Renal A2 pt.1

renal systems regulates

blood pressure

body fluid volume

body fluid electrolyte composition

acid base balance

renal system eliminates

metabolic wastes

excess fluid

pt hx

renal/uro dx or injury

chronic dx impacting kidney function

surgeries

ct scan/IR procedure/cardiac cath in renal failure pt

illicit substances, smoking, alc, diet, exercise, occupational hx, change in weight/appetite, changes in exercise tolerance

meds that can be nephrotoxic

anti drugs

neuro physical exam

alertness

orientation

speech

fatigue level

pain physical exam

generalized?

renal in nature?

CV physical exam

vitals

resp

SOB/DOE

rales (crackles)

CVA tenderness

costovertebral angle tenderness

murphy’s percussion

focused physical exam

palpable bladder

COCA (dark yellow, pink, red, tea, coke, green)

urine output

catheter in place

dysuria

difficulty urinating

urinary frequency, urgency, hesistency

urinary retention

incontinence

dribbling

COCA

color

odor

consistency

amount

focused physical exam

skin (color, temp, turgor, edema)

renal access (vascath, dialysis fistula or graph)

pt hx labs and assesment

thrill

feel on fistula

bruit

hear on fistula

minimum output per hour

30cc/hr

or

240/ 8hr

ph range for output

4.6-8

ideal 6

specific gravity for output

1.001-1.005

normal urine doesnt have

glucose

blood

large protein amounts

wbc

diagnostic studies of renal

BUN

creatinine

GFR

creatinine clearance

BMP

uric acid

serum osmolality

what are renal dx used for

evaluating kidney function

dosing meds

determining if a pt can have a test (CT with contrast) or a procedure (IR) that requires contrast

blood urea nitrogen

waste product from breakdown of protein to urea

range: 7-18

creatinine

waste product from normal breakdown of muscle

range: 0.6-1.2

glomerular filtration rate

volume of fluid filtered from the glomerular capillaries into Bowman’s capsule per unit time

normally 20% of renal plasma flow

creatinine clearance

estimation of GFR

normal: 95-120

gold standard for evaluating kidney function

creatinine clearance

24 hr urine

first urine (throw out)

then all for next 24 hr collected

used to test creatinine clearance

when to start 24 hr urine test over

pt poops in it

miss one

not on ice

other common tests for renal

urine cultures (for specific infection, in clean catch)

tox screen (for certain drugs)

bladder scan

urodynamic studies

direct visualization tests (cystoscopy, ureterostomy)

continuous bladder irrigation (CBI)

continuous infusion of sterile solution into urinary bladder using 3 way irrigation system with triple lumen catheter to remove loose tissue, clots, mucus shedding

speed adjusted with roller clamp

managed and set up by the nurse

when is CBI used

post surgery that impact urinary tract

goal of CBI

clear to pink urine and adequate urine output

urinary retention

retention of urine in bladder

bladder scan

supine position with head raised abdomen exposed

to measure urine in bladder

if pt has hysterectomy she is considered

a male

diagnostics post bladder scan

urine for culture and sensitivity

acute kidney injury (AKI)

also known as acute renal failure

is a rapid dec in renal function or accumulation of metabolic waste in body

3 causes of AKI

pre renal

intra renal

post renal

pre renal AKI

think heart!

factors that reduce systemic circulation and cause reduction in renal blood flow (hypoperfusion)

dec perfusion —> dec in GFR

cause oliguria/anuria

autoregulatory mechanisms attempt to preserve blood flow

pre renal AKI common etiologies

severe dehydration

bleeding

CHF

sepsis

intran renal AKI

conditions that cause direct damage to kidney tissue

hemolyzed rbc and myoglobin released from necrotic muscle cells can block tubules and impair nephron function

intran renal AKI common etiologies

prolonged ischemia

nephrotoxins

traumatic damage to kidneys

acute tubular necrosis (ATN)

most common cause of AKI in hospitalized pt

from ischemia or nephrotoxins

potentially reversible if basement membrane is not destroyed and tubular epithelium regenerates

post renal AKI

sudden obstruction of urine flow due to enlarged prostate, stones, tumor, or injury

