Beth - Week 11 - Exam 4 Flashcards
(60 cards)
1
Q
what is CKD?
A
chronic kidney disease
- presence of kidney damage defined by structural or functional abnormalities
- with or without ↓ GFR
- manifested by pathological abnormalities in blood, urine, or imaging
2
Q
what is the etiology of CKD?
A
the presence of GFR < 60mL/min/1.73 m2 for three months, with or without other signs of kidney damage
3
Q
what is the epidemiology of CKD?
A
- 26 million Americans have CKD
- 1 out of 9 Americans are at risk
- 1/2 million are receiving tx
- Approx 435,000 have ESRD
- Annual mortality rate for ESRD: 24%
- 90,000 die each year `
4
Q
Review: how does the kidney relate to regulating BP?
A
- Hypovolemia/Na+ depletion triggers release of
Renin (enzyme) which converts angiotensin to
A-I (ACE) which converts to A-II in the lungs.
A-II causes adrenal cortex to secrete
Aldosterone (secrete K+ & absorb Na+ & H20—
water balance)
5
Q
Look at review slide
A
REVIEWED
6
Q
what are the causes of CKD?
A
- glomerulonephritis
- nephrotic syndrome
- hypercalcemia
- multiple myeloma
- chronic UTI
- disease - (leading cause)
7
Q
what diseases cause CKD?
A
HTN and diabetes
8
Q
what are the stages of CKD?
A
- Stage 1*: GFR >= 90 mL/min/1.73 m2 - Normal or elevated GFR
- Stage 2*: GFR 60-89 (mild)
- Stage 3: GFR 30-59 (moderate)
- Stage 4: GFR 15-29 (severe; pre-HD)
- Stage 5: GFR < 15 (kidney failure-uremia)
9
Q
TEST: what are the general sxs of CKD?
A
- General (fatigue, malaise, edema)
- ophthalmologic (loss of •vision)
- respiratory (pleuritis, pulmonary edema)
- cardiac (HTN, HF, pericarditis, CAD)
- GI (A + N + V, GI bleed)
- Skin (pruritus, pallor)
- Neuro (MS changes, seizures, neuropathy)
- Metabolic (hyperglycemia)
10
Q
what is the management/tx of CKD?
A
** ID and treat factors associated with progression of CKD **
t
11
Q
how are the factors associated with the progression of CKD treated?
A
- dialysis (hemodialysis (permanent/temp) or peritoneal or continuous veno-venous hemofiltration CVVH)
- transplant
12
Q
what are the factors ID’d that are associated with CKD?
A
- HTN
- proteinuria
- metabolic changes (↑ glucose)
- anemia
- hyperlipidemia
13
Q
what is the target BP for someone with CKD?
A
< 130/80 mmHg
- <125/75 mmHg for pts with proteinuria
14
Q
what should pts with HTN consider for medications?
A
- consider several anti-HTN meds with different mechanisms of activity
- ACEs/ARBs
- Diuretics
- *HCTZ (less effective when GFR < 20)
15
Q
_____ is the single best predictor of disease progression
A
proteinuria
16
Q
what are the 4 stages of proteinuria?
A
• Normal albumin excretion - <30 mg/24 hours • Microalbuminuria - 20-200 µg/min or 30-300 mg/24 hours • Macroalbuminuria - >300 mg/24 hours • Nephrotic range proteinuria - >3 g/24 hours
17
Q
what are the metabolic changes with CKD?
A
- ↓ H+H
- ↓ calcium **
- ↑ phos **
- ↑ PTH
- ↑ triglycerides
18
Q
what can the metabolic changes result in??
A
- acidosis
- ↑ K+
- ↓ Na+
***BUN and Cr may also be ↑
19
Q
what are the metabolic and hematologic changes within the CKD patient?
A
- anemia (↓ erythropoietin and platelet function)
- leukocyte function
- humoral and cellular responses
- metabolic changes
- mineral metabolism
- dyslipidemia
- nutrition (renal diet)
20
Q
Test: what is the tx for anemia?
