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Transcript of Jules Brinley, RN, MSN/Ed, CNE. Which statement does not accurately characterize the kidneys: ◦...
Renal FailureJules Brinley, RN, MSN/Ed, CNE
Which statement does not accurately characterize the kidneys:◦ A. Each kidney contains millions of nephrons,
which produce urine.◦ B. The loop of Henle is the main filtration system
within the nephrons.◦ C. The kidneys receive more than 1 liter of blood
from the heart every minute.◦ D. The afferent arterioles carry unfiltered blood
from the renal arteries to the glomerular capillaries.
Question
Acute Kidney Injury (AKI)
Causes◦ Prerenal failure: decreased blood flow to
glomeruli ◦ Intrarenal failure: nephrotoxic agents, kidney
infections, occlusion of intrarenal arteries, hypertension, diabetes mellitus, or direct trauma to the kidney
◦ Postrenal failure: obstructions beyond the kidneys that cause urine to back up
Question The risk of developing prerenal failure is
greatest in a patient with:◦ A. Systemic lupus erythematosus.◦ B. Acute glomerulonephritis.◦ C. Heart failure.◦ D. Acute pyelonephritis.
Acute Kidney Injury (AKI): Stages Onset stage
◦ Short (1-3 days); increasing BUN and serum creatinine with normal to decreased urine output
Oliguric stage◦ The urine output decreases to 400 mL/day or
less ◦ Serum values for BUN, creatinine, potassium,
and phosphorus increase ◦ Serum calcium and bicarbonate decrease ◦ Follows onset stage and continues for up to 14
days
Question Which laboratory test result reflects the
oliguric phase of acute renal failure? A. BUN = 34 mg/dl B. Creatinine = 1 mg/dl C. Sodium = 159 mEq/liter D. Potassium = 3.4 mEq/liter
Acute Kidney Injury (AKI): Stages Diuretic stage
◦ Urine output exceeds 400 mL/day; may rise above
4 L/day ◦ Kidneys excrete BUN, creatinine, potassium,
and phosphorus and retain calcium and bicarbonate
Recovery stage◦ As renal tissue recovers, serum electrolytes,
BUN, and creatinine return to normal ◦ This stage lasts 1 to 12 months
Acute Kidney Injury (AKI)
Medical treatment ◦ Fluid and dietary restrictions, restoration of
electrolyte balance, and dialysis◦ Drug therapy◦ Diet ◦ Fluids ◦ Hemodialysis and peritoneal dialysis ◦ Continuous renal replacement therapy
Question In acute kidney injury (AKI), what
contributes to metabolic acidosis?◦ A. The renal tubules’ inability to form bicarbonate◦ B. Excess sodium conservation by the renal
tubules◦ C. Too few hydrogen ions, which increases the
blood pH◦ D. Potassium movement from extracellular to
intracellular fluid.
Acute Kidney Injury (AKI)
Assessment◦ Monitoring fluid status is critical◦ Signs and symptoms of electrolyte imbalances◦ Signs and symptoms related to immobility:
pressure sores, impaired circulation, constipation, and atelectasis
◦ Fears, anxiety, coping strategies, sources of support
Acute Kidney Injury (AKI)
Interventions◦ Excess Fluid Volume ◦ Decreased Cardiac Output ◦ Anxiety ◦ Disuse Syndrome ◦ Deficient Knowledge
Question The nurse is developing a plan of care for a
client diagnosed with AKI. Which statement is an appropriate outcome for the patient?◦ A. Monitor intake and output every shift.◦ B. Decrease of pain by 3 levels on a 1-10 scale.◦ C. Electrolytes are within normal limits◦ D. Administer enemas to decrease hyperaklemia.
