Med surg 2: exam 2

what is acute renal failure

rapid decline in renal function

increased BUN

decreased GRF

what is BUN

waste product from protein metabolism

what is creatine

waste product of muscle metabolism

what is GFR

speed of kidneys in filtrating blood/fluid

function of healthy kidneys

filter and remove waste products in the urine

which waste product best indicated renal failure

creatine

define azotemia

accumulation of BUN and Cr in the blood

what is uremia

accumulation of toxins in the blood

when does uremia occur with acute renal failure

during severe renal failure or end stage

effects of uremia

pulmonary edema

potassium

pericarditis

decreased consciousness

acidic blood

normal GFR

90-120

normal GFR for 60 year old

60 or higher

importance of getting baseline creatine and GFR

to be able to compare changes

risk for acute renal failure criteria

creatine: 1.5x normal levels

GFR: decreased 25% or more

criteria injury for kidneys for acute renal failure

creatine: 2x the normal/baseline level

GFR: decreased 50% or more

criteria for failure of kidneys in acute renal failure

creatine: 3x the normal/baseline level

GFR: decreased 75% or more

anuria

when is it considered end stage renal failure

GFR is under 15 for at least 3 months

4 phases of acute renal failure

1. initiation

2. oliguria

3. diuretic

4. recovery

what happens during the initiation phase of acute renal failure

exposure to the cause

causes of acute renal failure

iodine/contrast dye

bacteria

OD on NSAIDS

what happens during oliguria phase of acute renal failure

urine output of 400ml or less

waste products increase

distended jugular

crackles in the lungs

what are we worried about with acute renal failure

hyperkalemia

what happens during the diuretic phase of acute renal failure

filtration increases

urine output increases

waste products slowly decrease to normal

what to observe patient for in the diuretic phase of acute renal failure

dehydration

what happens during recovery phase of acute renal failure

renal function improves

urine output normalizes

renal function test improve

define pre-renal failure

factors that reduce blood flow to the kidneys

causes of pre renal failure

hypovolemia

decrease in cardiac output

obstruction of renal arteries/veins

cause of intrarenal or intrinsic failure

factors that produce direct damage to renal tissue

ways to combat intrarenal failure

remove causitive agent

give fluids

examples of what can cause intrarenal failure

iodine contrast

gadolinium contrast

nephrotoxic meds (NSAIDs)

acute polynephritis

what is postrenal failure

-caused by a factor that blocks the flow of urine and causes a back up or urine into the kidneys

-swelling within the ureters and kidneys and causes damage and infection

causes of postrenal failure

kidney stones

BPH

prostate backflow

bladder cancer

patho of pre-renal failure

decreased blood flow to kidneys

GFR decreases

RAAS and SNS activated

vasoconstriction of efferent artery

patho of intra-renal failure

reduced blood flow

edema of endothelial cells

reduces membrane permeability

GFR decreases

patho of post renal failure

urine flow is obstructed

urine backs into kidneys

hydronephrosis

increased pressure in renal tubules

decreased GFR

role of RAAS in acute renal failure

increase BP

role of aldosterone in acute renal failure

hold onto salt and water, kicks out potassiun

role of ADH with acute renal failure

holds onto fluid, thinks body is dehydrated

s/sx of acute renal failure

decreased urine output

proteinuria

volume overload

hyperkalemia

increased BUN and creatine

accumulation of waste products

cause of proteinuria in acute renal failure

kidneys cannot reabsorb protein into the bloodstream

effect of volume overload with acute renal failure

HTN

pulmonary edema

effect of hyperkalemia with acute renal failure

dysrhythmias

effect of increased BUN and creatine

n/v

effect if increased waste products

decreased appetite

lethargy

seizures

complications of acute renal failure

anemia

metabolic acidosis

hypocalcemia

hyperphosphatemia

puritis

diagnostics for acute renal failure

get medical hx and med list

find baseline Cr, BUN, GFR

abnormalities in serum electrolytes

urinalysis

renal ultrasound

why is a UA useful

revelas protein, blood, crystals, muddy brown casts

what does brown casts indicate with acute renal failure

acute tubular necrosis

goal of treatment with acute renal failure

find and treat cause of renal failure

prevent complications

return kidneys to normal state

airway priority for acute renal failure

not an issue unless uremia occurs

breathing concerns with acute renal failure

severe overload can cause edema and trouble breathing

circulation concerns with acute renal failure

determine fluid status

hypovolemic: give IV fluids

fluid overload: diuretics

diet changes for acute renal failure

high carbs

low salt, potassium, phos.