post renal AKI etiologies

cause a mechanical obstruction of outflow

bph

prostate cancer

calculi

trauma

extrarenal tumors

bilateral ureteral obstruction

AKI phases

oliguric

diuretic

recovery

oliguric phase AKI

urinary output <400ml/day

occurs within 1-7 days after injury

last 10-14 days

urinalysis may show casts, rbc, wbc

AKI oliguric phase clinical course

fluid volume (hypovolemia may exacerbate, dec urine output (jvd, bounding pulse, edema, htn, fluid overload)

metabolic acidosis

sodium balance

potassium excess

waste product accumulation

clinical manifestations oliguric phase

oliguria/anuria

SOB/crackles

JVD/elevated CVP

HTN

weight gain

fatigue/malaise

n/v

confusion

lethargy —> obtundation

nursing priorities of AKI oliguric phase

strict I&O

fluids y/n

weight daily

focused assessment

manage symptoms via nursing intervention (meds and non)

decompensation watching

diuretic phase AKI

daily urine output 1-3L

may reach 5L/day

kidneys regained ability to excrete wastes but cant concentrate urine (reabsorption impaired —> hypovolemia and hypotension

can last 1-3 weeks

nursing priorities for diuretic phase AKI

electrolytes

vitals

urine i & o strict

daily weight

find balance with fluids

iv carefully monitored

manifestations diuretic phase AKI

reduction in peripheral edema

tachycardia/hypotension

signs of dehydration

recovery phase AKI

begins when GFR inc so that BUN and creatinine start to stabilize

may take up to 12 months for kidney function to stabilize

AKI interventions**

pre renal: fluid and vasopressors (for hypotensive pt not responding to fluid)

intra-renal: limit nephrotoxic meds when possible, correct ischemic condition, dialysis may be needed

post renal: remove, break up, or medically treat obstruction, or ostomies

AKI indications for dialysis

no longer responding from medical interventions

volume overload unresponsive to diuretics

htn crisis related to renal failure

risk in dialysis

imminent risk for cardiac or brain injury

profound hyperkalemia

sever metabolic acidosis

significant change in mental status secondary to uremic encephalopathy

types of dialysis

peritoneal dialysis

hemodialysis

continuous renal replacement therapy

peritoneal dialysis

removes excess fluid and waste and resotores chemical and electrolyte balance

obtained by surgically inserting a catheter through anterior abdominal wall

PD procedure

1-2L of dialysate infused into abdominal cavity( solution may contain glucose, electrolytes)

solution must be warmed

fluid dwells in abdomen for time and diffusion and osmosis occurs between blood and peritoneal cavity

fluid is drained by gravity into drain bag (15-30 min)

advantages of PD

short training

simple

home based

inc pt participation

no need for special water systems

peritonitis in PD

watch for cloudy return, fever, rebound tenderness, abd pain, malaise, nausea

send outflow for specimen

peritonitis

inflammation of the lining in your stomach

complications of PD

exit site infections (difficult to treat and can lead to peritonitis)

pulling or twisting of catheter

insufficient flow of dialysate (try milking tube, x ray if migration suspected)

dialysate leakage (clear fluid)

hernias

lower back pain

bleeding

pulmonary complications

hemodialysis

removes excess fluid and waste and restores chemical and electrolyte balance

take blood out of body, clean it, return it

diffusion across membrane (filter)

what must HD be

anticoagulated

risk of bleeding 4-6h after dialysis

procedure for HD

in community based center

for 3-4 hours

3 days per week

keep same schedule

other HD options

short daily HD

home HD

hemodialysis access

temporary vascular access

arteriovenous fistulas and grafts

obtaining access is one of the most difficult problems

temporary vascular access

obtained by replacing dual or triple lumen catheter in subclavian or jugular (femoral short term)

bedside under sterile

placement verified by xray

infection risk (CLABSI)

HD complications

thrombosis/stenosis (check bruit and throll, declott or revisions)

infection

aneurysm formation

ischemia to distal areas to site (may have to d/c cath)

dialysis disequilibrium syndrome (cerebral edema develops —> neuro complications)

hepatitis infection

hypotension/vagal effects

muscle cramps

bleeding at site

AV fistula

anastomosis of artery to vein

inc blood flow about 400ml/min

can take up to 4 months to mature to be used

2 needles inserted (arterial and venous)

