Topic 9: CKD & Dialysis

Question 1

CKD

Answer 1

involves progressive, irreversible loss of kidney function. Defined as wither presence of kidney damage or decreased GFR less than 60mL/min for longer than 3 months

Question 2

Last stage of kidney disease is end-stage renal disease (ESRD), occurs when the GFR is

Answer 2

less than 15mL/min

Question 3

leading causes of CKD

Answer 3

diabetes and HTN

Question 4

Clinical Manifestations of CKD

Answer 4

· Retained urea, creatinine, phenols, hormones, electrolytes, water
· Uremia: a syndrome in which kidney function declines to a point that symptoms may develop in multiple body systems (occurs when GFR is 15mL/min or less)
· Difficulty with urine retention OLIGURIA
Increased BUN and Creatinine (waste product accumulation
· Kussmauls breathing (with severe acidosis)
· Dyspnea (fluid overload, pulmonary edema, etc.)

Question 5

Increased BUN manifestations

Answer 5

N/V, lethargy, fatigue, impaired thought process, HA

Question 6

CKD alters carbohydrate metabolism which means

Answer 6

client may present with Moderate hyperglycemia and hyperinsulinemia

Question 7

most patients with CKD die from

Answer 7

CVD: increased LD and Low HDL

Question 8

electrolyte imbalances associated with CKD

Answer 8

hyperkalemia
hypernatremia
hyperphospatemia

Question 9

hyperkalemia can lead to

Answer 9

can lead to fatal dysrhythmias

Question 10

Impaired sodium excretion for CKD can lead to

Answer 10

edema, HTN and HF

Question 11

in CKD kidneys are unable to excrete acid which means

Answer 11

Metabolic acidosis

Question 12

why is anemia a manifestation in CKD

Answer 12

due to decreased production of ERYTHROPOETIN

Question 13

neurologic changes in CKD (Result of increased nitrogenous waste products)

Answer 13

lethargy, apathy, decreased ability to concentrate, fatigue, irritability, altered mental status

Question 14

· CKD mineral and bone disorder

Answer 14

o Kidney is not turning vitamin D into its activated form, decreased vitamin D means decreased serum calcium levels
o This means hyperphosphatemia
o Increase risk for BONE FRACTURE

Question 15

· Uremic frost

Answer 15

o Rare condition in which urea crystalizes on the skin
o Usually only seen when BUN levels are really high

Question 16

what is usually the first sign of kidney damage

Answer 16

Persistent proteinuria (dipstick evaluation)

Question 17

diagnostic assessment for CKD

Answer 17

· Renal ultrasound, renal san, CT scan
· Renal biopsy
· BUN, creatinine and creatinine clearance levels
· Serum electrolytes
· Lipid profile
· Urinalysis
· Protein-to-creatinine ratio in first morning voided specimen
· Hematocrit and hemoglobin levels

Question 18

stage 1 CKD

Answer 18

GFR >90

Question 19

stage 2 CKD

Answer 19

GFR 60-89

Question 20

stage 3a CKD

Answer 20

GFR 45-59

Question 21

stage 3b CKD

Answer 21

GFR 30-44

Question 22

stage 4 CKD

Answer 22

GFR 15-29

Question 23

stage 5 CKD

Answer 23

GFR <15

Question 24

Hyperkalemia Interventions

Answer 24

· Restricting high potassium food and drugs
· IV gluconate
· IV glucose and insulin
· Sodium polystyrene sulfonate (given to lower potassium un stage 4 CKD)
· Monitor for changes in ECG

Question 25

HTN Interventions

Answer 25

· Weight loss · Lifestyle changes (exercise, avoid alcohol and smoking) · Diet: DASH Diet · Antihypertensives

Question 26

CKD-MBD Interventions

Answer 26

Limit dietary phosphorus · Supplementing vitamin D (oral or IV calcitriol) giving phosphate binders · Controlling hyperparathyroidism

