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NR203 Test 1 Renal failure and dialysis


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What indicators are present when a kidney is not functioning right?
Increased Urea ---dietary proteins
Increased Creatinine---muscle mass
Decreased Glomerular Filtration Rate -- at 80=1/2 of age 30 evidenced by decreased Creatinine clearance
Less able to concentrate urine---(Why elderly are at risk for dehydration)
Prolonged half life drugs-aminoglycosides, tetracycline, cephalosporins
What are some Disease processes of the Kidney
Polycystic - autosomal dominant 10% of population onset age 30-40 hematuria, polyuria, nocturia-- give ace inhibitors for increased BP-early manifestations of infection

Hydronephrosis -- Congenital, strictures, tumors or calculi --dull aching flank discomfort -- percutaneous nephrostomy tube, ureteral stent (output separated by tube)

Glomerulus Disorders --
DM (30-35% of people c ESRD),
systemic lupus erythematosis,
Goodpastures (immunologic) or idiopathic .
Acute post streptoccal glomerulonephritis(immune complexes trapped in glomerular membrane .
Nephrotic syndrome.
Symptoms of kidney disorders
Proteinuria -most important indicator of glomerular injury because it increases progressively with increased glomerular damage -foamy urine seen early
GFR decreased
Nitrogenous wastes increased
BUN - GI bleed and High Protein Diet increase so not always is a renal elevation
Creatinine - skeletal muscle contraction 0.5-1.2 normal over 4 is serious (educate dialysis or transplantation
N/V, weakness, abdominal or flank pain
What Labs and diagnostic tests help diagnose disorders of the kidney
Lytes- Na+, K elevated, Ca decreased, Phos. elevated
Hypoalbuminemia-reduces osmotic pressure of plasma proteins=Na + H20 retention =edema frequently periorbital or facial & upper extremity
Throat or skin cultures-Group A beta-hemolytic strep-follows infection 1-2weeks
ASO titer-antistreptolysin titer-antibody
ESR - Erythrocyte Sedimentation Rate
ANA Serum Antinuclear Antibody - develop to own DNA (SLE, rheumatoid arthritis, myasthenia gravis)
Creatinine clearance
UA - RBCs and protein
Kidney Scan - radioisotope
Treatments for glomerular disorders
Immunosuppressives - Cytotoxan or Imuran
Corticosteroids - Prednisone (NOT in post streptococcal period)
ACE Inhibitors = Decreases protein loss with nephrotic syndrome and protect membrane with DM
Antibiotics- Avoid nephrotoxic (aminoglycooside streptomycin, and some cephalosporins)
Plasmaphoresis- (Rapidly progressive glomerulonephritis
Goodpastures Syndrome)- antibodies removed. RBCs c equal
amount of plasma or albumin is re-injected. Need large IV access
and give anticoagulants
Diet Restrictions -- Na+ restricted diet and Protein restricted diet so when you eat protein, make sure your intake is complete proteins-Animal Proteins.
K + according to lab result
Nursing Care
Fluid Volume Excess
related to retention of Na+ & H20
secondary to decreased blood proteins
causing decreased oncotic pressure-BP-P-R Breath Sounds, I&0, Weigh Daily, Edema (face, periorbital, arms),
Monitor lab (K +, Phos+, H&H, BUN Crest.),
Fluid Restriction c frequent mouth care,
Diet (Na+ & Protein restricted),
diuretics (assess output and edema)

