amer a. hasanien, rn, cns,...

1

Amer A. Hasanien, RN, CNS, PhD

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & WilkinsAmer A. Hasanien, RN, CNS, PhD

2

True/False

1. Diabetes is the primary cause of chronic kidney disease.

2. In chronic glomerulonephritis, the kidneys are reduced to as little

as 50% of their normal size.

3. The glomerular filtration rate and the creatinine clearance

decrease with end-stage kidney disease.

4. Peritonitis is the most common and the most serious complication

of peritoneal dialysis.

5. Kidney transplantation has become the treatment of choice for

most patients with end-stage kidney disease.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kidney Disorders

• Fluid and electrolyte imbalances

• Most accurate indicator of fluid loss or gain, in an acutely ill patient, is weight.


3


Question

Is the following statement true or false?

The most accurate indicator of fluid loss or gain in an acutely ill patient is weight.



Answer

True

The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. A 1-kg weight gain is equal to 1000 mL of retained fluid.


4


Chronic Kidney Disease (CKD)

• kidney damage or a decrease in the glomerular filtration rate (GFR) lasting for 3 or more months.

• Untreated CKD can result in end-stage kidney disease (ESKD), which is the final stage of renal failure.

• ESKD results in

– retention of uremic waste products and

– the need for renal replacement therapies, dialysis, or kidney transplantation.


Renal replacement

therapy (RRT).


replaces non-endocrine kidney function in patients with renal failure and is

occasionally used for some forms of poisoning. Techniques

include intermittent hemodialysis, continuous hemofiltration and hemodialysis,

and peritoneal dialysis.

5


Causes of Chronic Kidney Failure

• Diabetes mellitus

• Hypertension

• Chronic glomerulonephritis (inflammation of the glomeruli or small blood vessels in the kidneys)

• Pyelonephritis (an inflammation of the kidney tissue, calyces, and pelvis)

or other infections

• Obstruction of urinary tract

• Hereditary lesions

• Vascular disorders

• Medications or toxic agentsAmer A. Hasanien, RN, CNS, PhD


http://en.wikipedia.org/wiki/Inflammation

http://en.wikipedia.org/wiki/Glomerulus

http://en.wikipedia.org/wiki/Parenchyma

http://en.wikipedia.org/wiki/Minor_calyx

http://en.wikipedia.org/wiki/Renal_pelvis

6



• Risk factors include cardiovascular disease, diabetes (primary cause), hypertension, and obesity.

• Pathophysiology:

– In early stages, significant damage to the kidneys without signs or symptoms.

– The reason is not yet clearly understood, but it is believed to be caused by prolonged acute inflammation.

• CKD is classified into five stages.


7

• Not all patients progress to

stage 5 CKD.

• In stage 5, renal

replacement therapies are

required to sustain life.


• Clinical Manifestations:

– Elevated serum creatinine levels (symptoms begin with Crt elevation).

– Anemia, due to decreased erythropoietin production by the kidney.

– Metabolic acidosis

– Abnormalities in calcium and phosphorus

– Fluid retention, evidenced by both edema and congestive heart failure, develops.

– As the disease progresses, abnormalities in electrolytes occur, heart failure worsens, and hypertension becomes more difficult to control.


8


• Assessment and Diagnostic Findings:

– The glomerular filtration rate (GFR) is the amount of plasma filtered through the glomeruli per unit of time.

– Creatinine clearance is a measure of the amount of creatinine the kidneys are able to clear in a 24-hour period.

• Medical Management: treat the underlying cause, BP < 130/80, renal replacement therapy, Prevention of complications by controlling cardiovascular risk factors; treating hyperglycemia; managing anemia; smoking cessation, weight loss, exercise programs as needed; and reduction in salt and alcohol intake.


9


Acute Kidney Injury (AKI)

• Rapid loss of renal function due to damage to the kidneys.

• Might result in life-threatening complications such as metabolic acidosis as well as fluid and electrolyte imbalances.

• AKI has a high mortality rate that ranges from 40% to 90%.

• A widely accepted criterion for AKI is a 50% or greater increase in serum creatinine above baseline (normal creatinine is less than 1 mg/dL).


10


• Pathophysiology: The pathogenesis of AKI and oliguria is not always known.

• Reversible causes include (these conditions reduce blood flow to the kidney and impair kidney function).

1. Hypovolemia;

2. Hypotension;

3. Reduced cardiac output and heart failure;

4. Obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone; and

5. Bilateral obstruction of the renal arteries or veins.


Classifications of

Acute Kidney Injury

11


Categories of Acute Kidney Injury

• The major categories of AKI are

– prerenal (hypoperfusion of kidney),

– intrarenal (actual damage to kidney tissue), and

– postrenal (obstruction to urine flow).

