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What does ARF stand for?

Acute Renal Failure

Normal kidneys excrete how much urine per/hr or /24hrs?

1ml per kg. or 1-2L in 24hrs

ARF occurs when metabolites accumulate in body and urinary output changes. What are the 3 types of ARF?

1) Prerenal (low blood flow) 2) Intrinsic/Intrarenal (damage) 3) Postrenal (Urinary Obstruction)

Prerenal ARF caused by what 5?

Low bld volume (hemorrhage/hypovolemia); Low BP; Hrt failure (dec CO); Renal ar stenosis (dec renal perfusion & bruits) and renal vein thrombosis.

In what cndtn of a Prerenal cause of ARF do you hear bruits?

Arterial stenosis (dt HTN)

Intrarenal ARF caused by prolonged prerenal state, vascular lesions, renal injury and what 4 specifics?

Glomerulonephritis (AGN infctn) or Acute Phyelonephritis (APN); Acute tubular necrosis (ATN); Acute interstitial nephritis (AIN); Nephrotoxins (NSAIDS, Salicylates, Antibiotics)

What 3 nephrotoxins cn cause intrarenal ARF?

NSAIDS, Salicylates, Antibtcs

What 4 things can cause Postrenal ARF (urinary obstruction)

Benign Prostatic hypertrophy (BPH); Kidney stones (calculi); Kidney Tumors; Urinary Catheter obstruction

Often, people with ARF go through what 3 phases?

Oliguric, Diuretic, Recovery (odor)

Oliguric phase of ARF (<400ml/day or __ml/hr) 2 lab inc? 2 lab dec? fluid and spcf grav?

<17ml/hr. Inc BUN/CR, K. Dec Na and pH (acidosis). Fluid overload (hypervolemic). High urine spcf grav >1.020

How many ml output in oliguric phase of ARF? Hence, how much fluid you want to give to pt?

<400ml/day or 17 ml/hr (give 100-400ml/day)

Diuretic phase of ARF up to __L/day. 2 lab Dec? fluid? Spcf grav?

10L/day. Dec K and Na. hypovolemia. Low spcf grav <1.020

Why is diuretic phase of ARF a good sign?

Shows pt moving on to recovery

If you notice pt with low urine output, what do you check first?

BUN/Cr levels

Norm values of BUN/Cr

Bun: 10-20. Cr 0.5 - 1

Recovery phase of ARF noted by?

Return to normal of BUN/Cr and other lab work.

Does everyone with ARF always go through oliguric before diuretic?

No, can go directly to diuretic w/10L/day

E-lytes affected by renal probs...shift in direction. What 2 ions are mainly extracellular? 2 intracellular?

Na and CL = extracellular. K and Ph = intracellular.

What is a good indicator of fluid retention and renal status, part in oliguric phase of ARF?

weight gain. Oliguric could gain 1lb/day. Weigh daily...same time, same scale.

Why are Na levels low in both hypovolemia and hypervolemia? Do you want to give them Na?

hypovolemia (prerenal ARF) excess H2O dilutes Na levels. Hypervolemia (intrarenal) Na excreted. No! limit Na and fluid intake!

In what phase of ARF do you want to limit protein intake?

Oliguric...cuz of high BUN/CR

What are high potassium foods you want to limit in ARF (5)? (part oliguric)

bananas, avocadoes, spinach, fish, salt substitutes

What 6 signs of hyperkalemia to look out for in ARF oliguric phase?

weakness, dizziness, cardiac Ireg, muscle cramps, diarrhea, nausea.

For clients with ARF monitor I/O (replace how much ml in oliguric phase?), monitor what lab values, assess level of consciousness, prevent cross-infection, nutrition? Monitor cardiac rate and rhythms (K levels), and drug levels.

400-500ml/24hrs; K, Ph, Na, Cl, spcf grav, BUN; low prtn/fat, high Carbs, low H2O/Na.

5 S/S of excess fluid? (ARF)

dyspnea, tachycardia, JVD, Per edema, Pulm edema

5 S/S of hypovolemia besides Dec urine output

Dec body wght; Dec skin turgor; Dry mucous mmbrns; Hypotn, Tachycardia

Tachycardia, JVD, and Peripheral edema signs of hyper/hypovolemia?

hypervolemia

Tachycardia, hypotension, dry mucous mmbrns signs of hyper/hypovolemia?

hypovolemia

Chronic Renal Failure (CRF) or End-Stage Renal Dse (ESRD) Described. 2 invasive tx often needed?