related to anemia, headaches, nausea, & anorexia-

Conserve limited energy,
Frequent small meals

Altered Protection
related to immune system depression
-Good handwashing,
Temp Vitals,
CBC, WBC & diff,
observe SX dysuria, frequency, urgency" Intermittent cath has lower risk of UTI than foley."
Altered Role performance
related to limited activity -bedrest decreased proteinuria
Name and describe some Vascular Disorders-
Hypertensive Nephropathy- both result or cause of renal disease, malignant when diastolic greater than 120, more in african americans & secondary to DM
Renal artery occlusion- thrombus secondary to abdominal trauma, OR or angiography, affects aortic or renal artery, CAD, Emboli from Lt. Heart (A-fib), SX slow without sx, Acute SX¬sudden severe flank pain, N,V, increased Temp, increased WBC, Increased AST, Increased LDH
Renal vein - Pregnancy, Oral Contraceptives
Trauma -Blunt trauma (falls, MV A, sports) SX hematuria, flank or ABD pain oliguria, Turners sign (bluish discoloration of flank). Increased AST(SGOT), CT,IVP TX Bedrest-OR for hemorrhage or shock
Describe Neoplastic
Neoplastic - (renal cell, Mets from lung or breast, melanoma, lymphoma), SX gross hematuria, flank pain, palpable mass, Increased Temp, fatigue, wt loss, Increased ESR, anemia, shock SX, CT or Ultrasound TX radical nephrectomy is TX of choice for tumor of kidney, interferon, chemo, radiation
Nursing Care for nephrectomy
Pain - incision disrupts large muscles (PCA, assessing pain, positioning, relaxation techniques

Ineffective Breathing Pattern related to Pain and splinting of respirations- Semi-Fowlers, TCDB q 2 hr., spirometer, ambulate

Risk for Altered Urinary Elimination- related to removal of one kidney - VS and U output q 1 hr., CVP within normal to prevent hypovolemia for risk of renal ischemia. Assess drainage from each site or tube separately and irrigate only with MD order. Strict aseptic technique. Encourage intake of 2000-2500 ml/day, monitor renal labs.

Anticipatory Grieving- trusting relationship, active listening, identify strengths, past experiences, and support systems
Renal Failure-Acute-what are the phases of acute renal failure
1. Onset of event {hours} -tubular injury
2. Maintenance {lasts 1-22 weeks} 40% oliguric SX azotemia, Increased or Decreased lytes, metabolic acidosis, fluid retention, anemia, immune impaired ends with diuresis
3. Recovery - BUN Creat begin to Decrease {1-25 days to 1 year} until labs stabilize
Renal Failure-Acute Diagnostics
Fixed specific gravity 1.010
Urine casts or protein
Retrograde pyleogram
Renal Failure-Acute
Dopamine – Increases renal perfusion
Loop or osmotic diuretic
ACE inhibitor
NSAIDS stopped
Antacids & H2 receptor antagonists- Increased risk of GI bleed Calcium chloride or calcium gluconate
Kayexalate (sorbital) Rectally to hold 30-60 min in bowel or given PO
Aluminum hydroxide gels for Increased Phos+ levels -Promote excretion of Phos through the bowel
Drug dosages decreased
Fluid Restriction 500 cc/day + output in last 24 hours
Protein Restricted Diet to decrease azotemia (After on dialysis when creatinine and BUN decrease, then high protein to replace protein lost with dialysis - either peritoneal or hemo)
Avoid nephrotoxic meds or dyes
Continuous renal replacement therapy
Continuous- slow but steady.
Either condition improves or to chronic dialysis.
Nursing Care Acute Renal Failure
Fluid Volume Excess --Increased weight, edema, CHF, Pulmonary edema, (Note changes in
(note changes in rhabdomyolysis)

Altered Nutrition Less than body requirements - Diet -Decrease-- Protein, Decrease--Na+, Decrease--K + given in frequent small meals to give adequate calorie for protein-sparing action