VIP Chart



Phases of Acute Kidney Injury

1. Initiation,

2. Oliguria, ↑ concentration of (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]).

3. Diuresis, (signals that glomerular filtration has started to recover)

4. Recovery. (improvement of renal function and may take 3 to 12 months)


12


• Clinical Manifestations: Dry skin (dehydration), drowsiness, headache, and seizures.

• Assessment and Diagnostic Findings: urine output varies from scanty to a normal volume, hematuria (possible), inability to concentrate the urine (low specific gravity), renal ultrasonography, renal CT, renal MRI, ↑ BUN, ↑creatinine, hyperkalemia (protein catabolism), metabolic acidosis, hypocalcemia (↓absorption), and anemia (↓erythropoietin).


13


• Radiocontrast-induced nephropathy (CIN) is a major cause of hospital-acquired AKI.

– This is a potentially preventable condition.

– Creatinine greater than 2 mg/dL identify patients at high risk.

– Prevention of CIN:

1. Prehydration with saline (the most effective)

2. Administration of N-acetylcysteine and sodium bicarbonate before and during procedures


14


• Gerontologic Considerations:

– About half of all patients who develop AKI during hospitalization are older than 60 years.

– Contributing factors: suppression of thirst, enforced bed rest, lack of access to drinking water, and confusion



• Medical Management:

– The kidneys have a remarkable ability to recover from insult.

– Objective, restore normal chemical balance and prevent complications.

– Eliminating the underlying cause; maintaining fluid balance; avoiding fluid excesses; and, when indicated, providing renal replacement therapy.


15


• Hemodialysis (a procedure that circulates the patient’s blood through an artificial kidney [dialyzer] to remove waste products and excess fluid),

• Peritoneal dialysis (a procedure that uses the patient’s peritoneal membrane [the lining of the peritoneal cavity] as the semipermeable membrane to exchange fluid and solutes),

• Continuous renal replacement therapies (CRRTs) (methods used to replace normal kidney function by circulating the patient’s blood through a hemofilter)


16


Hemodialysis System



Hemodialysis Catheter


17


Internal Arteriovenous Fistula and Graft


A vascular access is a surgically created vein used to remove and return blood during hemodialysis. An arteriovenous (AV) fistula is a connection, made by a vascular surgeon, of an artery to a vein. An AV graft is a looped, plastic tube that connects an artery to a vein.


18


• Avoid venipuncture and blood pressure measurements on the arm with the access device.


Peritoneal Dialysis


19

Peritoneal dialysis


• Treat hyperkalemia (life-threatening):

– cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema.

– IV dextrose 50%, insulin, and calcium replacement.


20


End-Stage Kidney Disease (or Chronic Renal Failure)

• ESKD: patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis (5th stage CKD).

• Pathophysiology:

– As renal function declines, the end products of protein metabolism (normally excreted in urine) accumulate in the blood (uremia: urea in the blood).

– The greater the buildup of waste products, the more pronounced the symptoms.

Urea like creatinine is an end product of amino acid (protein) metabolism.



• Clinical Manifestations: every body system is affected, severe pain and discomfort, CV disease is the primary cause of death.

• Other S & S, refer to chart 54-6.


21


Assessment and Diagnostic Findings

• Glomerular Filtration Rate: decrease due to nonfunctioning glomeruli, creatinine clearance decreases, whereas serum creatinine and BUN levels increase (creatinine is more accurate than BUN).

• Sodium and Water Retention: leading to edema, heart failure, and hypertension.

• Metabolic acidosis: results from the inability of the kidney tubules to excrete ammonia (NH3−) and to reabsorb sodium bicarbonate (HCO3−).

• Calcium and Phosphorus Imbalance: ↑ serum phosphate level and a reciprocal or corresponding ↓ in the serum calcium level.



Medical Management


• The goal is to maintain kidney function and homeostasis for as long as possible.

• Medications:

– Phosphorus Binders: medications that bind dietary phosphorus in the GI tract (↓absorption).

– Antihypertensive and Cardiovascular Agents: to manage hypertension, edema, heart failure.

– Antiseizure Agents

– Erythropoietin (to treat anemia)

22


• Nutritional Therapy: regulation of protein intake, fluid intake to balance fluid losses, sodium and potassium restriction.

• Dialysis

Patient with renal failure

Fluid, sodium, potassium, and protein restriction



Nursing Process: Assessment

• Fluid status

• Nutritional status

• Patient knowledge

• Activity tolerance

• Self-esteem

• Potential complications


23


Nursing Process: Diagnosis

• Excess fluid volume

• Imbalanced nutrition

• Deficient knowledge

• Risk for situational low self-esteem



Collaborative Problems and Complications

• Hyperkalemia

• Pericarditis

• Pericardial effusion

• Pericardial tamponade

• Hypertension

• Anemia

• Bone disease and metastatic calcifications


24


Nursing Process: Planning

• Goals may include preventing fluid excess, maintenance of adequate nutritional intake, increased knowledge, participation of activity within tolerance improved self-esteem, and absence of complications.


