Renal System
Terms
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- uremia
- syndrome of renal failure RT body's inability to properly excrete waste products
- Chronic renal failure
- an irreversible, progressive reduction of functioning renal tissue so that the kidnean no longer maintain homoeostasis (fluid vol, acid/base balance, electrolyte). HTN and DM accounts for greater than 60% of clients on dialysis. a gradual deterioration and destruction of nephrons c progressiv loss of function. remaining nephrons hypertrophy in order to try and filter the larger load of solute. in attempt to compensate, kidneys pass large amounts of dilute urine, gradually they lose ability to reabsorb lytes. GFR isn't affected until about 70% of the nephrons are gone. don't need dialysis until 90% of nephrons are gone. neurologic changes: confuusion, inability to concentrate, preipheral neuropathy, decreased LOC, twitching, seizures/coma. CV changes: HTN, increased triglycerides. Respiratiory changes more normally found in the acute phase: pulmonary edema due to fluid volume edema, crackles, inc resp rate from metabolic acidosis (Kussmauls), change in the ABG. INtegumentary changes: pruritis, dry skin, bruising and petechiae, pallor, skin orange/green/gray in color, brittle hair and nails. hematologic changes: anemia rt decr erythropoesis and destruction of RBCs. GI changes because uremic toxins still building up: anorexia, nausea and vomiting, metallic taste in mouth, loss of smell and taste, inspect oral mucosa, constipation or diarrhea. electrolyte imbalance: hypocalcemia, hyponatremia, hyperkalemia. musculoskeletal changes: renal osteodystrophy. Immunologic changes:altered immune response and function. causes a change in med metabolism. Reproductive changes: menstrual irregularities, infertility, impotence, decr libido. Endocrine changes: hypothryroidism, insulin utilization, parathyroid, growth hormone. Psychosocial changes: depression, mood swings, body image, time complications RT dialysis, lifestyle changes.
- internal ateriovenous (AV) fistula
- a surgically placed connection of artery and vein used for circulatory access for hemodialysis. palpate for a thrill and auscultate for bruite to ensure they are patent.
- blood urea nitrogen
- measure of the amount of nitrogen in the blood in the form of urea, and a measurement of renal function
- solute removal (diffusion), water removal (osmosis), ultrafiltration
- how hemodialysis works
- medications commonly used to treat patients c RF
- antihypertensive agents, analgesics, antacids/phosphate binders, antianemics (epogen and iron dextran), activated Vit D, cation exchange resins, diuretics, stool softeners/cathartics, histamine H2 receptor antagonists (decrease stomach acid), vitamins.
- average of 3 d/wk for 2.5-5 hours/tx
- typcial chronic hemodialysis prescription.
- proteinuria
- an excess of serum protein in the urine. can be measured with using the standard urine dipstick...total protein-creatinine ratio. albumin specific urine dipstick...albumin-creatinine ratio.
- oliguria
- a definition of RF. decrease or absense of urine production. 100-400ml/day
- steal syndrome
- the result of decreased arterial blood to the extremity b/c of internal arteriovenous fistula or arteriovenous graft. cold, numb, and discolored distal extremity d/t shunted arterial blood. some cases improve with time.
- temporary access lines
- hemodialysis circulatory access in the internal jugular or femoral lines.
- prerenal risk factors
- a problem prior to the kidney...before something can enter the kidney. causes decreased blood flow to the kidneys. ex: artery stenosis, HTN, hypovolemia.
- Creatinine clearance
- this measurement is gained from a 24 hr urine study or it can be calculated. measures GFR. adult male: 90-139ml/min. adult female: 80-125ml/min. values decrease 6.5 ml/min/decade of life p 20.
- intrarenal risk factors
- a parenchymal change within the kidney. 30-45% of kidney problems happen here. acute tubular necrosis is the most common (75% of these problems are atn).
- Oliguric-anuric phase
- a phase of acute renal failure which lasts 1-8 weeks. a decrease in urine output = fluid volume overload (Sx: crackles, JVD, pounding P, S3), increase in serum urea, Cr, K, Mg, Phos, uric acid....kidney cant't excrete these so the levels become elevated, anuria. assess for s&s of FVE.
- Results to look for in urine analysis
- low osmolality (urine is dilute....tubulules cannot concentrate urine), increased No, sediment c RBCs and casts. proteinuria.