A
- epoetin alfa (rHuEPO, Epogen)
- darbepoetin alfa (aranesp)
21
Q
what is the dosing and side effects for epoetin alfa?
A
- HD: 50 -100 U/kg IV/SC 3x/wk
- Non-HD: 10,000U qwk
- *Side effect is Iron deficiency
- Constipation from Iron treatment
22
Q
what is the dosing for darbepoetin alfa?
A
- HD: 0.45 µg/kg IV/SC qwk
- Non-HD: 60 µg SC q2wks
23
Q
what causes metabolic acidosis and what is the tx?
A
• Muscle catabolism - decreased albumin synthesis • Metabolic bone disease • Sodium bicarbonate - Maintain serum bicarbonate > 22 meq/L - Watch for sodium loading (Volume expansion + HTN)
•• Acidosis leads to release of bone calcium/phos
24
Q
what is mineral metabolism and the tx?
A
- calcium and phosphate metabolism abnormalities associated with:
• renal osteodystrophy
• calciphylaxis and vascular calcification - take CaCO3 or Ca-acetate with meals to bind phos
- ↓ phos intake
25
what is dyslipidemia and the tx?
abnormalities in the lipid profile
- triglycerides and total cholesterol
* *lipid lowering tx prevention of CV disease
26
what are the characteristics of a CKD pt's nutrition (diet)?
```
- think about uremia (elements normally eliminated in urine)
• catabolic state
• anorexia
• ↓ protein intake
• water restriction (limit 1-3 kg between dialysis)
• Na+ restriction (2-4g)
• K+ restriction (2-3g)
• phosphate restriction (1g)
- renal dietitian
```
27
Read the case study
READ
28
what are the diagnostics of CKD?
```
• Blood tests
- CBC with diff
- BMP
- Ca++
- phos
- PTH
- HbA1c
- LFTs
- uric acid and Fe2+ study
• Urine
- urinalysis with microscopy
- spot urine for microalbumin
- 24 hr urine collection for protein and creatinine
• Ultrasound - hydronephrosis, tumors, stones
```
29
what are the CKD tx options?
- peritoneal dialysis
- hemodialysis
- kidney transplant
30
what are the characteristics of peritoneal dialysis?
surgical placement of peritoneal catheter
31
what are the characteristics of hemodialysis?
• vascular access placed after 14 months
- arteriovenous fistula
- arteriovenous graft
- temporary vascular access
- CVVH
32
what are the characteristics of kidney transplants?
- live donors
- deceased donors
- only 1/4 ever receive a kidney
- once transplant survival is 90%
- lifetime medications (immunosuppressive)
- life long concern of infection and rejection
33
what is the risk for diseases for kidney transplant patients?
- CV
- malignancy (basal cell/lymphoma)
- recurrence of original disease into new kidney
- corticosteroid-related complications (↑glu)
- diabetes
34
what are the physiologic principles of hemodialysis?
- osmosis
- diffusion
- ultrafiltration
35
what is osmosis?
Movement of fluid from an area of lesser to area of
| greater concentration of solutes
36
what is diffusion?
Diffusive transport across semipermable membrane
(based on countercurrent flow of blood and
dialysate) removal of impurities
37
what is ultrafiltration?
- water and fluid removal (↓ BP ↑ HR)
| - results when there is an osmotic gradient across the membrane
38
what are the goals of dialysis?
• fluid removal
• osmosis and diffusion across semipermeable membrane
- solute clearance
- diffusive transport (based on countercurrent flow of blood and dialysate)
- conventive transport (solvent drage with ultrafiltration)
39
what are the nursing assessment/priorities for a pt with CKD?
* complete assessment (heart and lung sounds)
* condition of access
* temperature
* skin condition (itchy, edema)
* weight
* BP
* edema
* labs (renal panel, lytes, CBC)
* CXR
40
what is a arteriovenous fistula?
- Preferred form of dialysis access
| - Typically end-to-side vein-to-artery anastamosis
41
what are the different types of arteriovenous fistulas?
