NUR 213 exam #3 Dialysis, AKI, AKD, CKD, PTSD

Dialysis

Removal of waste & extra fluid the kidneys can’t handle

Hemodialysis

Removal of waste by the use of an artificial kidney (dialyzer)

• toxins and wastes in blood are removed by diffusion (higher concentration (blood) to an area of lower concentration (dialysate: circulates the machine), heparin to prevent clotting

Immediate vascular access

Central catheter

• Double lumen, large bore in right/ left jugular/ femoral vein in leg (temporary, removed once permanent access is established)

• Risks: hematoma, bleeding, pneumothorax, increased infection, thrombosis, inadequate flow

Fistula

• Connects artery to vein

• Takes 3 months to mature

• 2 IVs (arterial: goes to dialyzer then return via the venous segment

• Longer lifespan

Graft

Used if blood vessels aren’t compatible for a fistula

• synthetic tubing connects artery to vein

• Quick placement

• In arm, thigh, chest

• Increased risk of infection

Nursing actions before dialysis

• assess graft/ fistula

• Baseline vitals

• Hold key meds (BP)

• Baseline weight

Nursing actions during dialysis

• monitor vitals

• Assess blood loss

• Monitor muscle cramps

Nursing actions after dialysis

• Monitor vitals

• Assess access site for bleeding

• Weights

Peritoneal dialysis

Peritoneum used as a membrane to perform dialysis

• dialysate infused through a catheter & into peritoneal cavity ( catheter is clamped & dialysate filters the waste in the abdomen then drained out)

• Diffusion occurs as waste moves from blood to the dialysate through the peritoneum

Complication of peritoneal dialysis

Peritonitis (swelling of belly)

• redness, swollen, distended stomach, pain, tenderness, cloudy fluid, exit site red w/ pus, fever, N/V

Nursing management for HD & PD

• Pre treatment: labs weight, vitals, review new orders

• During: document vitals & catheter/fistula site

• After: weight, vitals

• HD complications: change in vitals, pain, arrhythmias

• PD complications: peritonitis, leakage, bleeding

• Education: fluid restriction, proper diet, family education

Continuous renal replacement therapy (CRRT)

Double linen catheter is placed in femoral artery or jugular vein

• connected to hemofilter where solutes are removed so the blood is filtered of toxins

• ICU setting

• Every hour monitoring

• Usher when too unstable for HD or PD

Function of kidney

Maintains volume & composition of body fluids

• Clears waste from protein metabolism & maintains acid base & electrolyte balance

• Excretes drugs

• Regulates vitamin D activation (helps maintain & regulate calcium)

• Regulates BP (RAAS)

• Production & secretion of erythropoietin (RBCs)

Blood urea nitrogen

Measures the amount of urea nitrogen in blood (7-20)

Creatinine

A waste product produced by muscle metabolism (0.6-1.2)

eGFR

Amount of plasma filtered through the glomeruli per unit of time (90-120)

• considered the best measure of overall function of the kidney

Urine specific gravity

Indicates how well the kidneys are concentrating urine (1.010-1.030)

Kidney diagnostic tests

• Renal ultrasound (obstructions & abnormalities of GU)

• CT (masses of vascular abnormalities)

• Renal scan

• Biopsy (cause of kidney disease, most definitive)

RIFLE

Classification of AKI, used to identify kidney injury and improve outcomes

• Risk, Injury, Failure, Loss, ESKD

• Risk, injury, & failure are grades of AKI severity

• Loss & ESKD are outcomes of loss that require RRT

AKI

Rapid loss of renal function

• causes build up of nitrogenous waste products & impairs F&E balance

• Tx: dialysis, RRT, restore normal chemical balance (treat underlying cause: hypovolemia, infection, HF, kidney stones), maintain F&E (I&Os, weight, BP), nutrition support (low sodium & potassium, high carb)

• Most common indicator is azotemia (accumulation of nitrogenous waste in blood and a decrease in GFR)

• S/S: 50% or greater increase in creatinine, increased BUN & sudden decrease in urine

• Monitor for complications, assess progress of interventions, pretty infection, support

Prerenal AKI

Most common, decrease in renal blood flow

• caused by:

