1
Q
What is the function of the kidneys?
A
“A WET BED”:
- A: Acid-base balance
- W: Water balance
- E: Electrolyte balance
- T: getting rid of Toxins
- B: Blood pressure control
- E: making Erythropoietin
- D: Vitamin D production
2
Q
What are the general interventions for any kidney problem?
A
- assess vital signs for FVO or FVD
- check electrolytes
- monitor intake and output
- weigh daily
- monitor renal labs - BUN, creatinine, GFR
3
Q
What 2 groups can have decreased kidney function?
A
Elderly and infants.
Be more concerned with nephrotoxicity from meds and substances in these 2 groups.
4
Q
What are some common classifications of medications that are nephrotoxic?
A
- antibiotics
- antineoplastics
- NSAIDs
5
Q
Describe:
Acute kidney injury (AKI)
A
The rapid loss of kidney function.
The client can recover but it can take years.
6
Q
What causes prerenal AKI?
A
Prerenal AKI is damage to the kidneys caused by problems before the kidneys such as:
- decreased cardiac output from shock
- prerenal infection or obstruction
The kidneys aren’t getting blood flow causing damage.
7
Q
What causes intrarenal AKI?
A
Intrarenal AKI is damage to the kidneys caused by problems inside the kidneys such as:
- renal infection
- nephrotoxic meds or substances
8
Q
What causes postrenal AKI?
A
Postrenal AKI is damage to the kidneys caused by problems in the bladder which is after the kidneys such as:
- bladder obstruction, infection or cancer
- kidney stones
9
Q
What are the 3 phases of AKI?
A
- oliguric phase: pee very little
- diuretic phase: pee a lot
- recovery phase: pee normally
10
Q
Describe:
Oliguric phase of AKI
A
- lasts 1 - 2 weeks
- urine output is very low at < 400 mL/day
- will get signs of fluid volume overload
11
Q
What are the labs in the oliguric phase of AKI?
A
Due to fluid volume overload and retaining toxins and electrolytes:
- ↑ BUN and ↑ creatinine
- ↓ GFR
- ↑ potassium and ↓ sodium (or sodium will be normal)
- ↑ phosphorus and ↓ calcium
12
Q
Describe:
Diuretic phase of AKI
A
- lasts 10 - 14 days
- urine output is excessive at 4 - 5 liters/day
- will get signs of fluid volume deficit
13
Q
What are the labs in the diuretic phase of AKI?
A
Due to fluid volume deficit:
- gradual decline in BUN and creatinine (but both still ↑)
- ↓ GFR, but improving
- ↓ potassium and ↓ sodium
- kidneys are able to get rid of extra electrolytes
14
Q
Describe:
Recovery phase of AKI
A
- may take 1 - 2 years
- urine output is normal
Can progress to chronic kidney disease if damage was extensive.
15
Q
Why can clients with AKI get confused and eventually go into a coma?
A
The client with AKI is retaining fluids and electrolytes and is unable to get rid of nitrogenous waste products.
This causes metabolic acidosis, which can cause confusion.
16
Q
Interventions:
Oliguric phase of AKI
A
Focus on the problems associated with fluid volume overload:
- restrict fluids
- if hypertension is present, restrict fluids to < 1000 mL/day
- give diuretics
17
Q
Interventions:
Diuretic phase of AKI
A
Focus on the problems associated with fluid volume deficit:
- give IV fluids
- replace electrolytes
18
Q
Describe:
Chronic kidney disease (CKD)
A
A slow and progressive loss of kidney function.
GFR is < or = to 60 mL per minute for 3 months or longer.
19
Q
Cause:
Chronic kidney disease (CKD)
A
Damage to kidneys from:
- diabetes mellitus
- chronic hypertension
- chronic urinary obstruction
- recurrent infections
- autoimmune disorders
- after AKI
20
Q
The signs and symptoms of CKD can affect every system. Why is this?
A
The kidneys have many functions including fluid and electrolyte balance, acid-base balance, and getting rid of toxins. If the kidneys cannot do their job, the entire body will be affected.
21
Q
What are the neuro symptoms with CKD?
A
Due to toxins and electrolytes building up in blood:
- asterixis (flapping of hand)
- can’t concentrate and lethargic
- paresthesias and twitching
- late sign is coma
22
Q
What are the cardiovascular symptoms of CKD?
A
Due to fluid volume overload and electrolyte imbalances such as hyperkalemia:
- edema and heart failure
- hypertension
- dysrhythmias
- pericardial effusion and friction rub
Put clients on continuous telemetry.
23
Q
What are the respiratory symptoms of CKD?
A
- crackles and tachypnea due to fluid volume overload
- pulmonary edema is a late sign
- Kussmaul’s due to metabolic acidosis
24
Q
What are the hematological symptoms of CKD?
