Client going into fluid volume. Fluid replacement = 24 hour fluid loss +.

Transcription

1 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 +. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 113

2 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. 114 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

3 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. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 115

4 C. Failure: Requires bilateral failure. 1. Causes: a. Pre- Failure: can t get to the kidneys. Hypotension heart rate. (arrhythmia) Hypovolemic Any form of b. Intra- 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- 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 116 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

5 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 e. HF Retaining 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 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+? Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 117

6 b. Diuretic phase: onset What is happening to the UO? This client is in a fluid volume. (Think Shock) D. Dialysis: What do you think will happen to the K+? 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. water 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. 118 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

7 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. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 119

8 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. 120 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

9 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 ( 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 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 121

10 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 1 st 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 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. 122 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.

11 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) Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. 123

12 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? 124 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.