Knowledge Deficit
Chronic Renal Failure-Describe
what causes/contributes to CRF
-- 90% nephrons destroyed Renal Insufficiency - 75 % nephrons
destroyed. Decreased renal reserve - 50% of nephrons destroyed L&B, 2004, 775
1. Diabetes Mellitus
2. Hypertension
3. Glomerulonephritis
4. Polycystic Kidney Disease
Symptoms of Chronic Failure -
Fixed urine specific gravity 1.010
Apathy, weakness, fatigue
Proteinuria, hematuria,
Inability to concentrate urine (polyuria, nocturia, Na+ & H20 retention
K increases cause muscle weakness, paresthesia, ECG changes (peaked t waves and wide QRS) Phos increases & --Ca+ decreases due to impaired activation of Vit D
Metabolic acidosis with Respirations increasing= deep Kussmaul
Hypertension - edema - CHF
Erythropoietin -decreases--, decreased--HCT, -decreased Folate, -decreased--Iron, shortened RBC life Anorexia, N/V
Uremic fetor –urine breath
Impaired clotting
Lab Diagnosis
Chronic Renal Failure
Specific gravity 1.010
Urine culture
BUN 20-50 mild--- tlOO poor prognosis
Creatinine above 4.0 & symptomatic N, V, anorexia
Hematocrit 20-30%
Treatment for Chronic renal failure
Phosphate Binders
Vitamin D supplement
Folic Acid
Hypertension meds -Frequently ACE Inhibitors Assess vascular access for bruit --Notify MD if absent No longer need to avoid nephrotoxins
CHOICES in Renal Failure
1. Hemodialysis
2. Transplant
3. Peritoneal Dialysis
4. Death
Hemodialysis-explain process
3-4 hours about 3x per week
Patent IV Access is REQUIRED c a blood flow of 200-500 cc/ MINUTE. Treatment requires HEPARINIZATION
Catheter type-explain
Catheter (2 PORT) insert IJ, subclavian vein, or femoral vein for Acute situations. To be used only for dialysis. Lock port with 10,000 units of heparin to keep patent between treatments.
Hemodialysis A V Fistula-type
A V Fistula is a artery and a vein connected together to make the vessel expand as venous system becomes engorged(Creates a bruit). Access of choice for chronic clients. Maturity takes about 12 weeks and is required before fistula can be used. Less danger of clotting and bleeding and decreased incidence of infection. Needle insertions required for dialysis. Aneurysm formation and hematomas with infiltration are problems. Arterial steal syndrome and CHF are considerations.
Internal A V Graft-type
Internal A V Graft Artificial graft made of GoreTex or a bovine(cow) carotid artery is used to create and artificial vein for blood flow between and artery and a vein. Maturity takes about 1-2 weeks and is required before fistula can be used. Less danger of clotting and bleeding and decreased incidence of infection. Needle insertions required for dialysis. Aneurysm formation and hematomas with infiltration are problems. Arterial steal syndrome and CHF are considerations.
Principles of hemodialysis
A. The semipermeable membrane is made of a thin, porous cellophane.
B. The pore size of the membrane allows small particles to pass through i.e. urea, uric acid, creatinine.
C. Proteins, bacteria, and blood cells are too large to pass through the membrane.
D. The client': blood flows into the dialyzer; the movement of substances occurs from the blood to the dialysate. Principles of diffusion, osmosis(wastes), and ultrafiltration(fluid).
What is a dialysate bath
⬢ Dialysate bath - Composed of bicarbonate solution (or acetate) and major electrolytes - Need not be sterile because bacteria are too large to pass through
Implementation-What meds do you hold before dialysis
⬢ Implementation - hold antihypertensives and sedatives prior to the procedure (attempt to prevent dramatic drop in BP after fluid removal). Client may eat prior to or during the procedure (unless past history of vomiting).
⬢ Hold water soluble vitamins because they dialyze off.
What is the procedure for hemodialysis
⬢ Procedure - Treatment time- normally 3-4 hours 3 times per week
1. Prime machine with normal saline
2. Get weight in kg
3. Take BP every 5-15 minutes
4. Insert needles-initate blood flow
5. Administer heparin-low dose -consider?
6. Turn up blood flow 200-500cc/MINUTE
7. Set fluid removal rate
8. Observe for hypovolemia-decreased BP, N, V, cramping-
9. Give Saline 100-200cc. Intravascular volume down
10. Trendelenberg position
11. Albumin given if need to pull more intravascular
12. Record fluid removal
13. Return blood by giving saline
14. Weigh on same scales. Record loss.

