2016 Student RN - · PDF filef. Dietary needs: Protein? ___ Na? _ Carbs? _ g. Dialysis h. Diuresis begins in _ to _ weeks after onset. i. ___ and protein may

VIII. RENAL

A. Glomerulonephritis:

Acute can lead to chronic.

1. Pathophysiology:

a. Inflammatory reaction in the _______________________.

b. Antibodies lodge in the glomerulus; get scarring & _____________ filtering.

c. Main cause: _______________________

2. S/S:

a. Sore throat

b. Malaise and headache

c. BUN & Creatinine _______

d. Sediment/protein/blood in urine

e. Flank pain (costovertebral angle tenderness)

f. BP_________

g. Facial ________

h. UO (urinary output) ________

i. Urine specific gravity ______

Client going into fluid volume ______________.

3. Tx:

a. Get rid of the strep.

b. Balance activity with rest.

c. I & O and daily weights

d. Monitor blood pressure.

e. How is fluid replacement determined?

Fluid replacement = 24 hour fluid loss + __________.

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f. Dietary needs:

Protein? ______ Na? __________ Carbs? _______

g. Dialysis

h. Diuresis begins in ___ to ___ weeks after onset.

i. ___________ and protein may stay in the urine for months.

j. Teach S/S of_________________________.

Malaise, headache, anorexia, nausea, vomiting, decreased output and weight gain.

B. Nephrotic Syndrome:

1. Pathophysiology:

It’s an inflammatory response in the ________________→ big holes form so protein

starts leaking out in the urine (what do we call this? ______________)→ Now the

client is hypoalbuminemic (low albumin in the blood)→ without albumin you can’t

hold on to fluid in the vascular space→ so where does all the fluid in the vascular

space go? ___________________→ Now the client is edematous→ since all the fluid

is going out into the tissue what has happened to the circulating blood

volume?________→ The kidneys sense this decreased volume and they want to help

replace it→ The renin-angiotensin system kicks in→ aldosterone is produced→ and

causes the retention of ___________ and __________________→ but is there any

protein (albumin) in the vascular space to hold it?__________→ So where does this

fluid go?____________ Total Body Edema = ____________________________________ Problems associated with protein loss:

Blood ________(thrombosis)

They are losing proteins that normally prevent their blood from clotting. Without these proteins, the blood can clot and put them at risk for thrombosis.

Cholesterol and triglycerides will be ___________________

The liver compensates by making more albumin, causing an increased release of cholesterol and triglycerides.

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2. Causes: Idiopathic, but has been related to:

a. Bacteria or viral ___________

b. NSAIDs

c. Cancer and ___________ predisposition.

d. Systemic diseases such as lupus or diabetes.

e. Strep

3. S/S:

a. Proteinuria

b. Hypoalbuminemia

c. Edema (anasarca)

d. Hyperlipidemia

4. Tx:

a. Diuretics

b. ___________________ to block aldosterone secretion.

c. Prednisone to _____________ inflammation.

Shrink holes so ____________ can’t get out.

Immunosuppressed.

d. Lipid lowering drugs for hyperlipidemia.

e. Na? __________

f. Protein? _______

g. Anticoagulation therapy for up to 6 months.

h. Dialysis Rule: Limit protein with kidney problems except with Nephrotic Syndrome.


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C. Renal Failure:

Requires bilateral failure.

1. Causes:

a. Pre-Renal Failure: _________ can’t get to the kidneys.

Hypotension

_________ heart rate. (arrhythmia)

Hypovolemic

Any form of __________

b. Intra-Renal Failure: damage has occurred ____________ the kidney.

Glomerulonephritis

Nephrotic syndrome

________ used in test such as heart cath and CT scan

Drugs (Aminoglycosides are nephrotoxic)

Malignant ____________________ (uncontrolled HTN)

and DM causes severe ________________ damage.

c. Post-Renal Failure: _________ can’t get out of the kidneys.

