Medsurg Renal

Adult/Gerontological Health Exam 1 Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Homeostasis Proper functioning of all body systems; requires fluid and electrolyte balance Extracellular fluid (ECF) Intracellular fluid (ICF) Interstitial fluid Transcellular fluids Normal distribution of total body water in adults Filtration Movement of fluid through cell or blood vessel membrane because of differences in water pressure (hydrostatic pressure) This is related to water volume pressing against confining walls Hydrostatic Pressure: “water-pushing pressure”/ pressure between vessels Force that pushes water outward from a confined space through a membrane Amount of water in any body fluid space determines pressure Example: Blood pressure Moving whole blood from the heart to capillaries where filtration occurs to exchange water, nutrients, and waste products between the blood and tissue Edema – water is pushed out into tissues. Develops with changes in normal hydrostatic pressure differences. Pitting edema seen in patients with heart failure Ascites – water accumulates in the stomach Diffusion Free movement of particles (solute) across permeable membrane from area of higher to lower concentration Important in transport of most electrolytes; other particles diffuse through cell membranes Sodium pumps out of cell – water follows sodium. K+ inside cell, Na+ outside Glucose cannot enter most cell membranes without help of insulin Osmosis & Filtration Act together at capillary membrane to maintain normal ECF and ICF volumes Thirst mechanism is example of how osmosis helps maintain homeostasis (excess sodium) Feeling of thirst caused by activation of brain cells responding to changes in ECG osmolarity Fluid Balance Closely linked to/affected by electrolyte concentrations Fluid intake/ Fluid loss Minimum urine amount needed to excrete toxic waste products = 400 to 600 mL/day Insensible water loss – Through skin, lungs, stool Hormonal Regulation of Fluid Balance Aldosterone – released by kidney to reabsorb sodium (water will follow sodium and increase volume) Antidiuretic hormone (vasopressin) blood volume is low -- will retain sodium and increase volume Pressure is exerted on the heart and heart must work harder Urine decreases and is more concentrated Natriuretic peptides Significance of Fluid Balance: Renin-Angiotensin II Pathway Blood (plasma) volume and intracellular fluid most important to keep in balance Kidneys are major regulator of water and sodium balance; maintain blood and perfusion pressure to all tissues/organs When the kidneys sense a low parameter, they secrete renin Renin-angiotensin II pathway is greatly stimulated with shock, or when stress response is stimulated ACE Inhibitors Disrupt renin-angiotensin II pathway by reducing amount of ACE produced With less angiotensin II, less vasoconstriction and reduced peripheral resistance Greater excretion of water and sodium in urine By locking angiotensin II receptors, blood pressure lowers Patients with hypertension often take ACE-inhibitor medications Dehydration Collaborative Care Fluid intake/retention does not meet body’s fluid needs; results in fluid volume deficit Assessment History Physical assessment/clinical manifestations: Cardiovascular Respiratory Skin Neurologic Renal Fluid Overload: Collaborative Care Assessment Patient safety Pulmonary edema: fluid in the lungs Drug therapy Nutrition therapy Monitoring of intake and output (I&O) 1 L of water weighs 2.2 lb, equal to 1 kg Weight change of 1 lb = fluid volume change of about 500 mL Sodium Normal level: 136-145 mmol/L “Where sodium goes, water follows” Hyponatremia (<136) Confused Headaches Seizure Coma Intervention: 3% normal saline as an intervention Hypernatremia: (>145) Thirsty Agitated Seizures – safety is most important Coma Intervention: Hydration Extracellular Sodium imbalances manifest as neurologic issues Potassium Normal level: 3.5-5.0 mEq/L Some control over intracellular osmolarity and volume Regulate protein synthesis, glucose use and storage Hypokalemia