15. Orthostatic BPs- Standing weight drops when dry
What is Continuous Renal Replacement Therapy (CCRT)
Continuous Renal Replacement Therapy (CRRT) - A very slow continuous form of hemodialysis for those who cannot tolerate an immediate loss in blood volume. -septic shock, sometimes bums
Explain Peritoneal Dialysis
Peritoneal dialysis- CAPD(Continuous Ambulatory Peritoneal Dialysis) No machine required.
IPD (Intermittent Peritoneal) Requires a cycling machine and performed 10-14 hours 3 or 4 times a week. NPD (nightly peritoneal dialysis) performed 8-12 hours each night with no daytime dwells. - The peritoneum is the dialyzing membrane through which the good blood supply of the peritoneal cavity moves solutes and fluids by an osmotic gradient from an area of higher concentration in the body to lower concentration in the dialyzing fluid.
Contraindications to Peritoneal dialysis
Contraindications - Peritonitis, Recent abdominal surgery, abdominal adhesions, impending renal transplant
Explain the dialysate solution that is used for peritoneal dialysis
Dialysate solution-Solution is sterile, contains differing amounts of lytes, glucose with the higher the glucose concentration the higher the amount of fluid to be removed (1.5, 2 .. 5, and 4.5 % solutions) Weight gain may be a problem due to glucose in the dialysate solution being absorbed, Potassium (usually 4 mEq), Heparin (minimal) to prevent clotting in the catheter, antibiotics if prophylactic to prevent peritonitis, and insulin for diabetic clients.
Complications from Peritoneal dialysis
⬢ Complications -Peritonitis - Meticulous sterile technique when hooking up or clamping off bags, and catheter site care- monitor for fever, cloudy outflow, and rebound tenderness., culture outflow if suspect, and antibiotics. Abdominal pain -Pain during inflow is common for 1-2 weeks, cold temperature of dialysate aggravates but to be warmed only with special warmer pad, place heating pad on abdomen during inflow. Insufficient outflow Reposition by MD if cath migration out of peritoneal area, full colon, maintain drainage bag below the client's abdomen, change client's outflow position by turning or ambulating, check for kinks in the tubing, encourage high fiber diet, stool softeners as prescribed
Characteristics of peritoneal dialysis
Characteristics - Outflow may be bloody during first few exchanges, should be clear and colorless to light yellow thereafter. A brown outflow indicates bowel perforation. Cloudy outflow indicates peritonitis.
What does the procedure for peritoneal dialysis entail?
⬢ Procedure -
1. Weigh
2. Gather supplies with dialysate appropriate for fluid removal
3. Mask during exchanges
4. Outflow by drainage bag low
5. Meticulous cleansing of the catheter and sterile technique for spiking a new bag
6. Inflow and fold and leave bag connected 7. Four exchanges per day
Explain a kidney Transplant
what must be done
Transplant- Implantation of a human kidney from a compatible donor into a recipient withirreversible kidney failure. Immunosuppressive medications must be taken for life!!! Hemodialysis performed until adequate kidney function immediately or after first few days.
Describe the Nursing Care that you would provide for patients who are in Chronic renal failure
Fluid Volume Excess-Intake 500cc+cc of output the previous day, assess weight gain, edema, lung sounds, ascites
Altered Nutrition: Less than Body Requirements
Risk for Infection-Risk of Hepatitis B, C, and HIV (Testing done on all new admits), strict aseptic technique,
Body Image Disturbance- Lack of independence
Knowledge Deficit- What to do in a snowstorm and can't get to dialysis- Disease process, diet, meds, symptoms to report, access care, lab values, financial assistance, trip planning and scheduling
1. Identify the functions of the kidney
1. Balance solute and water transport
2. Excrete metabolic waste products
3. Conserve nutrients
4. Regulate acid-base balance
5. Secrete hormones to help regulate blood pressure, erythrocyte production, and calcium metabolism
6. Form urine
2. Symptoms of early renal failure
General Symptom Swelling and Distention - With Swollen Legs
Box # 1

