologic changes Renal osteodystrophy r/t inability to produce vitamin D so calcium is released from the bones Skin changes: yellow, dry, pruritis, uremic frost (rare) Petechiae and bruising
  28. 28.  Preserve renal function  Delay need for dialysis or transplant  Alleviate symptoms  Improve body chemistry values  Provide optimal quality of life  Discuss living will and advanced directives
  29. 29.  Remove end products of protein metabolism from blood  Maintain a safe concentration of serum electrolytes  Correct acidosis and replenish bicarbonate levels  Remove excess fluid from the blood
  30. 30. DIALYSIS CONCEPTS ULTRAFILTRATION: Removal of fluid from blood using either osmotic or hydrostatic pressure DIFFUSION: Passage of particles (ions) from an area of high concentration to low concentration. SEMIPERMEABLE MEMBRANE has pores
  31. 31.      Semi-permeable membrane is the membrane lining the abdominal cavity 15% of dialysis in the USA, more outside US CAPD (Continuous Ambulatory Dialysis) doesn’t require electricity, drains in and out with gravity Advantages: may be done at home, fewer dietary restrictions, less cardiac stress, better for diabetic patients, good for patients with poor vascular access Disadvantages: peritonitis, requires surgery to place Tenckhoff catheter, protein loss, discomfort r/t fluids in abdomen
  32. 32.      Artificial membrane is inside a dialyzer Best for emergencies (rapid removal of fluids, urea and creatinine) and CRRT (Continuous Renal Replacement Therapy) Life schedule= 3-4 hours, 3x per week Advantages: effective K+ and triglyceride removal, less protein loss Disadvantages: vascular access problems, extensive equipment needed, hypotension, dietary and fluid restrictions, decreased independence
  33. 33.    External cannula or shunt Internal AV shunt (fistula) Looped synthetic graft
  34. 34. -Only skilled dialysis nurses can access a graft or shunt. -Although you NEVER USE a fistula or graft, you must ALWAYS ASSESS them: FEEL for a THRILL (vibration) LISTEN for a BRUIT (whooshing sound) In general, do not cover. Protect from infection. -If a SQ or IJ catheter has a dressing, use sterile technique when changing dressing. -No BPs, IVs, or labs in arm with access -Teach family to observe for s/s of infection
  35. 35.    Hypotension Sepsis: R/T infected access Disequilibrium Syndrome: due to rapid changes in blood of urea, sodium, causing high osmotic gradient in brain resulting in shift of fluid into brain causing cerebral edema. (Slow or stop dialysis, infuse saline, albumin or mannitol to draw fluid from brain cells back into systemic circulation.)  Blood Loss related to accidental dislocation of needle or separation of external shunt.
  36. 36.      Monitor weight, peripheral edema, BP, AP, heart sounds Check access, bruit and thrill Temperature (fever could indicate infection) Skin condition Hold BP meds & meds that can be dialyzed off (example: water-soluble vitamin supplements, etc.) Pharmacist can provide guidance, some drug books have an appendix listing dialysis safe medications, if any questions, consult MD
  37. 37.     54,000 are on a waiting list 14,000 transplants/year Waiting time for cadaver transplant: 18 mos. to 4 yrs. Need immunosuppressive therapy for life. Common oral medications include: Steroid (prednisone), Mycophenolate (MMF, Cellcept), Cyclosporine (CSA), tacrolimus (Prograf)   Monitor for rejection & infection Monitor urine output closely. Minimum post transplant should be 30ml/hr (720ml/day)
  38. 38.       Nursing Alerts Gerontological Considerations – throughout chapter Glomerulonephritis Nephrotic Syndrome/Nephrosclerosis Causes, Phases, & Prevention Acute Renal Failure –Chronic Kidney Disease – clinical manifestations –Dialysis Nursing Consideration for the patient with a kidney transplant

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