Involves progressive, irreversible loss of kidney function
Chronic Kidney Disease (CKD)
Defined as presence of ◦ Kidney damage
Pathologic abnormalities Markers of damage
Blood, urine, imaging tests
◦ Glomerular filtration rate (GFR) <60 mL/min for 3 months or longer
Chronic Kidney Disease
Disease staging based on decrease in GFR ◦ Normal GFR 125 mL/min, which is reflected by
urine creatinine clearance◦ Last stage of kidney failure
End-stage renal disease (ESRD) occurs when GFR <15 mL/min
Chronic Kidney Disease
In Chronic renal failure, the GFR usually is affected when how many nephrons are damaged?◦ A. LESS THAN 25%◦ B. FROM 40%-50%◦ C. FROM 60% - 70%◦ D. MORE THAN 75%
Question
Up to 80% of GFR may be lost with few changes in functioning of body.
Remaining nephrons hypertrophy to compensate.
End result is a systemic disease involving every organ.
Chronic Kidney Disease
Which of the following is NOT a likely cause of chronic renal failure?◦ A. Diabetes◦ B. Hypertension◦ C. Aplastic anemia◦ D. Glomerulonephritis
Question
Each year, 70,000 people die from causes related to renal failure.
More than 26 million Americans have CKD. Mortality rates are 19% to 24% for those
with stage 5 CKD on dialysis.
Chronic Kidney Disease
Leading causes of ESRD◦ Diabetes◦ Hypertension
Chronic Kidney Disease
Result of retained substances◦ Urea◦ Creatinine◦ Phenols◦ Hormones◦ Electrolytes◦ Water◦ Other substances
Clinical Manifestations
Uremia◦ Syndrome that incorporates all signs and
symptoms seen in various systems throughout the body
Clinical Manifestations
Clinical Manifestations
Fig. 47-2. Clinical manifestations of chronic kidney disease.
Polyuria◦ Results from inability of kidneys to concentrate
urine ◦ Occurs most often at night◦ Specific gravity fixed around 1.010
Clinical ManifestationsUrinary System
Oliguria ◦ Occurs as CKD worsens
Anuria ◦ Urine output <40 mL per 24 hours
Clinical Manifestations Urinary System
Waste product accumulation◦ As GFR ↓, BUN ↑ and serum creatinine levels ↑
BUN ↑ Not only by kidney failure but by protein intake, fever,
corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and
headache may occur.
Clinical ManifestationsMetabolic Disturbances
Altered carbohydrate metabolism◦ Caused by impaired glucose use
From cellular insensitivity to the normal action of insulin
Clinical Manifestations Metabolic Disturbances
Defective carbohydrate metabolism◦ Patients with diabetes who become uremic may
require less insulin than before onset of CKD.◦ Insulin dependent on kidneys for excretion
Clinical Manifestations Metabolic Disturbances
Elevated triglycerides◦ Hyperinsulinemia stimulates hepatic production of
triglycerides.◦ Altered lipid metabolism
↓ levels of enzyme lipoprotein lipase Important in breakdown of lipoproteins
Clinical Manifestations Metabolic Disturbances
Potassium◦ Hyperkalemia
Most serious electrolyte disorder in kidney disease Fatal dysrhythmias
Clinical ManifestationsElectrolyte/Acid-Base Imbalances
Sodium◦ May be normal or low◦ Because of impaired excretion, sodium is
retained. Water is retained.
Edema Hypertension CHF
Clinical Manifestations Electrolyte/Acid-Base Imbalances
Calcium and phosphate alterations Magnesium alterations
Clinical Manifestations Electrolyte/Acid-Base Imbalances
When reviewing the laboratory test results for a patient with chronic renal failure, you should NOT expect to find:◦ A. Decreased sodium and calcium levels.◦ B. Increased blood pH and bicarbonate levels◦ C. Urine with red blood cells and a low specific
gravity.◦ D. Decreased red blood cell count, hemoglobin
level, and hematocrit.
Question
Metabolic acidosis◦ Results from
Inability of kidneys to excrete acid load (primary ammonia)
Defective reabsorption/regeneration of bicarbonate
Clinical Manifestations Electrolyte/Acid-Base Imbalances
Hematologic System Anemia
◦ Due to ↓ production of erythropoietin From ↓ in functioning renal tubular cells
Bleeding tendencies◦ Defect in platelet function
Clinical Manifestations
Hematologic System Infection
◦ Changes in leukocyte function◦ Altered immune response and function◦ Diminished inflammatory response
Clinical Manifestations
Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis
Clinical Manifestations
Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Uremic pleuritis
Clinical Manifestations
Respiratory System Pleural effusion Predisposition to respiratory infection
Clinical Manifestations
Gastrointestinal System Every part of GI is affected.