A
- anemia due to decreased erythropoietin
- decreased platelets and bleeding due to hormone imbalances
- ecchymosis
25
What are the **skin symptoms** with CKD?
Due to **toxins coming through the skin:**
* pruritis
* yellow-gray pallor
* late sign: uremic frost (crystals on skin)
26
What are the **musculoskeletal symptoms** of CKD?
Due to **calcium and general electrolyte imbalances:**
* bone pain and fractures
* muscle weakness and cramping
27
What happens **psychologically** to the client with CKD?
Because CKD affects all the systems and **lifestyle changes are necessary**, the client with CKD can become:
* lethargic
* depressed
* suicidal
## Footnote
Use teaching and therapeutic communication to help the client cope.
28
What is the prescribed **diet** for a client with AKI and CKD?
1. **low to moderate protein intake** - to reduce workload of kidneys and prevent toxicity
2. **high carb** - need extra calories
3. **low potassium and phosphorus** - kidneys are unable to get rid of these electrolytes
29
What is **dialysis**?
The treatment for AKI (oliguric phase) and CKD.
## Footnote
Dialysis removes excess water, electrolytes, and toxins from the blood.
30
How is anemia **treated** for a client with CKD?
* give erythropoietin to increase the RBCs
* possible blood transfusion
31
What is **hemodialysis**?
When **blood is pumped out of the body to clean the blood** of toxins and electrolytes.
## Footnote
Assess for hypotension.
32
Which **medications** are typically held before dialysis?
**Before dialysis, hold cardiac meds** that affect blood pressure and heart rate. Give after the client comes back from dialysis.
## Footnote
If given before dialysis, the meds will be excreted during dialysis.
33
What can be used **temporarily** for hemodialysis?
A **CVAD** such as a subclavian or femoral catheter, especially for those with AKI.
## Footnote
When using a catheter for hemodialysis, DO ***_NOT_*** use it for anything else (such as meds or fluids).
34
What is used for **long-term** hemodialysis?
**Arteriovenous (AV) fistula or graft** for those with CKD.
35
How **long** does it take for an AV fistula or graft to heal and mature after it is made?
It takes **4 - 6 weeks to heal and mature** for use.
## Footnote
Have client squeeze a ball to help it heal.
36
What are the **basic assessments** while an AV fistula or shunt is healing?
* bleeding and clots
* infection
* decreased circulation by checking the pulses distal (below) the fistula or shunt
37
What should **NEVER** be done on an arm with an AV fistula or graft?
* blood pressure
* IV lines
* giving injections
## Footnote
These actions can cause damage. Tell client to tell everyone to _NOT_ touch that arm for invasive procedures.
38
What is **assessed** before using an AV fistula or shunt for hemodialysis?
Assess circulation by checking for a bruit and thrill:
* **bruit:** use stethoscope to _hear_ a "whoosh-whoosh" sound
* **thrill:** put hand over fistula to _feel_ a "whoosh-whoosh".
## Footnote
If absent, notify the HCP.
39
What is **peritoneal dialysis**?
When **fluids are pumped out of the abdominal cavity** to clean the body of toxins and electrolytes.
40
What are the **basic interventions** before peritoneal dialysis is started?
* warm the bag of fluids to prevent discomfort and to help the veins to dilate
* get vital signs, weight, fluid and electrolyte values
* check dressing for wetness
41
What are the **basic interventions** during peritoneal dialysis?
* get vital signs
* watch for respiratory distress, hyper- or hypotension due to fluid shifts
* monitor intake and output
42
What **color** should the dialysate be when it comes back out?
**Clear**.
* _cloudy_ is a sign of **infection**
* _red_ is a sign of **bleeding**
## Footnote
Report any abnormal color to HCP.
43
Should **more or less dialysate come out** after peritoneal dialysis is finished?
**More dialysate should come** out since the client needs to get rid of the extra fluids.
44
What is the **intervention** if all the dialysate isn't coming out of the client?
**Turn the client to the side** to move the tube into a different spot and see if the fluid starts coming out.
45
# Complete the sentence:
Peritoneal dialysis is a ________ procedure. _________ can occur.
Peritoneal dialysis is a **_sterile_** procedure. **_Peritonitis_** can occur.
## Footnote
Prevent infection and assess for signs of peritonitis (rigid, hard abdomen).
46
What is the last resort **treatment** if dialysis doesn't work for CKD?
Kidney transplant
47
What types of **meds** are given to prevent kidney rejection after a kidney transplant?
Immunosuppression meds
48
What type of **precautions** are implemented after a kidney transplant?
**Neutropenic precautions** due to immunosuppression.
49
# Describe:
Urinary tract infection (UTI)
An **infection in the urinary tract** for many different reasons.
## Footnote
It is more common in women due to a short urethra.