AV graft

a catheter surgically placed between vein and artery

acute pyelonephritis

inflammation of renal parenchyma and collecting system

acute pyelonephritis etiologies

bacterial infections (most common)

ECOLI!!

fungal, protozoa, viruses

what can acute pyelonephritis lead to

urosepsis

can lead to septic shock and death unless treated

acute pyelonephritis pre-existing factors present as

can present vesicoureteral reflux (retrograde movement of urine from lower to upper urinary tract

dysfunction of lower urinary tract (obstruction from bph, stricture, urinary stone)

urinary catheter CAUTI

acute pyelonephritis manifestations

flank pain (classic sign)

mild fatigue

sudden chills

fever

vomiting

malaise

lower urinary tract (dysuria, urgency, frequency)

CVA tenderness

acute pyelonephritis diagnostic studies

H&P

cbc with inc wbc

ua with bacteriuria and hematuria

renal ultrasound

acute pyelonephritis treatment

may require hospitalization if severe

broad spectrum antibiotics (ampicillin, vanco, tobramycin, gentamicin)

adequate fluid intake

pain management

follow up urine culture and imagining studies

acute glomerulonephritis

affect renal glomerulus

inflammation of glomeruli affecting both kidneys equally

may involve other renal structure

can be acute of chronic

acute glomerulonephritis risk factors

preceded by infection, recent surgery, recent travel, systemic dx (lupus)

when does acute glomerulonephritis symptoms start

10 days later

recover is usually complete and quick

acute glomerulonephritis etiology

strep most common

what can acute glomerulonephritis develop into

nephrotic or nephritic syndrome

acute glomerulonephritis manifestations

dyspnea/orthopnea

crackles

edema

heart sounds (gallop)

jvd

weight gain

changes in urine output

acute glomerulonephritis treatment

antibiotics

prevent complications (diuretics, water restriction, potassium/protein restriction, dialysis, plasmapheresis)

energy management (rest, minimized stress)

acute glomerulonephritis diagnosis

BUN/creatinine

UA (RBC, protein, rbc casts, positive for sediment)

24 hr urine for creatinine clearance to measure GFR and total protein

serum albumin (may be dec)

antistreptolysin-O (ASO) tite is elevated (post strep infection)

renal biopsy

nephrOtic syndrome

urinary excretion of 3.5g or more of protein/day

characteristic of glomerular injury

nephrOtic syndrome etiologies

primary: minimal change nephropathy, membranous glomerulonephrosis, and focal segmental glomerulonephrosis

secondary: systemic diseases such as diabetes and sclerosing autoimmune disorders

classic signs of nephrOtic syndrome

foamy urine

proteinuria (>3.5g)

patho nephrOtic syndrome

glomerular injury

inc glomerular filtration permeability to protein

loss of plasma proteins and immunoglobulins

dec vascular oncotic pressure

interstitial edema

nephrOtic syndrome manifestations

hypoalbuminemia/proteinuria of >3.5g/day

peripheral edema

foamy urine

weight gain

fatigue

vit D deficiency

hypercholesterolemia

nephrOtic syndrome diagnosis

H&P

UA

24 hr urine protein

low serum albumin level

nephrOtic syndrome treatment

moderation protein restriction

low fat diet

diuretics

steroids for immune related dx

certain bp meds may lower urine protein excretion

nephrItic syndrome

proteinuria but <3.5 grams (may have microscopic hematuria, rbc casts)

occurs primarily w/infection related glomerulonephritis and rapidly progressive crescentic glomerulonephritis, lupus, and diabetic nephropathy

nephrItic syndrome manifestations

same as nephrotic but with hematuria and less pronounced hypoalbuminemia/proteinuria

nephrItic syndrome diagnosis

same as nephrotic syndrome

H&P

UA

24 hr urine protein

low serum albumin level

nephrItic syndrome classic signs

<3.5 proteinuria

nephrItic syndrome treatment

similar to nephrotic

plasmapheresis may be needed

rhabdomyolysis

breakdown of damaged muscle which results in release of muscle cell contents in blood

what happens in rhabdomyolysis

protein and electrolytes released into the blood can cause organ damage including the kidneys