when would hemodialysis be needed for acute renal failure (AEIOU)

acidosis

electrolytes (low despite interventions)

intoxication

overload of fluids

uremic pericarditis or encephalopathy

dialysis treatments for acute renal failure

non tunneled catheter (Quinton) or tunneled cath (Permacath)

non tunneled vs tunneled cath

non: inserted into large vein, used urgently

tunneled: placed under skin then inserted into large vein, non urgent

which form of dialysis is riskier

tunneled

nursing care for catheters

inspection for hemorrhaging

IV pain relief

monitor for infection

teach about showering

what should be over a cath site

pressure dressing

tasks only a hemodialysis nurse should do

dressing changes

opening them, flushing

blood draws

most important nursing tasks done for inpatient hemodialysis

watch for fluid overload and disequilibrium syndrome

s/sx of disequilibrium syndrome

restlessness, headache, mental confusion, coma

cause of disequilibrium syndrome

HD causes rapid shifts of fluid in the brain

what does a EKG look life for a patient with acute renal failure

peaked T waves

pros of renal replacement therapy

more gentle and slower

where is renal replacement therapy done

in ICU for unstable patients

rapid hyperkalemia management for acute renal failure

-check EKG for peaked T waves

-give regular 10 units of regular insulin IV with 1 amp of 50% dextrose

-high dose of albuterol

meds given for hyperkalemia management for acute renal failure

Kayexalate

Calcium gluconate

how does kayexalate work

Na is exchanged for K+ in the bowel. K+ is removed via diarrhea

what juices should not be mixed with kayexalate

prune

grape

apple

orange

tomato

purpose of giving Calcium gluconate

prevents myocardial irritability

which steroids are produced by the adrenal gland

corticosteroids

3 types of corticosteroids

glucocorticoid

mineralcorticoids

androgens

function of glucocorticoids

released in response to stress and low BS

function of mineralcorticoids

retains water and salt while eliminating K+

cause of cushing’s syndrome

treatment with corticosteroids/ excess cortisol

adrenal tumors

tumors of lung/pancreas

cause of cushing’s disease

pituitary tumors

some lung cancers

s/sx of cushing’s syndrome

buffalo hump

trunkal obesity

moon face

acne

facial hair

risk of bone fx

normal cortisol levels at 8am

5-23 mcg/dl

best method to measure elevated cortisol levels

24 hour urinary cortisol collection test

why are blood tests unreliable for determining cushing’s

cortisol spikes at different times

blood tests done to measure cortisol levels

elevated serum ACTH

elevated serum cortisol

hyperglycemia

hypokalemia

what does an elevated serum ACTH mean

tumor on the pituitary gland or lung

scans done to diagnose cushing’s syndrome

CT

MRI

reason for a CT for cushing’s disease

assess for adrenal tumors

reason for MRI for cushing’s disease

assess for pituitary tumor

tx if pituitary tumor is the cause of cushing’s

remove pit. gland through sphenoid sinuses

tx if adrenal tumor is the cause of cushings

adrenalectomy

if steroid admin is the cause of the cushings

reduce dose of corticosteroids

why would we first reduce the doses if we suspect cushing’s

if symptoms still persist after ween, that is when we would do tests

what is Addison’s

insufficient adrenal corticosteroids

causes of Addison’s

autoimmune and adrenal hemorrhage

timeframe where steroids can suddenly be stopped

5-7 days

GI symptoms for Addison’s

n/ v

constipation

abdominal pain

diarrhea

telltale symptom of Addison’s

hyperpigmented skin

affect of Addison’s on blood glucose

hypoglycemia

lab value changes for Addison’s

decreased aldosterone

decreased sodium

increased ACTH

places to check for hyperpigmentation in Addison’s

palms and armpit

effect of Addison’s on hair

thins hair

effect of Addison’s on muscle

loses muscle tone