- AV fistula, AV graft, temporary access lines, perm catheters
- circulatory access dor hemodialysis
- serum creatinine
- normal 0.5-1.2mg/dl (critical above 4mg/dl). product of muscle metabolism, excreted entirely by the kidney. not affected by hepatic function. doubling of Cr suggests a 50%drop in GFR.
- Acute tubular necrosis
- this causes impaired renal perfusion. nephrotoxins include heavy metals, antibiotics, ASA, NSAIDS, and contrast dyes. heme pigments...Hgb from transfusion rxn, myoglobin is found in muscles p crushing injuries.
- postrenal
- an obstruction in the urinary tract until the exit...anywhere from the tubules to the urethral meatus. ie:kidney stones, mass, tumor, prostate obstruction...all of these prevent the bladder from emptying.
- renal ultrasound
- a diagnositc renal study which is good for indicating the anatomy and function of the kidney. helpful in addressing obsvious obstructions.
- Blood urea nitrogen
- normal range: 10-20 mg/dl (critical at greater than 100mg/dl). this is an end product of protein metabolism. an indirect measurement of renal function and GFR when liver function is normal. it is directly related to metabolic function of liver and excretory function of kidney. not a reliable indicator of RF, but does indicate the kidneys are stressed.
- predialysis patient assessment
- fluid status, patient interview, condition and patency of access, review lab results, and check the weight.
- diuretic phase
- a phase of acute renal failure where the urine output = 1-2 L/day....possibly even 3-4 L/d. tubules can't concentrate the urine. assess for dehydration. labs start to return to normal/ deplete. hypokalemia (dry skin, arrhythmias, HPO). may last 1-3 wks.
- renal osteodystrophy
- as the GFR decreases, Phos. excretion decreases, low Ca stimulates parathyroid to produce more Ca. Ca taken from bone. Decreased synthesis of cholecalciferol.
- recovery phase
- a phase of acute renal failure which lasts 3-12 months. 30% of individuals do not fully recover. urine output returns to normal....they may have a new norm of kidney efficiency.
- Renal scan
- a diagnostic renal study which indicates structure, perfusion, and excretory function.
- peritoneal dialysis
- the dialyzing membrane of this dialysis is the peritoneum. occurs through repeated cycles of instilling diastylate into the peritoneum and then letting it drain with passive diffusion. adv. incr freedom with activity, better homeostasis, fewer dietary and fluid restrictions. Complications: peritonitis, catheter-related complications, dialysis related complications (pain, HPO, FVE, hypoalbuminuria)
- Glomerular filtration rate
- flow rate of filtered fluid through the kidney
- perm catheters
- hemodialysis circulatory access tunneled catheters with chest wall exit site.
- oliguric-anuric, diuretic, recovery
- clinical phases of acute renal failure. there is a 15% mortality rate...even higher % c the elderly.
- anuria
- definition of RF. nonpassage of urine...less than 100 ml/day.
- Stages of chronic kidney disease
- 1) GFR > 90= mild. 2) 60-90 = ?normal for age, progressing; 3) 30-59= S&S occur, need tx; 4) 15-29= renal insufficiencym oreoare for dialysis or transplant; 5) GFR <15 ueremic, should start dialysis. many people die becore the fifth stage b/c of comorbidities....ex. diabetes, HD
- azotemia
- a defn of FR characterized by abnormal levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood. cause decrease in GFR, and an increase in BUN and serum creatinine
- creatinine
- a break-down product of creatine phosphate in muscle, and is usually produced at a fairly constant rate by the body. it is filtered by the kidneys
- monitoring of patients on Hemodialysis
- monitor vital signs and complications.....muscle cramping, nausea, HPO
- acute renal failure
- a dudden and almost complete loss of kidney function. can happen over a few hours/days. it is potentially reversible...p major MI or in a post op. patient. causes an increase in serum Cr and BUN.
- normal functions of a kidney
- fluid balance, solute concentration,acid/base homeostasis, excrete wastes, secrete hormones
- ESRD diet before dialysis
- fluid restriction, protein restriction, fat, CHO, low K, low Na, low P.
- CT and MRI
- diagnostic renal studies which indicate masses, fluid collections and vascular abnormalities. more expensive.