Underlying metabolic disorders Arrhythmias Intervention: give K+ IV/PO Hyperkalemia Cardiac dysrhythmias Cramping in legs Muscle impairment Intervention: less bananas, watch foods with K+, medications, dialysis Heart, nerves, growth of cells Helps with acid base balance Potassium is regulated by the kidneys Calcium Normal level: 9.0-10.5 mg/dL Absorption requires active form of vitamin D Stored in bones Balanced through the parathyroid hormone Thyrocalcitonin Hypocalcemia Left: Palmar flexion indicating a positive Trousseau’s sign in hypocalcemia. Right: Facial muscle response indicating a positive Chvostek’s sign in hypocalcemia – tapping side of face Hypercalcemia Cancer Problem with parathyroid hormone Lethargic/ confused Nausea/vomiting Bone pain Polyuria/dehydration Intervention: blood work, change Ca+ diet, mobile Helps nerve impulses, contraction of muscle Phosphorus Normal level: 3.0-4.5 mg/dL Found in bones Activates vitamins and enzymes; assists in cell growth and metabolism Plasma levels of calcium and phosphorus exist in a balanced reciprocal relationship Hypophosphatemia Hyperphosphatemia Magnesium Normal level: 1.3 to 2.1 mg/dL Critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation (Adenosine triphosphate), vitamin activation, cell growth Given for respiratory issues (asthma) relaxes smooth muscle of lungs, cardiac issues Hypomagnesemia Hypermagnesemia Chloride Normal level: 98 to 106 mEq/L Imbalance occurs as a result of other electrolyte imbalances Treat underlying electrolyte imbalance or acid-base problem Considerations for Older Adults At risk for most electrolyte imbalances from age-related organ changes Have less total body water than younger adults; more at risk for fluid imbalances; more likely to be taking drugs affecting fluid or electrolyte balance Adult/Gerontological Health Exam 1 Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances Acid-Base Balance Fluid contains equal number of positive charges, ions with negative charges Balance occurs by matching rate of hydrogen ion production with loss Normal Blood pH Balance of acids and bases in body fluids Normal for: Arterial blood = 7.35 to 7.45 Venous blood = 7.31 to 7.41 Changes can affect: Shape of hormones and enzymes Distribution of other electrolytes (fluid and electrolyte imbalance) Excitable membranes Effectiveness of hormones and drugs *When measuring blood pH, use arterial blood because it is rich with oxygen, venous blood contains waste. Acidic < 7.0 Basic > 7.5 Acid Base Chemistry Acids – Release hydrogen ions when dissolved in water Bases – Bind with hydrogen ions in solutions Buffers – Critical in maintaining normal body fluid pH Body fluid chemistry: Bicarbonate ions (HCO3-) Relationship between CO2 and hydrogen ions Calculation of free hydrogen ion level Excess Acid: incomplete breakdown of glucose, breakdown of protein and fats, destruction of cells (carbonic acid: bicarbonate = 1:20). Bicarbonate: weak base Major buffer of extracellular fluid (ECF) From intestinal absorption of ingested bicarbonate into ECF, kidney absorption and breakdown of carbonic acid Level is typically 20 times greater than that of carbonic acid (1:20) Excess absorption of bicarbonate = alkaline Acid-Base Control Actions & Mechanisms: Respiratory When chemical buffers alone cannot prevent blood pH changes, respiratory system is second line of defense: Hyperventilation Hypoventilation Lungs compensate for acid-base imbalances of metabolic origin Acid-Base Control Actions & Mechanisms: Kidneys Third line of defense against pH changes Stronger for regulating acid-base balance; take longer than chemical and respiratory Kidney movement of bicarbonate Formation of acids and ammonium Kidneys can correct/compensate for pH changes when respiratory system is overwhelmed or unhealthy Bicarbonate is released with acidosis to balance it out and reach equilibrium – bicarb released by kidney Mechanism does not work in kidney failure Compensation Body attempts to correct blood pH changes pH <6.9 or >7.8 usually fatal Respiratory system more sensitive