Greatly reduced urine output, swelling of the abdomen and legs, nausea and vomiting
headache, itching, back pain, recent surgery or serious trauma

Body Area Abdomen
General Symptom Swelling and Distention - With Swollen Legs
Box # 2

chronic decrease in urine output, numbness of hands or feet, generalized swelling, bad breath, itching, shortness of breath with exercise, history of diabetes, history of glomerulonephritis, Fluid and electrolyte imbalances, Little or no urine output

Body Area Abdomen
Body Area Abdomen
General Symptom Swelling and Distention - With Swollen Legs
Box # 5
severe headache, blood in urine, blurred vision, nausea and vomiting,itching, generalized swelling, loss of appetite, weight gain, history of hypertension

4 Body Area Abdomen
General Symptom Nausea and Vomiting
Box # 9
Greatly Reduced Urine Output, Generalized Swelling, Headaches, Nausea, Vomiting, Weight Gain, Itching, Recent Severe Illness

Body Area Other Symptoms
General Symptom Weight gain
Box # 10

decreased urine output, generalized swelling, nausea and vomiting, itching, weight gain,
loss of appetite
3. What type of tests might be used to identify renal failure?
1. Urinalysis often shows the following abnormal findings in acute renal failure:
a. A fixed specific gravity of 1.010 (equal to the specific gravity of plasma) as the tubules are unable to concentrate the filtrate
b. Proteinuria
c. The presence of RBCs (due to glomerular dysfunction), WBCs (related to inflammation), and renal tubular epithelial cells (indicating ATN)
d. Cell casts, which are protein and cellular debris molded in the shape of the tubular lumen (In ARF, RBC, WBC, and renal tubular epithelial cell casts may be present. Brownish pigmented casts and positive tests for occult blood indicate hemoglobinuria or myoglobinuria.

2. Serum Creatinine and BUN are used to evaluate renal function. In ARF, serum creatinine levels increase rapidly, within 24 to 48 hours of the onset. Creatinine levels generally peak within 5-10 days. Creatinine and BUN levels tend to increase more slowly when urine output is maintained. The onset of recovery is marked by a halt in the rise of serum creatinine and BUN.
3. Serum electrolytes are monitored to evaluate the fluid and electrolyte status. The serum potassium rises at a moderate rate and is often used to indicate the need for dialysis. Hyponatremia is common, due to the water excess associated with ARF.
4. Arterial blood gases often show a metabolic acidosis due to the kidneys’ inability to adequately eliminate metabolic wastes and hydrogen ions
5. CBC shows reduced RBCs, moderate anemia, and a low hematocrit. ARF affects erythropoietin secretion and RBC production. Iron and folate absorption may also be impaired, further contributing to anemia.
6. Renal ultrasonography is used to identify obstructive causes of renal failure, and to differentiate acute renal failure from end-stage chronic renal failure. In ARF, the kidneys may be enlarged, whereas they typically appear small and shrunken in chronic renal failure
7. Computed tomography (CT scan). Also may be done to evaluate kidney size and identify possible obstructions
8. Intravenous pyelography (IVP), retrograde pyelography, or antegrade pyelography may also be used to evaluate kidney structure and function
4. Describe polycystic kidney disease and its pathology.
Polycystic kidney disease is a hereditary disease characterized by cyst formation and massive kidney enlargement, affects both children and adults.
The autosomal dominant form affects adults, the autosomal recessive form is present at birth.
Renal cysts are fluid-filled sacs affecting the nephron, the functional unit of the kidneys. They develop in the tubular epithelium of the nephron, filling with straw-colored glomerular filtrate. The cysts may range in size from microscopic to several centimeters in diameter and affect the renal cortex and medulla of both kidneys. As the cysts fill, enlarge, and multiply, the kidneys also enlarge. Renal blood vessels and nephrons are compressed and obstructed and functional tissue destroyed. The renal parenchyma atrophies and becomes fibrotic and scarred.
Manifestations: Slowly progressive. Symptoms develop by age 40-50. Flank pain, microscopic or gross hematuria, proteinuria, and polyuria and nocturia as the concentrating ability of the kidneys is impaired.
5. Identify options for the ESRD patient and the benefits and disadvantages of each option End stage renal disease options
Transplantation if it is considered: tissue typing and identification of potential living related donors can be done prior to the onset of ESRD. To make an informed decision, both the client and potential donor need to understand the risks, benefits, and options available. If the decision for transplant is made early, dialysis can potentially be avoided. The client’s age, concurrent health problems, donor availability, and personal preference influence the choice of renal replacement therapy
Manages symptoms of ESRD, does not cure it.
In-Center Hemodialysis
+ Facilities are widely available.
+ You have trained professionals with you at all times.
+ You can get to know other patients.
- Treatments are scheduled by the center and are relatively fixed.
- You must travel to the center for treatment.
Home Hemodialysis
+ You can do it at the times you choose (but you still must do it as often as your doctor orders).
+ You don't have to travel to a center.
+ You gain a sense of independence and control over your treatment.
- You must have a helper.
- Helping with treatments may be stressful to your family.
- You and your helper need training.
- You need space for storing the machine
and supplies at home.