Enlarged ______________

Kidney stone

Tumors

Ureteral obstruction

Edematous __________ (Ileal conduit)

NCLEX® Critical Thinking Exercise: 18- month old went to surgery for bilateral ureteral stents. After surgery you notice the UO has dropped. What would be the priority nursing intervention? 1. Call primary healthcare provider 2. Turn from side to side. 3. Irrigate 4. Reassess in 15 minutes


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2. S/S:

a. Creatinine and BUN ___________

b. Specific gravity:

Initially _______

Fixed specific gravity:

May lose ability to concentrate and dilute urine.

Fluid challenge - bolus with 250 mLs or greater of normal saline

c. Anemia

Not enough erythropoietin.

d. HTN Retaining __________

e. HF

f. Anorexia, nausea, vomiting→ retaining ____________.

g. Itching frost (Uremic frost)

Good skin care

h. Acid - base/fluid and electrolyte imbalances

____________________ could cause lethal arrhythmias.

Metabolic acidosis.

Retain phosphorous→ serum calcium _____→ calcium pulled from ____________________

3. Two phases of Acute Renal Failure:

Kidneys have been damaged by one of the causes: this damage leads to the oliguric phase.

a. Oliguric phase:

What has happened to UO? ________________

UO of _______ to _______ mL/ 24 hours.

This client is in a fluid volume ____________.

What do you think will happen to the K+? ______________


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b. Diuretic phase:

____________ onset

What is happening to the UO? _____________

This client is in a fluid volume ______________. (Think Shock)

What do you think will happen to the K+? _________

D. Dialysis:

1. Hemodialysis:

a. General Information:

The machine is the glomerulus (filter).

Is done 3-4 times per week so the client has to watch what they _______ and _________ between treatments.

To prevent blood ____________ from forming, the client is given an

anticoagulant during dialysis.

Usually Heparin- implement what? _________________________

Depression → Suicide

Electrolytes and ___________ are watched constantly.

Can all clients tolerate hemodialysis? ________

Unstable cardiovascular system can’t tolerate hemodialysis.

NCLEX ® Critical Thinking Exercise What medications should you hold for a client going to dialysis? Select all that apply.

1. lisinopril (Zestril®)

2. nitroglycerin (Nitro-Bid®)

3. ater soluble vitamin

4. ampicillin (Polycillin®)

5. famotidine (Pepcid®)

NCLEX Tip: Multiple Response items are described as having 5 or 6 options with a minimum of 2 correct options. These items contain the statement “Select all that apply.”


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b. Vascular Access:

Must have a vascular access:

1) Types of Access:

With hemodialysis, blood is being removed, cleansed, and then returned at a rate of _________ mL/min.

What is a vascular access?

A site where they have access to a large blood vessel because very rapid blood flow is essential for hemodialysis.

AVF (arteriovenous fistula) in forearm with an anastomosis

between an artery and a vein.

AVG (arteriovenous graft) a synthetic graft to join the vessels.

Both require surgery. The access site takes weeks to mature and to be ready for repeated venipunctures.


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During dialysis two needles are inserted into the vascular access.

One needle will allow blood to be pulled from the circulation and sent to the hemodialysis machine.

The other is used to return the filtered blood to the client’s circulation.

The _________ end of the access will remove the blood and the return is through the low pressure _________ end.

For temporary access, the internal jugular or femoral vein is often used for catheter placement. Surgery is not required for temporary placement.

2) Care of Access:

Do not use for IV access (drawing blood, administering meds, etc.)

When a client has an alternate vascular access, what is the associated nursing care for that extremity?

No __________________________

No ________________ sticks No ____________________________

3) Assessment of Access:

Why? ______________________

How?

Thrill-cat purring sensation (palpate)

Bruit-turbulent blood flow (auscultate)

Feel a_________…Hear the _________.


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2. Peritoneal Dialysis:

Use peritoneal membrane as a _____________.

Dialysate is warmed and infused into the peritoneal cavity by gravity via a Tenckhoff catheter.