◦ Due to excessive urea Mucosal ulcerations Stomatitis Uremic fetor (urinous odor of breath) GI bleeding Anorexia, nausea, vomiting
Clinical Manifestations
Neurologic System Expected as renal failure progresses
◦ Attributed to ↑ nitrogenous waste products Electrolyte imbalance Metabolic acidosis Axonal atrophy Demyelination of nerve fibers
Clinical Manifestations
Neurologic System Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate Peripheral neuropathy
Clinical Manifestations
Neurologic System Altered mental ability Seizures Coma Dialysis encephalopathy
Clinical Manifestations
Musculoskeletal System CKD mineral and bone disorder
◦ Systemic disorder of mineral and bone metabolism
◦ Results in skeletal complications (osteomalacia, ostetis fibrosa) and extraskeletal (vascular) calcifications
Clinical Manifestations
Mechanisms of CKD-MBD
Fig. 47-3. Mechanisms of chronic kidney disease–mineral and bone disorder (CKD-MBD). GFR, Glomerularfiltration rate.
Integumentary System Pruritus Uremic frost
Clinical Manifestations
Reproductive System Infertility
◦ Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction
Clinical Manifestations
Psychologic Changes Personality and behavioral changes Emotional ability Withdrawal Depression
Clinical Manifestations
History and physical examination Dipstick evaluation Albumin-creatinine ratio (first morning void) GFR
Diagnostic Studies
50
Renal ultrasound Renal scan CT scan Renal biopsy
Diagnostic Studies
Conservative Therapy Correction of extracellular fluid volume
overload or deficit Nutritional therapy Erythropoietin therapy Calcium supplementation, phosphate
binders
Collaborative Care
Conservative Therapy Antihypertensive therapy Measures to lower potassium Adjustment of drug dosages to degree of
renal function
Collaborative Care
Drug Therapy Hyperkalemia
◦ IV insulin IV glucose to manage hypoglycemia
◦ IV 10% calcium gluconate
Collaborative Care
Drug Therapy Hyperkalemia (cont’d)
◦ Sodium polystyrene sulfonate (Kayexalate) Cation-exchange resin Resin in bowel exchanges potassium for sodium.
Collaborative Care
Drug Therapy Hypertension
◦ Weight loss◦ Lifestyle changes◦ Diet recommendations◦ Sodium and fluid restriction
Collaborative Care
Drug Therapy Hypertension (cont’d)
◦ Antihypertensive drugs Diuretics Calcium channel blockers ACE inhibitors ARB agents
Collaborative Care
Drug Therapy CKD-MBD
◦ Phosphate intake restricted to <1000 mg/day
Collaborative Care
Drug Therapy CKD-MBD
◦ Phosphate binders Calcium carbonate (Caltrate)
Binds phosphate in bowel and excretes Sevelamer hydrochloride (Renagel)
Lowers cholesterol and LDLs
Collaborative Care
Drug Therapy CKD-MBD
◦ Phosphate binders (cont’d) Should be administered with each meal Side effect: Constipation
Collaborative Care
Drug Therapy CKD-MBD
◦ Supplementing vitamin D Calcitriol (Rocaltrol) Serum phosphate level must be lowered before
calcium or vitamin D is administered.
Collaborative Care
Drug Therapy CKD-MBD
◦ Controlling secondary hyperparathyroidism Calcimimetic agents
Cinacalcet (Sensipar) ↑ sensitivity of calcium receptors in parathyroid glands
Subtotal parathyroidectomy
Collaborative Care
Drug Therapy Anemia
◦ Erythropoietin Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3
weeks Side effect: Hypertension
Collaborative Care
Drug Therapy Anemia (cont’d)
◦ Iron supplements If plasma ferritin <100 ng/mL Side effects: Gastric irritation,
constipation May make stool dark in color
Collaborative Care
Drug Therapy Anemia (cont’d)
◦ Folic acid supplements Needed for RBC formation Removed by dialysis
◦ Avoid blood transfusions.