Peritoneal dialysis
+ You can do it alone.
+ You can do it at times you choose as long as you perform the required number of exchanges each day.
+ You can do it in many locations.
+ You don't need a machine.
- It can disrupt your daily schedule.
- This is a continuous treatment, and all exchanges must be performed 7 days a week.
- It carries the risk of peritonitis.
- Some patients cannot achieve adequate clearance of solutes with PD.
Identify areas of teaching for the new patients on hemodialysis
Hemodialysis cleans and filters your blood using a machine to temporarily rid your body of harmful wastes, extra salt, and extra water. Hemodialysis helps control blood pressure and helps your body keep the proper balance of important chemicals such as potassium, sodium, calcium, and bicarbonate.

How It Works
Hemodialysis uses a special filter called a dialyzer that functions as an artificial kidney to clean your blood. During treatment, your blood travels through tubes into the dialyzer, which filters out wastes and extra water. Then the cleaned blood flows through another set of tubes back into your body. The dialyzer is connected to a machine that monitors blood flow and removes wastes from the blood.

Hemodialysis is usually needed three times a week. Each treatment lasts from 3 to 5 or more hours. During treatment, you can read, write, sleep, talk, or watch TV.

Who Performs It
Hemodialysis is usually done in a dialysis center by nurses and trained technicians. In some parts of the country, it can be done at home with the help of a partner, usually a family member or friend. If you decide to do home dialysis, you and your partner will receive special training.

Diet for Hemodialysis
Hemodialysis and a proper diet help reduce the wastes that build up in your blood. A dietitian is available at all dialysis centers to help you plan meals according to your doctor's orders. When choosing foods, remember to:

b. Eat balanced amounts of high-protein foods such as meat, chicken, and fish.
c. Control the amount of potassium you eat. Potassium is a mineral found in salt substitutes, some fruits (bananas, oranges), vegetables, chocolate, and nuts. Too much potassium can be dangerous to your heart.
d. Limit how much you drink. When your kidneys aren't working, water builds up quickly in your body. Too much liquid makes your tissues swell and can lead to high blood pressure, heart trouble, and cramps and low blood pressure during dialysis.
e. Avoid salt. Salty foods make you thirsty and make your body hold water.
f. Limit foods such as milk, cheese, nuts, dried beans, and dark colas. These foods contain large amounts of the mineral phosphorus. Too much phosphorus in your blood causes calcium to be pulled from your bones, which makes them weak and brittle and can cause arthritis. To prevent bone problems, your doctor may give you special medicines, which you must take with meals every day as directed.
7.Identify common complications of dialysis
Vascular access problems are the most common reason for hospitalization among people on hemodialysis. Common problems include infection, blockage from clotting, and poor blood flow. These problems can keep your treatments from working. You may need to undergo repeated surgeries in order to get a properly functioning access.
Other problems can be caused by rapid changes in your body's water and chemical balance during treatment. Muscle cramps and hypotension—a sudden drop in blood pressure—are two common side effects. Hypotension can make you feel weak, dizzy, or sick to your stomach.
You'll probably need a few months to adjust to hemodialysis. Side effects can often be treated quickly and easily, so you should always report them to your doctor and dialysis staff. You can avoid many side effects if you follow a proper diet, limit your liquid intake, and take your medicines as directed.