• loss of extra cellular fluid volume: GI losses (vomit, diarrhea, NG suction), hemorrhage, renal losses (diuretics, osmotic diuresis)

• impaired perfusion: arrhythmias, cardiogenic shock, hf, mi

• vasodilation: anaphylaxis, anti HTN meds, sepsis hemorrhage

• Main symptom: low UO

Intrarenal AKI

Results from conditions that cause damage (ischemia) to structures within the kidney (parenchyma, vessels, tubules, interstitium

• anemia, rhabdomyolysis, ACE inhibitors, heavy metals, NSAIDS, acute glomerulonenephritis, acute pyelonephritis

Postrenal AKI

Result from obstruction of urine flow (calculi, stictures, tumors, prostatic hyperplasia *, blood clots)

Initiation phase of AKI

Initial, ends when oliguria occurs

Oliguric phase of AKI

Decreased urine output, increase in BUN & CR, uremic symptoms first appear, hyperkalemia

Diuretic phase of AKI

Recovery begins, gradual increase in urine output, labs stabilize, monitor for dehydration

Recovery phase of AKI

Recovering (up to 12 months), labs are normal

CKD

Damage of decrease in GFR for more than 3 months, permanent loss of nephrons = kidney failure

• caused by prolonged inflammation that isn’t organ specific (HTN, diabetes, obesity)

• Albuminuria** key sign

• Azotemia** key early sign

• Stage GFR: 1 (>90), 2 (89-60), 3 (59-45), 4 (44-30), 5 (29-15) ESKD (<15)

• S/S: increased CR, decreased GFR & RBCs (anemia), edema, HF, fluid retention, F&E imbalance, puritus (result of too much phosphorus)

• Monitor labs, treat underlying cause, encourage exercise, low sodium/potassium/phosphorus, smoking cessation

CKD in kids

Causes severe growth impairment

• developmental delays, delay in sexual maturation, bone abnormalities, psychosocial problems

• Physical/cognitive development are significantly slowed

CKD management

Treat underlying cause, early referral

• Treat hyperglycemia, manage anemia, encourage smoking cessation, weight loss, exercise program, reduce salt and alcohol intake, minimize nephrotoxins

ESKD

Severe kidney damage, RRT required permanently

• uremia develops

• Disease progresses faster if excreting excess amounts of proofing and show HTN

• Severity of symptoms dependent on amount of kidney impairment

• Meds: vitamins, anti HTN, erythropoietin, dialysis

• Monitor: labs, sodium, acidosis, anemia

Nephrotic syndrome

Increased glomerular permeability and proteinuria, results from glomerular damage

• leak of massive amounts of protein (albumin)

• Causes: acute glomerulonephritis, cancer, drugs, bee sting/pollen, HIV, hepatitis, mono, syphillis, malaria, diabetes

• S/S: pitting edema everywhere, proteinuria, hypoalbuminemia, frothy, foamy urine, high cholesterol, hyperlipidemia, hypercoagulability (increased risk for DVT, renal VT, PE

• Dx: 24 hr urine

• Mangement: treat underlying cause, prevent AKI, meds, relieve symptoms, measure abd. girth, I&Os, weight, low sodium/ fluid diet, monitor for blood clots

• Meds: diuretics, albumin infusions, corticosteroids, ACE/ ARBS

Acute nephritic syndrome (glomerulonephritis)

Inflammation of glomerular capillaries (leakage of RBCs, mild protein loss)

• causes: infections, beta hemolytic strep infections, HIV, Hepatitis B, Epstein Barr, autoimmune diseases

• S/S: HTN, hematuria, edema, azotemia, severe flank pain, headache, mild proteinuria, tea colored urine, pus, cellular & granular casts in urine

• Labs: low GFR, high BUN/ CR

• Mangement: monitor BP, I&Os, potassium, edema, diet (low sodium & fluid)

• Tx: meds depend on cause, ‘treating the symptoms’ → corticosteroids, antibiotics, manage HTN, control proteinuria

• Diet: low protein & sodium

Chronic glomerulonephritis

Kidney shrinks to 1/5 their size, glomeruli scarred

• can progress to CKD if not managed

• May have no symptoms

• S/S: high BUN/ CR, proteinuria, HTN, poor nourishment, periorbital/peripheral edema, neuro changes, nocturia, headaches, dizziness, digestive disturbances

