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Renal - Coggle Diagram
Renal
Glomerulonephritis
Patho
Inflammatory reaction in glomerulus > antibodies lodge in glomerulus > scarring and decreased filtering
Main cause: strep
S/S
-Flank pain (CVA tenderness)
-Dec UO (oliguria)
-Hematuria
-Proteinuria
-Periorbital edema
-BP inc
-Fluid volume excess
-Urine specific gravity inc
-Azotemia (high BUN and Cr)
-Malaise and HA (toxins = tired)
Treatment
-Get rid of strep or the cause
-I/O and daily weight
-Diuretics
-Monitor BP
-Restrict fluids (Replacement = 24 hr loss + 500mL)
-Balance activity with rest
-Diet: Inc Carbs, Dec Na, Dec Protein
-Dialysis
Teaching
-Diuresis begins 1-3 weeks after onset
-Blood/protein may stay in urine for months
-S/S of renal failure (malaise, HA, anorexia, N/V, dec output, weight gain)
Nephrotic Syndrome
Patho
Inflammatory response in glomerulus > big holes form > protein leaks out in urine > hypoalbuminemic > can't hold fluid in vascular space > fluid leak to tissue > edema > volume decrease > kidneys sense volume decrease > RAAS > retain sodium/water > still no albumin to hold it so it leaks into tissue > more edema
Total body edema = Anasarca
Associated problems with protein loss
-Blood clots: losing proteins that prevent clotting > risk for thrombosis
-High cholesterol and triglycerides: liver compensates by making more albumin causing inc release of cholesterol and triglycerides
Causes:
-Bacterial/viral infection
-NSAIDs
-cancer/genetic predisposition
-systemic disease (lupus, diabetes)
-
Treatment
-Diuretics
-ACE inhibitors to block aldosterone secretion
-prednisone to dec inflammation
-cyclophosphamide to dec body immune response (shrink holes so protein can't leak, immunosuppressed, infection major complication of Nephrotic syndrome)
-diet: moderate protein 1-2g/kg/d. Dec sodium.
-lipid lowering drugs
-anticoagulation therapy for up to 6 months
-dialysis
-daily weight
-I/O
-measure abd girth/extremity size
-good skin care
-
Acute Kidney Injury (AKI)
A sudden episode of renal dmg. Goal is to reverse it to prevent chronic renal failure.
Causes
Pre-Renal failure: blood can't get to the kidneys
-Hypotension
-Dec HR (arrhythmia)
-Hypovolemic
-Any type of shock
Intra-Renal failure: dmg inside the kidney itself
-Glomerulonephritis or Nephrotic syndrome
-malignant hypertension which is uncontrolled HTN and diabetes mellitus
-acute tubular necrosis: dmg to filtering bodies of kidneys
-dyes used in heart cath/CT scans
-nephrotoxic drugs
-NSAIDs
Post-renal failure: urine can't get out of kidneys
-enlarged prostate
-kidney stone
-tumors
-ureteral obstruction
-edematous stoma
Phases of kidney injury
-Initiation phase (injury occurs)
-Oliguric phase (output may be <100ml/24hr) (10-14 days)
-DIuretic phase (kidney recovering) (begins when output increases; fluid/lyte replacements based on labs)
-Recovery phase 3-12 months (activity as tolerated)
S/S
-Cr/BUN increase
-specific gravity inc
-HTN and HF d/t retaining fluid
-anorexia, N/V d/t retaining toxins
-itching frost (uremic frost)
-retain phosphorus > serum Ca decrease > Ca pulled from bone
-anemia (not enough erythropoietin)
-hyperkalemia
-metabolic acidosis (can't filter or retain hydrogen)
Treatment: goal to prevent complications, manage S/S, and eliminate the cause of the injury
Nursing
-Bedrest to decrease metabolism and caloric needs
-TCDB
-monitor intake and output
-daily weight
-monitor vital signs closely
Medications
-loop diuretics or osmotic diuretics
-treat hyperkalemia with IV glucose and insulin
-IV calcium gluconate (dysrhythmias)
-polystyrene sulfonate to dec potassium
-Phosphate binders to prevent hypocalcemia
-smallest volume for IV drugs
Nutrition
-Inc carbs and fats
-Low protein diet
-Avoid food/fluid high in phosphorous/phosphates
-avoid foods high in potassium (bananas, citrus, coffee)
Prevent infection
-aseptic technique
-skin care
-prevent pressure ulcers
-mouth care
-no catheter if possible
-protect form others who have infectious disease
Renal Replacement Therapy (RRT): when BUN and Cr levels can't be decreased, FVE is compromising heart/lungs, or hyperkalemia and metabolic acidosis can't be treated successfully.
Hemodialysis
-Machine is the glomerulus (filter)
-3-4 times a week; client must watch what they eat/drink between treatments
-Prevent blood clots from forming with an anticoagulant during dialysis (usually Heparin)
-Depression -> suicide
-Assess fluid status before beginning
-Watch lytes and BP constantly
-Some cannot tolerate hemodialysis
Vascular access
Types of access
-Blood is being removed, cleansed, returned at a rate of 300-800mL/min
-Need a site to have access to large blood vessels b/c rapid flow is essential
AVF (arteriovenous fistula): in firearm with anastomosis between an artery and a vein
AVG (arteriovenous graft): synthetic graft to join vessels
-Both require surgery. Access site takes weeks to mature to be ready for repeated punctures.
-During dialysis 2 needles are inserted into the access. One pulls blood, the other returns.
-Temporary access can be done at internal jugular or femoral vein.
Care of access: Do not use for IV access (drawing blood, giving meds, etc)
For that arm:
-No BP
-No needle sticks
-No constriction
Assessment of access
-Assessing for patency
-Thrill: palpate cat purring sensation
-Bruit: auscultate turbulent blood flow
Feel the thrill, hear the bruit
Continuous Renal Replacement Therapy (CRRT)
-Typically ICU setting and done so there isn't drastic fluid shifts
-Never more than 80mL out of body at one time being filtered
-Stresses CV system less
-done on clients with fragile CV status and AKI
Peritoneal dialysis
-Peritoneal membrane as a filter
-Dialysate infused via gravity into peritoneal cavity
-2000-2500mL fills cavity
-Remains in the cavity for a prescribed dwell time.
-The bag is then lowered and the fluids/toxins drain (exchange)
-Warm the fluid (cold promotes vasoconstriction > limit blood flow)
-Drainage: should look clear, straw colored. Cloudy = infection.
-Turn side to side if all fluid doesn't come out.
-Who does it?: can't tolerate hemodia or they just want to.
Types of PD
- CAPD (continuous ambulatory peritoneal dialysis)
-4 times a day, 7 days a week
-client must have the desire to be active in their treatment and follow instructions
- APD (automated peritoneal dialysis)
-connect to a cycler at night and exchange happens in sleep. D/C in morning.
Complications
-Exit site infection
-Peritonitis (abd pain, cloudy effluent)
Dietary needs
-Increase fiber: they have decreased peristalsis d/t abd fluid
-Increase protein: big holes in peritoneum and lose protein with exchange
Kidney Stones
S/S
-Sharp pain, N/V
-WBCs in urine
-Hematuria
-If suspect a kidney stone, get a urine specimen ASAP and check for RBCs
-if stone present > pain med immediately
Treatment
-Zofran
-NSAIDS, opioids
-alpha adrenergic blockers (relax smooth muscle of ureter)
-Inc fluids
-surgery to remove stone
-extracorporeal shock wave lithotripsy to crush stone
-strain urine > send stone for analysis.