Collaborative Care
Drug Therapy Dyslipidemia
◦ Goal Lowering LDL below 100 mg/dL Triglyceride level below 200 mg/dL
◦ Statins HMG-CoA reductase inhibitors
Most effective for lowering LDL
Collaborative Care
Drug Therapy Complications
◦ Drug toxicity Digitalis Antibiotics Pain medication (Demerol, NSAIDs)
Collaborative Care
Nutritional Therapy Protein restriction
◦ Benefits are being studied. Water restriction
◦ Intake depends on daily urine output.
Collaborative Care
Nutritional Therapy Sodium restriction
◦Diets vary from 2 to 4 g, depending on degree of edema and hypertension.
◦Sodium and salt should not be equated. ◦Salt substitutes should not be used
because they contain potassium chloride.
Collaborative Care
Nutritional Therapy Potassium restriction
◦ 2 to 3 g◦ High-potassium foods should be avoided.
Collaborative Care
Nutritional Therapy Phosphate restriction
◦ 1000 mg/day◦ Foods high in phosphate
Dairy products ◦ Most foods high in phosphate are also high in
protein.
Collaborative Care
Complete history of any existing renal disease, family history
Long-term health problems Dietary habits
Nursing ManagementNursing Assessment
Excess fluid volume Risk for injury Imbalanced nutrition: Less than body
requirements Grieving Risk for infection
Nursing ManagementNursing Diagnoses
Overall goals◦ Demonstrate knowledge and ability to comply
with therapeutic regimen.◦ Participate in decision making. ◦ Demonstrate effective coping strategies.
Nursing ManagementPlanning
Overall goals (cont’d)◦ Continue with activities of daily living within
psychologic limitations.
Nursing ManagementPlanning
Health promotion◦ Identify individuals at risk for CKD.
History of renal disease Hypertension Diabetes mellitus Repeated urinary tract infection
◦ Regular checkups and changes in urinary appearance, frequency, and volume should be reported.
Nursing ManagementNursing Implementation
Acute intervention◦ Daily weight◦ Daily BPs◦ Identify signs and symptoms of fluid overload.◦ Identify signs and symptoms of hyperkalemia.◦ Strict dietary adherence
Nursing ManagementNursing Implementation
Acute intervention◦ Medication education◦ Motivate patients in management of their disease.
Nursing ManagementNursing Implementation
Ambulatory and home care◦ When conservative therapy is no longer effective,
HD, PD, and transplantation are treatment options.
◦ Patient/family need clear explanation of dialysis and transplantation.
Nursing ManagementNursing Implementation
Maintenance of ideal body weight Acceptance of chronic disease No infection No edema Hematocrit, hemoglobin, and serum
albumin levels in acceptable range
Nursing ManagementEvaluation
When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to:
1. Monitor for proteinuria daily with a urine dipstick.
2. Weigh daily and report a gain of greater than 4 pounds.
3. Take calcium-based phosphate binders on an empty stomach.
4. Perform self-catheterization every 4 hours to accurately measure I & O.
Question
81
Case Study
82
35-year-old man began to notice weakness with activities such as walking distances or running.
Also began experiencing tingling all over his body, particularly in his hands and feet
Case Study
Symptoms progressed over 4 months, with 10 pounds of weight lost with no decline in appetite.
Increased urinary output with normal frequency
Strong thirst at night
Case Study
Sought out medical help because he was afraid he was getting diabetes
History reveals grandmother and aunt have diabetes with no family history of renal disease.
Case Study
At age 5, he was admitted to the hospital for hematuria.◦ Urinary protein 4+◦ BUN 31 mg/dL◦ Hb 11.6 g/dL◦ Was diagnosed with acute glomerulonephritis
Case Study: History
At age 11, he was admitted to the same hospital with gross hematuria.◦ Albuminuria 4+◦ BUN 10.5 mg/dL◦ Hb 15.7 g/dL◦ Diagnosed with recurring acute
glomerulonephritis
Case Study: History
He had no follow-up medical care after that hospitalization until his current admission to the hospital.