- Radiocephalic (first choice)
- Brachiocephalic (second choice)
- Brachiobasilic (third choice, requires superficialization of
basilic vein, i.e. transposition)
- lower extremity fistulae are rare
42
what are the assessments for arteriovenous fistulas?
• Look - site, condition, s/s infection
• Feel - look for the Thrill...Pulse is bad
• Listen - bruit, low pitched…high short is
bad
43
what is a arteriovenous graft?
• Synthetic conduit, usually polytetrafluoroethylene (PTFE, aka Gortex), between an artery and a vein
- Either straight or looped
44
what are the common sites for AV grafts?
- Straight forearm : Radial artery to cephalic vein
- Looped forearm : brachial artery to cephalic vein
- Straight upper arm : brachial artery to axillary vein
- Looped upper arm : axillary artery to axillary vein
45
what are tunneled cuffed catheters?
- dual lumen catheters
- most commonly placed in the internal jugular vein, exiting at the upper, anterior chest
* - can also be placed in the femoral vein
- subclavian catheters should be avoided given the risk of subclavian stenosis (rise in infection)
46
what is peritoneal dialysis?
- peritoneal access is obtain by inserting a catheter through the anterior wall
- technique for catheter placement varies
- usually done via surgery
47
what are the three phases of peritoneal dialysis?
* called an exchange*
- inflow (fill)
- dwell (equilibration)
- drain
48
what does "inflow" phase consist of?
- Prescribed amount of solution infused through
established catheter over about 10 minutes
- After solution infused, inflow clamp closed to
prevent air from entering tubing
49
what does the "dwell" phase consist of?
- Diffusion and osmosis occur between patient’s
blood and peritoneal cavity
- Duration of time varies depending on method
50
what does the "drain" phase consist of?
- 15 - 30 minutes
| - may be facilitated by gently massaging abdomen or changing position
51
TEST: what is the nursing management of peritoneal dialysis specific patient?
```
- Skin must be cleaned with antiseptic
solution and sterile dressing applied
- Must be connected to sterile tubing
system
- Secured to abdomen with tape
- Mask & gloves during connecting and
disconnecting
- Maintain sterile environment !!!!
```
52
what is the nursing management and assessment of a dialysis patient before treatment?
• before tx, RN should
- complete assessment of fluid status, condition of access, temp, skin condition
- weight
- BP
- edema
- heart and lung sounds
53
what is the nursing management and assessment of a dialysis patient during treatment?
- be alert to changes in condition
| - perform VS every 30 - 60 minutes
54
what is the nursing management and assessment of a dialysis pt post tx?
weight
55
test: what are the complications of dialysis?
- hypotension
- muscle cramping
- loss of blood (damanged during dialysis)
- hepatitis
- sepsis
- disequilibrium syndrome
56
what are the possible complications of the dialysis access site?
- thrombosis
- infection (10% for AVG, 5% for AVF, 2%)
- aneurysms and pseudoaneurysms (3% of AVF, 5% of AVG)
- HF (avoid AVFs in pt with severely depressed LVEF)
- local bleeding
- peritoneal dialysis (peritonitis/sepsis, cath clogged or dislodged)
57
what is the pt education for someone on dialysis?
- understanding of regular scheduled tx
- acceptance of chronic disease
- risk for infections (sxs of infection)
- edema (daily weight)
- dietary restrictions
58
what is the family education for someone on dialysis?
- same as pt
- understand their role
- risk for infection
- med routine
- maintain healthy lifestyle
59
T/F it is important to be in collaboration with the dialysis nurse
TRUE
60
what are the things we should communicate to the dialysis nurse?
- clinical situation (hold meds?)
- meds (BP, ATB, diuretic, pain meds)
- lab results (K, Cl, BUN, Cr, H/H)
- assessment (access device)
- plan of care (ongoing assessment, medicate prn, pt comfort (bedrest), nutrition (hold food d/t N+V), psychosocia support, family education)