Question 27

diagnosis for CKD-MBD

Answer 27

· Gold standard for diagnosis is bone biopsy

Question 28

Anemia Interventions

Answer 28

· Exogenous erythropoietin (use lowest possible dose to avoid thrombolytic events like MI, HF, stroke) · EPO may lead to iron deficiency: iron supplementation is recommended

Question 29

nutrition therapy CKD

Answer 29

· Protein must be high enough if patient is on HD or PD, but high protein diets can overburden diseased kidneys · Fluid intake is usually as desired, but TEACH patients to limit fluid intake so that weight gain are no more than 1 t0 3 kg between dialyses (interdialytic weight) · Restrict sodium · Restrict potassium · Restrict phosphorus

Question 30

Foods high in phosphorus

Answer 30

milk, ice cream, yogurt, pudding

Question 31

Health Promotion for CKD

Answer 31

· Ask patient about what medications they are taking as some may be nephrotoxic · Weight and weight changes · Patients with diabetes need to have their urine checked for albuminuria and changes in urine appearance · Monitor creatinine, BUN, GFR if patient needs a potentially nephrotoxic drug · MONITOR BP, treat HTN Treat diabetes

Question 32

patient teaching CKD

Answer 32

· Dietary sodium, potassium, phosphate restrictions · S/S of electrolyte imbalances, especially high potassium · Alternative ways to reduce thirst (sucking on ice cubes, lemons or hard candy)

Question 33

patients with CKD should report

Answer 33

o Weight gain >4lb (2kg) o Increasing BP o SOB o Edema o Increasing fatigue or weakness, lethargy Confusion

Question 34

Dialysis

Answer 34

corrects fluid and electrolyte imbalances and removes waste products in kidney failure

Question 35

Hemodialysis

Answer 35

· Blood taken out, "washed" and put back into the patient · 3-4 times per week

Question 36

access site for hemodialysis

Answer 36

AV Fistula and grafts

Question 37

how long to AV grafts need to heal

Answer 37

2-4 weeks

Question 38

Peritoneal Dialysis

Answer 38

access obtained by inserting a catheter through anterior abdominal wall

Question 39

peritoneal dialysis catheter

Answer 39

· A Dacron cuff forms holding catheter in place The tip of the catheter rests in the peritoneal cavity

Question 40

Before Dialysis

Answer 40

· Assess fluid status (weights current and previous) · VS · ASSESS FISTULA (SHUNT) · HOLD MEDS (especially if the cause lowered BP) · IV heparin is added during dialysis to prevent clots · Consent

Question 41

assesing fistula/shunt

Answer 41

o Feel a THRILL (vibration) o Hear a BRUIT (swoosh) o Report to HCP if NOT present

Question 42

what is added to dialysis to prevent clots

Answer 42

iv heparin

Question 43

SAFETY for AV Fistula and Grafts

Answer 43

· Never perform BP, IV insertion, or venipuncture in the extremity with AV access · Place signs in room and label band "No BP, blood draws, or IV in this arm"

Question 44

Complications of Hemodialysis

Answer 44

· Hypotension o Decrease fluid volume removed and infuse 0.9% saline · Muscle cramps o Reduce ultrafiltration rate and give fluids · Loss of blood o Hold firm pressure on access sites (remember heparin was given to reduce clots)

Question 45

Disequilibrium Syndrome s/s

Answer 45

· Restless and disoriented!!! · Causes brain cells to swell which increases ICP

Question 46

Disequilibrium Syndrome intervention

Answer 46

· STOP/SLOW THE INFUSION AND REPORT TO HCP

Question 47

Peritoneal Dialysis intervention

Answer 47

· Take weight and warm the solution · Monitor for exit site infection · Monitor for peritonitis · Hernias may develop due to increased intrabdominal pressure · Lower back pain · Monitor for bleeding · Monitor for pulmonary complications Monitor for protein loss

Question 48

peritonitis s/s

Answer 48

o Abdominal pain, rebound tenderness, cloudy peritoneal effluent with a WBC greater than 100 cells/uL