to acid-base changes; can begin compensating in seconds to minutes Kidneys more powerful; result in rapid changes in ECF composition; fully triggered for imbalance of several hours to days Normal CO2: 35-45 Normal O2: 80-100 Pulse ox above 90%, measures peripheral Arterial Blood Gas 80+ ( @ 80 you are functioning at 60% of your bodily function) Respiratory state, metabolic will compensate Metabolic state, respiratory will compensate R: Respiratory: O: Opposite: pH and CO2 are always opposite increase pH, decrease CO2 – respiratory alkalosis decrease pH, increase CO2 – respiratory acidosis – COPD patients, hyperventilating and retaining CO2 M: Metabolic: E: Equal: if pH and CO2 are equal = metabolic condition increase pH, decrease CO2 – metabolic alkalosis decrease pH, increase CO2 – metabolic acidosis Acidosis: Patient-Centered Collaborative Care CNS changes Neuromuscular changes ? Muscle tone, deep tendon reflexes Cardiovascular changes Early: ? Heart rate, cardiac output changes Worsening: Hyperkalemia; ? heart rate; T wave peaked and QRS widened; weak peripheral pulses; hypotension Respiratory changes Kussmaul respiration – fast and rapid breathing Skin changes (metabolic and respiratory acidosis) Warm, dry, and pink (vasodilation) Psychosocial assessment Metabolic Acidosis Hydrogen ions Overproduction Under-elimination Bicarbonate ions Under-production Over-elimination Laboratory Assessment: pH <7.35 – acidotic Bicarbonate <21 mEq/L Normal: 21-28 mEq/L Pao2 normal Paco2 normal or slightly decreased Serum potassium high Interventions: Hydration Drug therapy: insulin to treat DKA, antidiarrheals, bicarbonate (only with low serum level) Respiratory Acidosis Respiratory function is impaired, causing problems with O2 and CO2 Retention of CO: Respiratory depression Inadequate chest expansion Airway obstruction Reduced alveolar-capillary diffusion Hallmark of respiratory acidosis: Decreased Pao2 with rising Paco2 Laboratory Assessment: pH <7.35 Pao2 low Paco2 high Serum bicarbonate variable Serum potassium levels elevated (if acute acidosis) Serum potassium levels normal or low (if renal compensation present) Interventions: Focus is on improving ventilation and oxygenation, maintaining patent airway Drug therapy Bronchodilators Anti-inflammatories Mucolytics Oxygen therapy Pulmonary hygiene Ventilation support Prevention of complications Alkalosis: Patient-Centered Collaborative Care Assessment (same for metabolic and respiratory alkalosis) Hypocalcemia Hypokalemia CNS changes – Positive Chvostek’s and Trousseau’s signs Neuromuscular changes – Tetany Cardiovascular changes Respiratory changes Metabolic Alkalosis Base excess – Excessive intake bicarbonates, carbonates, acetates, citrates Acid deficit – Prolonged vomiting, excess cortisol, hyperaldosteronism, thiazide diuretics, prolonged NG suction Hallmark of base excess acidosis: ABG result with ? pH and ? bicarbonate level with normal O2 and CO2 levels Respiratory Alkalosis Hyperventilation – Anxiety, fear, improper vent settings, stimulation of central respiratory center due to fever, CNS lesion, salicylates Hallmark of respiratory alkalosis: ABG result with ? pH coupled with low CO2 level O2 and bicarbonate usually normal Interventions: Alkalosis Prevent further losses of hydrogen, potassium, calcium, chloride ions Restore fluid balance Monitor changes, provide safety Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion Adult/Gerontological Health Exam 1 Chapter 68: Care of Patients with Acute Kidney Injury and Chronic Kidney Disease Acute Kidney Injury (AKI) Rapid reduction in kidney function resulting in a failure to maintain fluid and electrolyte balance and acid base balance. Types Prerenal failure: caused by reduced perfusion Intrarenal failure: damage to kidney tissue and reflects injury to the glomeruli, nephrons, or tubules Postrenal failure: obstruction of urine flow **With prerenal or postrenal pathology, the kidney compensates by the three responses of constricting kidney blood vessels, activating RAA pathway, and releasing ADH (these