Case Study
Current lab values◦ Potassium 6.0 mEq/L◦ BUN 110 mg/dL◦ Creatinine 12 mg/dL◦ Hct 20%◦ Hb 6 g/dL
Case Study
1. Why would his symptoms seem similar to diabetes?
2. Why is he developing chronic renal failure so many years after his primary diagnosis?
Discussion Questions
3. What is the priority of care for him?
4. What patient teaching should be done with him?
Discussion Questions
Focus on Dialysis
JSB
Movement of fluid/molecules across a semipermeable membrane from one compartment to another
Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure
Treat drug overdoses
Dialysis
Two methods of dialysis available◦ Peritoneal dialysis (PD)◦ Hemodialysis (HD)
Dialysis
Begun when patient’s uremia can no longer be adequately managed conservatively
Initiated when GFR (or creatinine clearance) <15 mL/min
Dialysis
Diffusion◦ Movement of solutes from an area of greater
concentration to an area of lesser
General Principles of Dialysis
Osmosis and Diffusion Across Semipermeable Membrane
Osmosis◦ Movement of fluid from an area of lesser to an
area of greater concentration of solutes
General Principles of Dialysis
Ultrafiltration◦ Water and fluid removal◦ Results when an osmotic gradient occurs across
the membrane
General Principles of Dialysis
Peritoneal access is obtained by inserting a catheter through the anterior wall.
Technique for catheter placement varies. Usually done via surgery
Peritoneal Dialysis
Tenckhoff Catheter
Fig. 47-5. Peritoneal dialysis showing peritoneal catheter inserted into peritoneal cavity.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
After catheter is inserted, skin is cleaned with antiseptic solution and sterile dressing applied.
Connected to sterile tubing system Secured to abdomen with tape Catheter irrigated immediately
Peritoneal Dialysis
Waiting period of 7 to 14 days preferable 2 to 4 weeks after implantation,
exit site should be clean, dry, and free of redness/tenderness.
Once site has healed, patient may shower and pat dry.
Peritoneal Dialysis
Peritoneal Catheter Exit Site
Fig. 47-6. Peritoneal catheter exit site.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%
Electrolyte composition similar to plasma Solution warmed to body temperature
Peritoneal DialysisDialysis Solutions and Cycles
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Three phases of PD cycle◦ Inflow (fill)◦ Dwell (equilibration)◦ Drain
Called an exchange
Peritoneal DialysisDialysis Solutions and Cycles
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Inflow◦ Prescribed amount of solution infused through
established catheter over about 10 minutes◦ After solution infused, inflow clamp closed to
prevent air from entering tubing
Peritoneal DialysisDialysis Solutions and Cycles
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Dwell◦ Diffusion and osmosis occur between patient’s
blood and peritoneal cavity.◦ Duration of time varies, depending on the
method.
Peritoneal DialysisDialysis Solutions and Cycles
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Drain◦ 15 to 30 minutes◦ May be facilitated by gently
massaging abdomen or changing position
Peritoneal DialysisDialysis Solutions and Cycles
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Automated peritoneal dialysis (APD)◦ Cycler delivers the dialysate.◦ Times and controls fill, dwell, and drain.
Continuous ambulatory peritoneal dialysis (CAPD)◦ Manual exchange
Peritoneal DialysisSystems
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Automated Peritoneal Dialysis
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Exit site infection Peritonitis Hernias
Peritoneal DialysisComplications
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Lower back problems Bleeding Pulmonary complications Protein loss
Peritoneal DialysisComplications
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Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD
Peritoneal DialysisEffectiveness and Adaptation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
The patient diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse?◦ A. The ability to auscultate a bruit over the
fistula.◦ B. The dialysate instilled was 1,500 ml and
removed was 1,500 ml.◦ C. The dialysate being removed from the client’s
abdomen is clear.◦ D. The client’s abdomen is soft, is nontender, and
has bowel sounds.
