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Flashcards in Renal Deck (15):

Patho & S/S

Acute can lead to chronic.
1. Pathophysiology:
a. Inflammatory reaction in the glomerulus from systemic infection
b. Antibodies lodge in the glomerulus; get scarring & decreases filtering.
c. Main cause: streptococcal
2. S/S:
a. Sore throat
b. Malaise and headache
c. BUN & Creatinine increase. Not excreting urea or creatinine
d. Sediment/protein/blood in urine glomerulus has holes and it leaks out
e. Flank pain (costovertebral angle tenderness)
f. BP increases
g. Facial increases
h. UO decreases
i. Urine specific gravity decreases
Client going into fluid volume excess.



a. Get rid of the strep.
b. Balance activity with rest.
c. I&Oanddailyweights
d. Monitor blood pressure.
e. How is fluid replacement determined?
• Fluid replacement = 24 hour fluid loss + 500cc for insensible loss.
f. Dietary needs:
• Protein low; Na low; Carbs high
g. Dialysis
h. Diuresis begins in 1 to 3 weeks after onset.
i. blood and protein may stay in the urine for months.
j. Teach S/S of renal failure.
• Malaise, headache, anorexia, nausea, vomiting, decreased output, weight
gain. Retain fluids and toxins


Nephrotic syndrome

1. Pathophysiology:
It’s an inflammatory response in the glomerulus→ big holes form so protein starts leaking out in the urine (what do we call this? Proteinuria)→ 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? into tissue→ Now the client is edematous→ since all the fluid is going out into the tissue what has happened to the circulating blood volume?decreased→ 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 Na and H2O→ but is there any protein (albumin) in the vascular space to hold it? no→ So where does this fluid go? Into the tissue
Total Body Edema = anasarca
Problems associated with protein loss:
• Blood clots (thrombosis)
They are losing protein that normally prevents their blood from clotting without these proteins, the blood can clot and put them at risk for thrombosis.
• Cholesterol and triglycerides will be high
The liver compensates by making more albumin causing an increased release
of cholesterol and triglycerides.


Nephrotic syndrome
Causes & S/S

2. Causes; Idiopathic, but has been related too: a. Bacteria or viral infections
c. Cancer and genetic predisposition.
d. Systemic disease like lupus or diabetes.
e. Strep
3. S/S:
a. Proteinuria
b. Hypoalbuminemia
c. Edema(anasarca)
d. Hyperlipidemia


Nephrotic syndrome

a. Diuretics
b. Ace inhibitors to block aldosterone secretion.
c. Prednisone to decrease inflammation.
• Shrink holes so protein can’t get out.
• Immunosuppressed.
d. Lipid lowering drugs for hyperlipidemia.
e. Na decreases
f. Protein increase in diet (one kidney disease that you need to increase protein)
g. Anticoagulation therapy for up to 6 months. h. Dialysis
Rule: Limit protein with kidney problems except with Nephrotic Syndrome.

Albumin returns fluid to vascular space
Lasix decreases fluid


Renal failure

• Requires bilateral failure.
1. Causes:
a. Pre-Renal Failure: Blood can’t get to the kidneys.
• Hypotension. BP<90
• decrease heart rate. (arrhythmia)
• Hypovolemic
• Any form of shock
b. Intra-Renal Failure: damage has occurred inside the kidney.
• Glomerulonephritis
• Nephrotic syndrome
• Dye used in test such as heart cath and CT scan
• Drugs (Aminoglycosides, Mycins)
• Malignant hypertension (uncontrolled HTN)
• And DM causes severe kidney damage.
c. Post-Renal Failure: urine can’t get out of the kidneys.
• Enlarged prostate
• Kidney stone
• Tumors
• Ureteral obstruction
• Edematous stoma (Ileal conduit)


Renal failure

a. Creatinine and BUN increases
b. Specific gravity
• Initially concentrated
• Fixed specific gravity:
• May lose ability to concentrate and dilute urine.
• Fluid challenge- bolus with 250 mLs or greater of normal saline. If kidneys are working, UO increases, dilute urine. If they are damaged, specific gravity does the same.
c. Anemia
• Not enough erythropoietin.
d. HTN
Retaining fluid
f. Anorexia, nausea, vomiting→ retaining toxins
e. CHF
g. Itching frost (Uremic frost)
• Good skin care
h. Acid- base/fluid and electrolyte imbalances
• hyperkalemia could cause lethal arrhythmias.
• Metabolic acidosis.
• Retain phosphorous→ serum calcium down→ calcium pulled from bones


Renal failure
2 phases

Kidneys have been damaged by one of the causes, this damage leads to the oliguric phase.
a. Oliguric phase:
• UO Decreased
• UO of 100 to 400 mL/ 24 hours.
• This client is in a fluid volume excess
• K+ Increase
B. diuretic phase
• sudden onset
• UO increasing
• This client is in a fluid volume deficit (Shock)
• K+ decreases

C. 12 month recovery, keep appts, watch BP



• The machine is the glomerulus. (filter)
• Is done 3-4 times per week; so the client has to watch what they eat and drink between treatments.
• To prevent blood clots from forming the client is given an anticoagulant during dialysis.
Usually Heparin- implement bleeding precautions for 4-6 hours after
• Depression → Suicide (possibly by eating)
• Electrolytes and BP are watched constantly.
• Can all clients tolerate hemodialysis? NO
Unstable cardiovascular system can’t tolerate hemodialysis.


Hemodialysis vascular access

1) Types of Access:
• With hemodialysis, blood is being removed, cleansed, and then returned at a rate of 300-800 mL/min.
• What is 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, takes weeks to mature and to be ready for repeated venipunctures.
• 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 arterial end of the access will remove the blood and the return is through the low pressure venous 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 any of the above 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 NEEDLE sticks
3) Assessment of Access:
• Ensure patency
• Thrill-cat purring sensation (palpate)
Bruit-turbulent blood flow (auscultate)
Feel a thrill...Hear the bruit


Peritoneal dialysis

Use peritoneal membrane as a filter.
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) remains in 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 toxins, etc., are drained. And that is called the exchange.
Why do we warm the fluid? Cold promotes vasoconstriction→ limits blood flow We want it warm, this promotes vasodilation, and more blood flow.
What should the drainage look like?
Clear, straw-colored
cloudy = infection
Should be able to read a newspaper through the drainage/effluent.
What type of client gets peritoneal dialysis? Someone who can’t tolerate hemodialysis or someone who chooses peritoneal.
What if all the fluid doesn’t come out? Turn side to side and reposition.

b. Complications of Peritoneal Dialysis:
• Major complication is peritonitis (Cloudy effluent 1st sign)
• Constant sweet taste
• May get hernia.
• 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.


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 4 times a day, 7 days a week.
• Could a client with disc disease or arthritis do this? No
Fluid causes pressure on back.
• Could a client with a colostomy do this? No High risk for infection


CCPD (Continuous Cycle Peritoneal Dialysis)

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


Continuous renal replacement therapy

• Typically done in an ICU 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 renal failure.


Kidney stones

1. S/S:
Pain (nausea/vomiting)
WBCs in urine
Anytime you suspect a kidney stone get a urine specimen ASAP and have it checked for RBCs.
2. TX:
If a kidney stone is present the client will get pain medication immediately.
Ketorolac (Toradol®), Ondansetron (Zofran®), Hydromorphone (Dilaudid®)
Increase fluids.
Maybe surgery
Strain urine
Extracorporeal shock wave lithotripsy (ESWL)