increase blood volume and improve kidney perfusion)** Prerenal azotemia: the retention and buildup of nitrogenous wastes in the blood Causes Reduced perfusion to the kidneys, damage to kidney tissue, and obstruction Hypovolemic shock Heart failure Phases of AKI Rapid decrease in kidney function leads to collection of metabolic wastes in the body Phases Onset Oliguric: urine output less than 400mL/day Diuretic Recovery Acute syndrome may be reversible with prompt intervention Hypovolemic Shock Nursing interventions for: nutritional considerations, electrolyte imbalances, dosing implications Chronic Kidney Disease (CKD) Progressive, irreversible kidney injury; kidney function does not recover End-stage kidney disease (ESKD) Azotemia: the retention and buildup of nitrogenous wastes in the blood Uremia Uremic syndrome Stages of CKD Reduced renal reserve Reduced glomerular filtration rate (GFR) ESKD Stages of CKD Changes (1) Kidney changes (2) Metabolic changes - urea and creatinine (3) Electrolyte changes - sodium, potassium, acid-base imbalance, calcium and phosphorus (4) Cardiac changes – hypertension, hyperlipidemia, heart failure, pericarditis (5) Hematologic changes (6) GI changes Priority Nursing Care Dietary restrictions Uremic frost Muscle strength, energy Family members Excess fluid volume Decreased cardiac output Recombinant human erythropoietin Interdisciplinary team Hemodialysis Patient selection Dialysis settings Procedure Anticoagulation Complications: dialysis disequilibrium syndrome, infectious disease, Hep B and C, HIV Subclavian Dialysis Catheters: These catheters are radiopaque tubes that can be used for hemodialysis access. The Y-shaped tubing allows arterial outflow and venous return through a single catheter. Mahurkar catheters: made of polyurethane and used for short-term access. PermCath catheter: made of silicone and used for long-term access. Vascular Access Arteriovenous fistula or graft for long-term permanent access Hemodialysis catheter dual or triple lumen, or AV shunt for temporary access Precautions Complications: thrombosis or stenosis, infection, aneurysm formation, ischemia, heart failure Peritoneal Dialysis: involves siliconized rubber catheter placed into abdominal cavity for infusion of dialysate Peritoneal dialysis exchange for control of fluids, electrolytes, nitrogenous wastes, blood pressure, and acid-base balance. Types: Continuous ambulatory (CAPD) Automated Intermittent Continuous-cycle Complications Peritonitis, pain Exit site/tunnel infections Poor dialysate flow Dialysate leakage Nursing Care for Peritoneal Dialysis Before treatment: Evaluate baseline vital signs, weight, laboratory tests Continually monitor patient for respiratory distress, pain, discomfort Monitor prescribed dwell time, initiate outflow Observe outflow amount and pattern of fluid Kidney Transplantation Candidate selection criteria Donors Preoperative care Immunological studies Surgical team Operative procedure Postoperative Care Urologic management Assessment of hourly urine output x 48hrs Complications: Rejection Acute tubular necrosis Renal artery stenosis Immunosuppressive drug therapy Psychological preparation A patient with diabetes who has chronic kidney disease (CKD) often requires reduced doses of insulin and/or antidiabetic drugs because the failing kidneys do not excrete or metabolize these drugs well. Thus the drugs are effective longer, increasing the risk for hypoglycemia. A patient’s temperature is elevated after dialysis because the dialysis machine warms the blood slightly. Weight and blood pressure should be decreased because excess fluid is removed during dialysis. Heparin is required during hemodialysis and increases clotting time. All invasive procedures should be avoided for 4 to 6 hours after dialysis. Adult/Gerontological Health Exam 1 Chapter 65: Assessment of the Renal/Urinary System Kidney/Urinary System Changes Associated with Aging Reduced blood flow to kidneys Thickened glomerular and tubular basement membranes Decreased tubule length Decreased GFR Nocturnal