Question
Obtaining vascular access is one of the most difficult problems.◦ Types of access include
Arteriovenous fistulae and grafts Temporary vascular access
HemodialysisVascular Access Sites
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Vascular Access for Hemodialysis
117
Fig. 47-8. Vascular access for hemodialysis. A, Arteriovenous fistula. B, Arteriovenous graft.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Arteriovenous Fistula
Fig. 47-9. Arteriovenous fistula created by anastomosing an artery and vein.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Vascular Access Catheter
Fig. 47-10. Temporary double-lumen vascular access catheter for acute hemodialysis. A, Soft, flexible double-lumen tube is attached to a Y hub. B, The distance between the arterial intake and the venous return lumina typically provides recirculation rates of 5% or less.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Vascular Access Catheter
Fig. 47-11. A, Right internal jugular placement for a tunneled, cuffed semipermanent catheter.B, Temporary hemodialysis catheter in place. C, Long-term cuffed hemodialysis catheter.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Long plastic cartridge that contains thousands of parallel hollow tubes or fibers
Fibers are the semipermeable membrane.
HemodialysisDialyzers
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Two needles placed in fistula or graft
Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer.
Blood is returned from dialyzer to patient through second needle or blue catheter.
HemodialysisProcedure
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Components of Hemodialysis
Fig. 47-12. Components of a hemodialysis system. Blood is removed via a needle inserted in a fistula or viacatheter lumen. It is propelled to the dialyzer by a blood pump. Heparin is infused either as a bolus predialysis or through a heparin pump continuously to prevent clotting. Dialysate is pumped in andFlows in the opposite direction of the blood. The dialyzed blood is returned to the patient through aSecond needle or catheter lumen. Old dialysate and ultrafiltrate are drained and discarded.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Dialyzer/blood lines primed with saline solution to eliminate air
Terminated by flushing dialyzer with saline to remove all blood
Needles removed and firm pressure applied
HemodialysisProcedure
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Before treatment, nurse should◦ Complete assessment of fluid status, condition of
access, temperature, and skin condition During treatment, nurse should
◦ Be alert to changes in condition◦ Perform vital signs every 30 to 60 minutes
HemodialysisProcedure
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The patient is receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?◦ A. Place the patient in the Trendelenburg
position.◦ B. Turn off the dialysis machine immediately.◦ C. Bolus the client with 500ml of NS◦ D. Notify the health-care provider as soon as
possible.
Question
Hypotension Muscle cramps Loss of blood Hepatitis
HemodialysisComplications
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Cannot fully replace metabolic and hormonal functions of kidneys
Can ease many of the symptoms Can prevent certain complications
HemodialysisEffectiveness and Adaptation
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The patient receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the patient?◦ A. Encourage significant other to make decisions
for the client.◦ B. Keep fingernails short and try not to scratch
the skin.◦ C. Apply ice to the access site if it starts bleeding
at home.◦ D. Notify the HCP if oral temperature is 102 F or
greater.
Question
Alternative or adjunctive method for treating AKI
Means by which uremic toxins and fluids are removed
Acid-base status/electrolytes adjusted slowly and continuously
Continual Renal Replacement Therapy (CRRT)
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Can be used in conjunction with HD Contraindication
◦ Presence of manifestations of uremia requiring rapid resolution
Continued for 30 to 40 days
Continual Renal Replacement Therapy (CRRT)
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Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow. Specimens may be obtained for evaluation.