50
# Risk factors:
Urinary tract infection
**Due to bacteria imbalances:**
* using soaps that are irritants
* foley and straight catheters for draining urine
* sex
* polyester underwear
* not urinating or drinking enough water
* using douches that interfere with the normal pH of the vagina
51
What are the **characteristic signs and symptoms** of a UTI?
* small amounts of urine that is frequent and urgent
* burning sensation
* back discomfort
* foul urine smell
* chills/fever/high WBC count
52
What is a **common symptom** of a UTI in the elderly?
Confusion.
53
How is a UTI **diagnosed**?
By doing a **urine culture and sensitivity test:**
* The test will be:
* **+** for leukocyte esterase
* **+** for nitrates
54
# Interventions:
Urinary tract infection
* antibiotics
* encourage fluids
* pain meds
55
# Teaching:
Urinary tract infection
* drink fluids
* urinate after sex
* wear cotton underwear
* don't take bubble baths or use irritating soap
* drink cranberry juice
56
When a client has a UTI, what types of substances irritate the bladder and should be avoided?
Avoid alcohol, caffeine and acidic foods.
57
# Describe:
Polycystic kidney disease
A **genetic disorder where cysts form on the kidneys** and the client gets hypertension.
## Footnote
The client will eventually need dialysis or a kidney transplant.
58
# Describe:
Hydronephrosis
**Too much water in the kidneys** caused by obstructions, stones, scar tissue or a big prostate.
## Footnote
Client may need nephrostomy tubes to drain urine.
59
Why is the urine **strained** for a client with a kidney stone?
To **catch the stone** and determine which type it is:
* purine stone?
* calcium stone?
* oxalate stone?
## Footnote
The diet will be modified to prevent that type of stone.
60
What type of **pain** does a client experience when they are passing a kidney stone?
Pain from kidney stones **starts in the lumbar region and radiates down to the genitals.**
## Footnote
It can be sudden pain that is sharp and severe.
61
# Teaching:
Kidney stones
* drink plenty of fluids
* don't eat foods that contribute to kidney stone formation
62
Why does **immobilization** cause kidney stones?
When a client is immobile, **calcium from the bones goes into the blood.**
## Footnote
Too much calcium can cause a kidney stone.
63
What is **lithotripsy**?
A procedure used to **break up a kidney stone** using ultrasonic waves.
64
What are the **interventions** after a lithotripsy?
* encourage fluids to flush out small stones and sediment
* monitor for bleeding and infection
65
# Describe:
Benign prostate hyperplasia (BPH)
BPH is a **large prostate** that occurs in older men due to the gradual growth of the prostate.
## Footnote
The large prostate blocks the ability to urinate. Urination is in smaller amounts and more frequent.
66
Which meds are **avoided** with BPH?
Meds that cause urinary retention such as:
* **anticholinergics** - benztropine (antiparkinson meds)
* **antihistamines** - diphenhydramine
* **antidepressants** - SSRIs
67
What is a **transurethral resection of the prostate (TURP)**?
A TURP is a **surgical procedure to decrease the size of a prostate** or to take the entire prostate out due to cancer.
68
What type of **foley catheter** is inserted after a TURP procedure?
After a TURP, the client will have a foley catheter with **continuous bladder irrigation** to prevent bleeding.
69
What is **continuous bladder irrigation**?
When there are **3 lumens (tubes) coming from the foley**:
* **Lumen 1:** inflating the balloon to keep the foley in the bladder
* **Lumen 2:** instillation of sterile solution for irrigating the bladder
* **Lumen 3:** for urine and fluid to leave the bladder
## Footnote
It is used to prevent bleeding after a TURP.
70
What are the **main interventions** for a client with continuous bladder irrigation?
Focus on **preventing bleeding:**
* keep traction on catheter: taut, taped, and keep leg straight
* keep sterile solution running to keep urine light pink
* increase the solution rate if bright red drainage or clots appear
71
What are the **steps** if the urinary catheter becomes obstructed and no urine is coming out?
1. **turn off** the continuous bladder irrigation
2. **irrigate the catheter** with 30 - 50 mL of normal saline.
## Footnote
If it's still obstructed, notify the HCP.
72
When will the continuous bladder irrigation for TURP be **discontinued**?
The catheter is taken out **24 - 48 hours** after the surgery.
73
What are **normal findings** after the catheter is removed after a TURP?
The client may experience **some burning, frequency, and dribbling of urine.**
## Footnote
Passing small clots and tissue debris for a few days is also normal.
74
# Teaching:
Transurethral resection of the prostate (TURP)
* no driving, sex or heavy/strenuous activity for up to 6 weeks
* drink up to 3000 mL of fluid each day before 8 p.m.
* don't stimulate the bladder—avoid alcohol, caffeine, and spicy foods
75
What should the client do at home if they **start to bleed after a TURP**?
Tell the client to **rest** and **increase fluid intake**.
## Footnote
If bleeding still doesn't stop, call the surgeon.
NCLEX-PN (5) Adult Health
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