The most common problem with peritoneal dialysis is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contamination occurs as the catheter is connected or disconnected from the bags. Peritonitis requires antibiotic treatment by your doctor.
To avoid peritonitis, you must be careful to follow procedures exactly and learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor immediately so that peritonitis can be treated quickly to avoid serious problems.
What Meds are common for the hemodialysis patient? What medications are held prior to hemodialysis
1. Multi-vitamins: replace vitamins lost during dialysis and add vitamins you may not be getting with the special renal diet. Water soluble multi-vitamins are held and given after dialysis because the vitamins would be taken out with the extra fluid
2. Phosphate binders: control your phosphorous level and help prevent bone disease
3. Calcium supplements are used if your body needs calcium and for phosphate binding
4. Other common meds: iron, high blood pressure meds, heart stimulants, and stool softeners
5. Synthetic Erythropoietin: a drug to prevent anemia

Blood pressure meds and sedatives are held and given after dialysis
9. Identify three nursing diagnoses that might apply for the hemodialysis patient admitted with respiratory symptoms-labored breathing, respiration 36, moist rales bilaterally, 3+ edema in the ankles
Fluid volume excess
Ineffective breathing pattern
Activity intolerance
What are the lab tests most commonly followed on dialysis patients? What is normal, and what is a typical value for hemodialysis patient.
1. Creatinine (usually high) (8.0-20.0 mg/dl)
2. Blood Urea Nitrogen (high) (60-110 mg/dl)—BUN of 20-50=mild azotemia; levels greater than 100 mg/dL indicate severe renal impairment
3. Potassium (3.5-5 mEq/L)-usually below 6.5 mEq/L
4. Chloride
5. Sodium (135-145 mEq/L)
6. Calcium (60-100 mg/dl) (usually decreased in dialysis pt)
7. Phosphorus (high usually in dialysis pts) 2.3-4.7 mg/dl
8. Alkaline Phosphatase (25-100 units/L
9. Albumin and total protein (3.8-5.5 gm/dl)
10. Glucose (fasting) (60-100), Less than 140
11. Hematocrit (usually low) (33%-36%)
12. Hemoglobin 11-12
. A nurse, developing a plan of care for a client diagnosed with polycystic kidney disease, would not plan to include

1. referral for genetic counseling.
2. hypertension control.
3. fluid restriction.
4. prevention of urinar
3. fluid restriction.

Clients with polycystic kidney disease are encouraged to maintain a fluid intake of at least 2500 mL per day. Since this disease is an autosomal dominant disorder, genetic counseling and screening for evidence of the disease is necessary. Hypertension associated with polycystic disease is generally controlled using angiotensin-converting enzyme (ACE) inhibitors. Prevention and treatment of urinary tract infections is stressed to prevent further kidney damage.
Planning; Physiological Integrity; Application
A male client presents to the emergency department with complaints of fatigue, anorexia, nausea, and vomiting, and states that his urine is coffee-colored. The nurse notes periorbital edema, and the blood pressure is elevated. The nurse suspects the clie
3. acute glomerulonephritis

Acute glomerulonephritis is manifested by hematuria, cocoa or coffee-colored urine; salt and water retention; periorbital, facial, and possibly dependent edema; hypertension; azotemia; anorexia; nausea; vomiting; and headache. Infection of the pharynx or skin with Group A beta-hemolytic streptococcus is the common precipitating factor of this disorder.
Assessment; Physiological Integrity; Analysis
. A client with nephrotic syndrome is being admitted to the unit. The nurse includes which of the following in planning the care for this client?