Continual Renal Replacement Therapy (CRRT)
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Two types of CRRT◦ Venous access◦ Arterial access
Continual Renal Replacement Therapy (CRRT)
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Most common: Venovenous approaches ◦ Continuous venovenous hemofiltration (CVVH)◦ Continuous venovenous hemodialysis (CVVHD)
Continual Renal Replacement Therapy (CRRT)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Continuous Vevovenous Therapies
Fig. 47-14. Basic schematic of continuous venovenous therapies. Blood pump is required to pump blood through the circuit. Replacement ports are used for instilling replacement fluids and can be given prefilteror postfilter. Dialysate port is used for infusing distillate. Regardless of modality, ultrafiltrate is drainedvia the ultrafiltration drain port.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Continuous venovenous hemofiltration (CVVH)◦ Large volumes of fluid removed hourly, then
replaced◦ Fluid replacement dependent on
stability/individualized needs of patient
Continual Renal Replacement Therapy (CRRT)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Continuous venovenous hemodialysis (CVVHD)◦ Uses dialysate◦ Dialysate bags attached to distal end of
hemofilter
Continual Renal Replacement Therapy (CRRT)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Continuous venovenous hemodialysis (CVVHD)◦ Fluid pumped countercurrent to blood flow◦ Ideal treatment for patient who needs fluid/solute
control but cannot tolerate rapid fluid shifts with HD
Continual Renal Replacement Therapy (CRRT)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Highly permeable, hollow fiber hemofilter Uses double-lumen catheter placed in
femoral, jugular, or subclavian vein. Removes plasma water and nonprotein
solutes
Continual Renal Replacement Therapy (CRRT)
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CRRT versus HD◦ Continuous rather than intermittent◦ Solute removal by convection (no dialysate
required), in addition to osmosis and diffusion◦ Less hemodynamic instability
Continual Renal Replacement Therapy (CRRT)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
CRRT versus HD (cont’d)◦ Does not require constant monitoring by HD nurse◦ Does not require complicated HD equipment
Continual Renal Replacement Therapy (CRRT)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased quantity of:
1. Fat.2. Protein.3. Calories.4. Carbohydrates.
Question
142Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Case Study
143Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
65-year-old woman with history of progressive renal failure for 5 years
Diagnosed with type 1 diabetes mellitus when 15 years old
Case Study
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She has diabetic retinopathy with macular degeneration.
Gives herself insulin using an insulin pen
Case Study
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Lab values◦ BUN 72 mg/dL◦ Serum creatinine 7.5 mg/dL◦ GFR 12 mL/min
Case Study
1. What are her options for renal replacement therapy?
2. Which one would be the best choice for her?
Discussion Questions
Focus on Kidney Transplant
Kidney Transplantation More than 75,000 patients are currently
awaiting kidney transplants. Less than ¼ ever receive a kidney.
Kidney Transplantation Extremely successful 1-year graft survival rate
◦ 90% for cadaver transplants◦ 95% for live donor transplants
Kidney Transplantation Advantages of kidney transplant compared
with dialysis◦ Reverses many of the pathophysiologic changes
associated with renal failure◦ Eliminates dependence on dialysis◦ Less expensive than dialysis after the first year
Kidney TransplantationRecipient Selection Candidacy determined by a variety of
medical and psychosocial factors that vary among transplant centers.
Kidney TransplantationRecipient Selection Contraindications to
transplantation◦ Disseminated malignancies◦ Untreated cardiac disease◦ Chronic respiratory failure◦ Extensive vascular disease◦ Chronic infection◦ Unresolved psychosocial disorders
Kidney TransplantationHistocompatibility Studies Purpose of testing is to identify the HLA
antigens for both donors and potential recipients.
Kidney TransplantationDonor Sources Compatible blood type deceased donors Blood relatives Emotionally related living donors Altruistic living donors Paired organ donation
Kidney TransplantationSurgical Procedure Live donor
◦ Nephrectomy performed by a urologist or transplant surgeon
◦ Begins an hour or two before the recipient’s surgery is started
◦ Rib may need to be removed for adequate view ◦ Takes about 3 hours
Kidney TransplantationSurgical Procedure Live donor
◦ Laparoscopic donor nephrectomy Alternative to conventional nephrectomy Most common approach of live kidney procurement
Kidney TransplantationSurgical Procedure Kidney transplant recipient
◦ Usually placed extraperitoneally in the iliac fossa◦ Right iliac fossa is preferred.
Kidney Transplant
Fig. 47-15. A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney.
Kidney Transplantation Surgical ProcedureKidney transplant recipient Before incision
◦ Urinary catheter placed into bladder◦ Antibiotic solution instilled
Distends the bladder Decreases risk of infection
◦ Crescent-shaped incision
Kidney Transplantation Surgical ProcedureKidney transplant recipient Rapid revascularization critical Donor artery anastomosed to recipient
internal/external iliac artery Donor vein anastomosed to recipient
external iliac vein
Kidney Transplantation Surgical ProcedureKidney transplant recipient When anastomoses complete,
clamps released and blood flow reestablished
Urine may begin to flow, or diuretic may be given.