polyuria Risk for dehydration Laboratory Assessment: Serum creatinine, BUN, BUN to serum creatinine ration, blood osmolarity Urinalysis Color, odor, turbidity Specific gravity pH, glucose, ketone bodies, protein leukoeserase, nitrites cells, casts, crystals, bacteria Other Urine Tests Urine for culture and sensitivity Composite urine collections Creatinine clearance- best indication of overall kidney function Urine electrolytes and osmolarity Other Studies Bedside sonography/bladder scanners Imagine assessment Retrograde procedures Urodynamic studies Kidney biopsy Patients with kidney failure are anemic because they cannot produce the hormone erythropoietin. A high oxygen saturation in an anemic patient who is showing signs of respiratory distress may still be hypoxemic. Clients who have decreased hemoglobin could have a high percentage of the hemoglobin saturated with oxygen, but because they have a decreased hemoglobin level, not enough oxygen is provided. Administering oxygen is necessary Adult/Gerontological Health Exam 1 Chapter 66: Care of Patients with Urinary Problems Cystitis: inflammation of bladder Most commonly caused by bacteria moving up urinary tract from external urethra to bladder Catheters: high risk factor in developing nosocomial cystitis Frequent urge to urinate Dysuria/urgency Urinalysis needed when testing for leukocyte esterase Organism type confirmed by urine culture Urethritis: inflammation of urethra causing symptoms similar to UTI Role of estrogen in treating estrogen-depletion urethritis Urethral Structures Narrowed areas of urethra Most common symptom: obstruction of urine flow Surgical treatment by urethroplasty: best chance of long term cure Dilation of urethra (temporary) Stress Incontinence Involuntary loss of urine during activities that increase abdominal and detrusor muscle pressure. It is often caused by weakening of the bladder neck support associated with childbirth. Urine loss occurs with physical exertion such as coughing, sneezing, or exercise. Interventions: kegal exercises, drug therapy (estrogen), vaginal cone therapy, surgery Urge Incontinence Interventions: Anticholinergics, antihistamines, avoid caffeine and alcohol Overflow Incontinence (reflex incontinence) Interventions: Surgery to relieve obstruction, intermittent catheterization, bladder compression Functional Incontinence Interventions: treatment of reversible causes, urinary habit training, urinary catheterization, containment of urine/protection of skin Urolithiasis Presence of calculi (stones) in urinary tract Pain relief measures: drug therapy, complementary/alternative med, lithotripsy Lithotripsy: uses sound, laser, or dry shock wave energy to break up stones into small fragments. Patient undergoes conscious sedation; topical anesthetic cream applied, and continuous ECG monitoring. Urothelial Cancer Malignant tumors or urothelium, lining of transitional cells in kidney, renal pelvis, ureters, urinary bladder, and urethra Bladder Trauma Causes may be from injury to lower abdomen or stabbing/GSW Surgical intervention required Fractures should be stabilized before bladder repair Nursing interventions prior to surgical interventions Pyelonephritis Bacterial infection in kidney and renal pelvis (upper urinary tract) Acute symptoms: Fever, chills, tachycardia, tachypnea Flank, back, or loin pain Abdominal discomfort Turning, nausea and vomiting, urgency, frequency, nocturia General malaise or fatigue Key features of chronic pyelonephritis Hypertension Inability to conserve sodium Decreased ability to concentrate urine Development of hyperkalemia and acidosis Renal Cell Carcinoma Adenocarcinoma of kidney Paraneoplastic syndromes Anemia, erythrocytosis, hypercalcemia, liver dysfunction, increased sedimentation rate, and hypertension Kidney Trauma Minor injuries – Contusions, small lacerations Major injuries – Lacerations to cortex, medulla, or branches of renal artery Collaborative management Nonsurgical management – Drug therapy, fluid therapy Surgical management – Nephrectomy or partial nephrectomy