25


Excess Fluid Volume

• Assess for s/s of fluid volume excess, keep accurate I&O, and daily weights

• Limit fluid to prescribed amounts

• Identify sources of fluid

• Explain to patient and family the rationale for fluid restrictions

• Assist patient to cope with the fluid restrictions

• Provide or encourage frequent oral hygiene



Imbalanced Nutrition: Assessment

• Nutritional status; weight changes, laboratory data

• Nutritional patterns, history, preferences

• Provide food preferences within restrictions

• Encourage high-quality nutritional foods while maintaining nutritional restrictions

• Stomatitis or anorexia: modify intake related to factors that contribute to alterations

• Adjust medication times related to meals

Stomatitis: inflammation of the mouth and libs.


26


Risk for Situational Low Self-Esteem

• Assess patient and family responses to illness and treatment

• Assess relationships and coping patterns

• Encourage open discussion about changes and concerns

• Explore alternate ways of sexual expression

• Discuss role of giving and receiving love, warmth, and affection



Nursing Process: The Care of the Hospitalized Patient on Dialysis—Assessment

• Protect vascular access; assess site for patency, signs of potential infection, do not use for blood pressure or blood draws

• Carefully monitor fluid balance, IV therapy, accurate I&O, IV administration pump

• s/s of uremia and electrolyte imbalance, regularly check lab data

• Monitor cardiac/respiratory status carefully

• Cardiovascular medications must be held prior to dialysis


27


Nursing Process: The Care of the Hospitalized Patient on Dialysis—Interventions

• Monitor all medications and medication dosages carefully

• Address pain and discomfort

• Stringent infection control measures

• Dietary considerations: sodium, potassium, protein, fluid, individual nutritional needs

• Skin care: pruritus, keep skin clean and well moisturized, trim nails, and avoid scratching

• CAPD catheter careC A PD: continuous ambulatory peritoneal dialysis



Positioning and Incisional Approaches (kidney surgery)

28


Kidney Transplantation

True/False

1. Diabetes is the primary cause of chronic kidney disease.

2. In chronic glomerulonephritis, the kidneys are reduced to as little

as 50% of their normal size.

3. The glomerular filtration rate and the creatinine clearance

decrease with end-stage kidney disease.

4. Peritonitis is the most common and the most serious complication

of peritoneal dialysis.

5. Kidney transplantation has become the treatment of choice for

most patients with end-stage kidney disease.

29


Question

The nurse is instructing a patient to perform continuous ambulatory dialysis correctly at home. Which of the following educational information should the nurse provide to the patient?

a) Keep the catheter stabilized to the abdomen, below the belt line.

b) Use an aseptic technique during the procedure.

c) Clean the catheter insertion site daily with soap.

d) Wear a mask while handling any dialysate solutions.



AnswerB. Use an aseptic technique during the procedure

The patient should be instructed to use an aseptic technique during the procedure. The patient should also

demonstrate the continuous ambulatory peritoneal dialysis (CAPD) should also demonstrate an exchange

procedure in case of failure or unavailability of a cycling machine). A mask is generally worn only while

performing exchanges, especially when a patient has an upper respiratory infection. The catheter insertion site

should be cleaned daily with an antiseptic such as povidone-iodine (Betadine), not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant

rubbing.


30


Question

A nurse is caring for an acutely ill patient. The nurse understands that the most accurate indicator of fluid loss or gain in an acutely ill patient is which of the following?

a) Weight

b) Pulse rate

c) Blood pressure

d) Edema



Answer

a. Weight

The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded. Blood pressure, pulse rate, and edema are not the most accurate indicator of fluid loss or

gain.


31


Question

The nurse is caring for a patient with acute renal injury (AKI). The patient is experiencing an increase in the serum concentration of urea and creatinine. The nurse understands the patient is experiencing which of the following phases of AKI?

a) Diuresis

b) Oliguria

c) Recovery

d) Initiation



Answer

b. Oliguria

The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids,

and the intracellular cations [potassium and magnesium]). The initiation periods begins with the initial

insult and ends when oliguria develops. The diuresis period is marked by a gradual increase in urine output. The recovery period signals the improvement of renal

function and may take 6 to 12 months.


32


Thank YouAmer A. Hasanien, RN, CNS, PhD

amer a. hasanien, rn, cns,...

Documents