• Management: manage symptoms, daily weights, diuretics, dialysis,education, monitor labs

• Avoid NSAIDS

Polycystic kidney disease

Incurable genetic disorder

• growth of fluid filled cysts in kidneys → kidney failure

• Most common side effect is polyuria

Nephrosclerosis

Hardening of renal arteries

• causes: HTN, diabetes, aging

• Progresses elevation of BUN, CR

• Mild proteinuria

• TX: ACE inhibitors

Priority assessments & cues in kidney disorders

• Assess for: anorexia, N/V, lethargy, fatigue = high BUN

• Monitor for: neuro changes, itching, signs of fluid overload, hyperkalemia, metabolic acidosis (kussmaul breathing), anemia

• Review OTC meds that may be toxic

Loop diuretics

Block chloride pump in the ascending loop of henle ( inhibits NA, K, Cl transporters)

• greatest degree of diuresis

• Furosemide, bumetanide, torsemide

• Ototoxic so push slow

• Monitor: electrolytes, vitals, I&Os, daily weights

• SE: alkalosis, hypokalemia, hypotension, hypercalcemia

Potassium sparing diuretics

Prevent reabsorption of sodium in the distal tubule collect duct while holding on to potassium

• not as powerful, used in conjunction with other diuretics

• Spironolactone

Thiazide diuretics

Block the chloride pump in the distal convoluted tubule

• keep chloride and sodium in the tubule to be excreted in the urine, thus preventing the reabsorption of Cl and NA in the vascular system

• Doesn’t increase UO (urine will have high concentration of NA)

• ASE: GI upset, F&E imbalances, hypotension

• Hydrocholorothiazide, chlorothiazide

Trauma

Disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury

Types of trauma

Individual, collective

Individual trauma

Abuse, illness, sudden loss

Collective trauma

Disasters, historical trauma, generational trauma

PTSD

Disturbed pattern of behavior lasting at least 1 month, disrupts ADLs

• follows a traumatic event, starting at 3 months post event

• Caused by actual or potential threat

• Feelings of intense fear, helplessness, terror

• S/S: reexperiencing trauma (dreams, intrusive/recurrent thought), avoidance, negative cognition/thoughts, being on guard, hyperarousal

• Risks: trauma, peri-trauma dissociation, existing psychiatric disorders, poor support, high stress

Adjustment disorder

Reaction causes problems, starts within 1 month & lasts no longer than 6 months

• group of symptoms (stress, sadness, hopelessness) & physical symptoms that occur following a stressful event

• Reaction is stronger than would be expected for the event that occurred

Acute stress disorder

Reexperiencing, avoidance, hyperarousal

• starts 3 days to 4 weeks, PTSD can follow

Reactive attachment disorder

Occurs before 5, response to trauma of child abuse or neglect

• Exhibits minimal social and emotional responses to others, lacks a positive effect, may be sad, irritable, or afraid for no apparent reason

Disinhibited social engagement disorder

Occur before 5, responded to trauma of child abuse or neglect

• exhibits undelevtive socialization, allowing/ tolerating social interaction with all people, they lack hesitation approaching or talking to others

Dissociative amnesia

Disruption of memory

Dissociative identity disorder

> 2 identities/ personalities

Depersonalization/ derealization disorder

Detachment from body/self, dream like unreal environment, repressed memories

Assessment for PTSD

• Appearance/motor behavior: hyper alert, anxious

• Mood/ affect: angry, scared

• Cognitive concerns: oriented until flashback, memory gaps

• Self awareness: variable

• Self concept: guilt, low self esteem

• Relationship concern: difficulty maintaining them

• Physiological concerns: insomnia, substance abuse

PTSD Treatment

Counseling, CBT (exposure therapy: addresses avoidance), cognitive restructuring/ processing (addresses negative thoughts), adaptive disclosure, SSRIs

PTSD caring interventions

Discuss self harm thoughts, help develop a plan for going to a safe place, grounding techniques, validate their feelings/fear, supportive touch, deep breathing, distraction techniques, establish support system, convey empathy, be nonjudgmental