The fluid (2000-2500 mL) fills the peritoneal cavity (takes about 10 min) and

remains in the peritoneal cavity for a prescribed amount of time. This is called the dwell time.

Then the bag is lowered and the fluid, along with the ________, etc., are drained.

That is called the exchange.

Why do we warm the fluid? Cold promotes vasoconstriction→ limits blood flow

We want it warm; this promotes _______________ and more blood flow.

What should the drainage look like?

__________, straw-colored. Cloudy = _______________

Should be able to read a newspaper through the drainage/effluent.

What type of client gets peritoneal dialysis? Someone who can’t tolerate ___________ or someone who chooses peritoneal.

What if all the fluid doesn’t come out? __________________________________

a. Two Types of Peritoneal Dialysis:

1) CAPD (Continuous Ambulatory Peritoneal Dialysis):

Must have a client that has the energy and the desire to be active in their treatment and that also has the ability to learn and follow instructions.

Done ______ times a day, 7 days a week. Could a client with disc disease or arthritis do this? ________

Fluid causes pressure on back.

Could a client with a colostomy do this? _______

High risk for ________________________


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2) CCPD (Continuous Cycle Peritoneal Dialysis):

Connect their peritoneal dialysis catheter to a cycler at _______ and their exchange is done automatically while they sleep. Disconnected in the AM. The client has more freedom.

b. Complications of Peritoneal Dialysis:

Major complication is ___________________ (cloudy effluent 1st sign).

Constant sweet taste

May get a _____________.

Altered body image/sexuality

Anorexia

Low back pain

c. Dietary Needs of the Peritoneal Client:

Increase what in the diet?

Fiber→ Have decreased peristalsis due to abdominal fluid.

Protein→ Big holes in peritoneum and lose protein with each exchange.

3. Continuous Renal Replacement Therapy (CRRT):

Typically done in an _______ setting and is continuous so that the client doesn’t have drastic fluid shifts.

Never more than 80 mL of blood out of the body at one time being filtered and therefore does not stress the cardiovascular system as much.

CRRT is performed on a client with:

A fragile cardiovascular status and acute ____________ failure.


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E. Kidney Stones (urolithiasis, renal calculi):

1. S/S:

Pain, and nausea/vomiting

WBCs in ________________.

Hematuria

Anytime you suspect a kidney stone, get a ________ specimen ASAP and have it checked for ________.

If a kidney stone is present, the client will get pain medication immediately.

2. Tx:

ketorolac (Toradol®), ondansetron (Zofran®), hydromorphone (Dilaudid®)

____________ fluids.

Maybe surgery

Strain urine

Extracorporeal shock wave lithotripsy (ESWL)


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NCLEX® Critical Thinking Exercise:

The nurse is assessing a client diagnosed with kidney stones who just returned from extracorporeal shock wave therapy (lithotripsy).

The client is supine in bed with a an indwelling catheter in place. Which finding would be the best indicator that the treatment has been effective?

1. Total absence of pain.

2. The indwelling catheter is draining freely.

3. Rebound tenderness is absent during abdominal assessment.

4. Sand-like sediment has settled in the bottom of the indwelling catheter

bag.

NCLEX® Critical Thinking Exercise:

A nurse is working in the ED and is assigned to care for the clients in examination rooms 1, 2, and 3. The nurse received the following report from the off going nurse:

1. The client in Room 1 is an elderly person who has fallen and is currently in CT to rule out a subdural hematoma.

2. Client in room 2 is diagnosed with kidney stones, positive for hematuria and has 8/10 pain.

3. The client in room 3 has a blood pressure of 90/40.

Let me ask you a question: which client would you go see first?


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2016 Student RN - · PDF filef. Dietary needs: Protein? _____ Na? _____ Carbs? _____ g. Dialysis h. Diuresis begins in ___ to ___ weeks after onset. i. _____ and protein may

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2016 Student RN - · PDF filef. Dietary needs: Protein? ___ Na? _ Carbs? _ g. Dialysis h. Diuresis begins in _ to _ weeks after onset. i. ___ and protein may