Surgery takes 3 to 4 hours.
Kidney TransplantationNursing Management Preoperative care
◦ Emotional and physical preparation◦ Immunosuppressive drugs◦ ECG◦ Chest x-ray◦ Laboratory studies
Kidney TransplantationNursing Management Postoperative care
◦ Live donor Care is similar to laparoscopic nephrectomy. Close monitoring of renal function Close monitoring of hematocrit
Kidney TransplantationNursing Management Postoperative care (cont’d)
◦ Recipient Maintenance of fluid and electrolyte balance is first
priority. Large volumes of urine soon after transplanted
kidney placed due to New kidney’s ability to filter BUN Abundance of fluids during operation Initial renal tubular dysfunction
Kidney TransplantationNursing Management Postoperative care (cont’d)
◦ Recipient Urine output replaced with fluids milliliter by milliliter
hourly Urine output closely measured
Acute tubular necrosis can occur. May need dialysis
Maintain catheter patency.
Kidney TransplantationImmunosuppressive Therapy Goals
◦ Adequately suppress the immune response.◦ Maintain sufficient immunity to prevent
overwhelming infection.
Kidney TransplantationComplications Rejection
◦ Hyperacute (antibody-mediated, humoral) rejection Occurs minutes to hours after transplantation
Kidney TransplantationComplications Rejection (cont’d)
◦ Acute rejection Occurs days to months after transplantation
Kidney TransplantationComplications Rejection (cont’d)
◦ Chronic rejection Process that occurs over months or years and is
irreversible
Kidney TransplantationComplications
Infection◦ Most common infections observed in the first
month Pneumonia Wound infections IV line and drain infections
Kidney TransplantationComplications Infection (cont’d)
◦ Fungal infections Candida Cryptococcus Aspergillus Pneumocystis jiroveci
Kidney TransplantationComplications Infection (cont’d)
◦ Viral infections CMV
One of the most common Epstein-Barr virus Herpes simplex virus
Kidney TransplantationComplications Cardiovascular disease
◦ Transplant recipients have increased incidence of atherosclerotic vascular disease.
◦ Immunosuppressant can worsen hypertension and hyperlipidemia.
◦ Adhere to antihypertensive regimen.
Kidney TransplantationComplications Malignancies
◦ Primary cause is immunosuppressive therapy.◦ Regular screening is important preventive care.
Kidney TransplantationComplications Recurrence of original renal disease
◦ Glomerulonephritis◦ IgA nephropathy◦ Diabetes mellitus◦ Focal segmental sclerosis
Kidney TransplantationComplications Corticosteroid-related complications
◦ Aseptic necrosis of the hips, knees, and other joints
◦ Peptic ulcer disease◦ Glucose intolerance and diabetes
Kidney Transplantation Complications Corticosteroid-related complications
(cont’d)◦ Dyslipidemia◦ Cataracts◦ Increased incidence of infection and malignancy ◦ Close monitoring of side effects
Nursing ManagementEvaluation Maintenance of ideal body weight Acceptance of chronic disease No infection No edema Hematocrit, hemoglobin, and serum
albumin levels in acceptable range
Six days after a kidney transplant from a deceased donor , the patient develops a temperature of 101.2° F (38.5°C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate:
1. Acute rejection, which is not uncommon and is usually reversible.2. Hyperacute rejection, which will necessitate removal of the transplanted kidney.3. An infection of the kidney, which can be treated with intravenous antibiotics.4. The onset of chronic rejection of the kidney with eventual failure of the kidney.
Question
180
Case Study
181
Case Study (same patient as in dialysis presentation) 65-year-old woman with history of
progressive renal failure for 5 years
Diagnosed with type 1 diabetes mellitus when 15 years old
Case Study (same patient as in dialysis presentation) After waiting for 9 months, she is notified
that a diseased (cadaver) kidney has become available.
The kidney transplant is done.
Discussion Questions
1. She does very well postoperatively and is ready for discharge. What are the priority teaching interventions?
Discussion Questions
2. Because she is a diabetic individual, what are her special needs?