1. Interventions for client with generalized edema
2. Interventions for frank blood loss t
1. Interventions for client with generalized edema

Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema. The client is generally hypertensive and has fluid volume excess. Microscopic hematuria is noted, but frank blood loss is not expected.
Planning; Physiological Integrity; Application
A nurse is providing discharge instructions to a client undergoing a renal biopsy. Which of the following statements made by the client indicates a need for further teaching?
1. "I will avoid coughing the first 24 hours after the procedure.&qu
4. "I will probably experience pain in my shoulder or back."

Signs and symptoms of hemorrhage following a renal biopsy include flank or back pain, shoulder pain, pallor, and lightheadedness. The client is instructed to report these manifestations to the physician immediately. The other responses demonstrate an understanding of teaching for care following a renal biopsy.
A 28-year-old male presents to the emergency department with multiple trauma after falling off a roof while working. Which of the following signs or symptoms indicates to the nurse the possibility of retroperitoneal bleeding from the kidney?

1. Bluish discoloration of the flank

Bluish discoloration of the flank (Turner's sign) is evidence of retroperitoneal bleeding from the kidney. Tachycardia, tachypnea, and cool, pale skin are signs of shock, and may be present with retroperitoneal bleeding, but may be related to other trauma.
Assessment; Physiological Integrity; Analysis
A nurse implementing preoperative teaching for a client scheduled for a total nephrectomy of the left kidney would not include which of the following in the teaching plan?
1. Coughing, turning, and spirometry
2. Anticipated tubes, stents, or
4. Postoperative dialysis

Postoperative dialysis is not generally indicated for the client having one kidney removed, as long as the remaining kidney is functioning. Pain management, general postoperative routines such as coughing, turning, and spirometry, as well as anticipated tubes, stents, or drains should be discussed preoperatively with the client to facilitate understanding and cooperation postoperatively.
Planning; Physiological Integrity; Application
A client, newly diagnosed with chronic renal failure, has recently begun hemodialysis. The nurse, establishing the client's plan of care, includes monitoring the client for disequilibrium syndrome. Which of the following symptoms will the nurse assess th
1. Headache, nausea and vomiting, altered level of consciousness, and hypertension

Disequilibrium syndrome is manifested by headache, nausea and vomiting, altered level of consciousness, and hypertension. Rapid changes in the blood urea levels and pH, and electrolyte shifts during dialysis may lead to the development of cerebral edema, causing signs of increased intracranial pressure. Chills, fever, and shortness of breath are indicative of a transfusion reaction, and cramping and seizure activity may be caused by excess fluid removal.
Planning; Physiological Integrity; Application
A nurse is evaluating a client's demonstration of peritoneal dialysis. Which of the following actions by the client demonstrates a need for further teaching?
1. Primes the tubing with solution and connects it to the peritoneal catheter, taping conn
2. Instills the dialysate into the abdominal cavity quickly and clamps the tubing
An elderly client is admitted with acute renal failure. Which of the following is the priority nursing diagnosis for this client?
1. Excess Fluid Volume
2. Imbalanced Nutrition: Less Than Body Requirements
3. Deficient Knowledge
1. Excess Fluid Volume

Fluid retention leads to rapid weight gain and edema, and heart failure and pulmonary edema may develop. Assessing for fluid volume excess and accompanying complications is the priority.
Analysis; Physiological Integrity; Application
A client is admitted for emergency dialysis for newly diagnosed chronic renal failure. The nurse recognizes that which of the following laboratory values poses the greatest risk to the client?
1. BUN 40 mg/dL
2. Serum Creatinine 5.8
3. Potassium 7.0 mEq/L

Though all of the laboratory values are abnormal and related to renal failure, the greatest immediate risk to the client is the potassium level of 7.0 mEq/L. Hyperkalemia can result in cardiac dysrhythmias and cardiac arrest. The client should be placed on cardiac monitoring. An exchange resin, such as Kayexalate may be prescribed.
Assessment; Physiological Integrity; Analysis

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