Progressive irreversible damage to nephrons & glomeruli resulting in trauma. Dialysis or transplant.

Acute Renal Failure vs Chronic/End-Stage RD. Which is reversible? Which requires dialysis/transplant?

ARF is reversible. CRF or ESRD needs dialysis/transplant

S/S of ESRD: Edema (excess fluid volume), BP? Neuro? Urine fxn? Skin? Mouth? Labs?

Inc BP; Neuro: weak/drowsy; Dec Urine fxn: hematuria, prtnuria, cloudy, oliguric (100-400) and anuric (<100ml/day); Yellow skin; Metallic taste, ammonia breath; Inc BUN/Cr, Ph, Mg & Dec Ca.

End-Stage Renal Failure (ESRD) aka?

Chronic Kidney Dse (CKD)

in what Dse will pt have metallic taste, ammonia breath and inc Mg and Dec Ca?

End-Stage Renal Dse (ESRD)

What is azotemia? How related to ESRD?

Anorm levels of Nitrogen cmpds like urea, Cr, and other wastes in bld. R/T insufficient filtering by kidneys.

Waste product accumulation (from prtn metblsm) is primary cause of uremia in ESRD. What is a good indicator of level of prtn consumption?

GFR: Glomerular Filtration Rate

Medicare and ESRD?

W/dialysis you are eligible for Medicare. Transplant included. If dialysis not needed after 6 mos, Medicare ends

Is deficient fluid volume common with ESRD or Chronic Renal Failure?

No. Mainly Excess Fluid volume.

ESRD interventions: Strict I&O; Weigh Daily (don't want weight gain); Monitor e-lytes; Check for signs of fluid overload (JVD/edema); Diet? Phosphate? And __

Low Prtn, Na, K, pH diet w/high calories (don't want so low you get muscle wasting) Ph binders like aluminum hydroxide cuz can't excrete Ph (no Mg antacids!) Observe for complications.

Besides infection what are 4 complications with ESRD?

Anemia, Resistant HTN, Metabolic acidosis, Renal Osteodystrophy (dt abnorm Ca mtblsm)

Low amnts of K in ESRD or Diuretic ARF can cause toxicity with what drug?

digoxin (visual disturb, HB<60, arrhythmia)

What drug can you give an ESRD pt with a complication of anemia? Elderly? Shake? Hct values?

Erythropoietin (Epogen). Elderly may have inc risk of thrombosis. Shaking vial may inactivate glycoprtn. Report Hct>30-33% or inc 4 ptns in 2 wks.

When give Epogen for anemia in ESRD (CKD) besides making sure Hct is not>33%, what will occur for 1st 12 hrs of taking only?

Bone, pelvic, and limb pain.

What are the 3 types of Renal Dialysis? Which is most rare? Fast e-lyte correction? Loses prtn?

Hemodialysis (rapid), Cont Hemofiltration (Rare), Peritoneal (Prtn lost)

What is the main diff b/w dialysate for hemodialysis and peritoneal? Sign?

More glucose in peritoneal...Inc hyperglycemia and infctn.

Hemodialysis: Access? Tx length? Blood/prtn loss? Comp?

Venous access (AV, shunt, fistula); 3x/wk 3-8 hrs (rapid e'lyte correct); Bld loss, no prtn loss. Comp: Hep B/C thrill/bruits

For which type of dialysis may the pt develop Hep B/C?

hemodialysis

For which type of dialysis is heparinization not req'd? (is for others)

Periotneal

Continuous Art Hemofiltration (CAVH) access? Speed? Losses? Comp?

Vascular access (femoral/subclavian cath); Slow. No bld/prtn loss. Filter may rupture (bld loss). Only special care use)

Peritoneal access? Speed? Losses? Home okay? Comp?

Surgical abd catheter, Slow, Prtn loss, not bld. Easy at home. Bowel/bladd perforation, infection, peritonitis.

Which renal dialysis is costly?

they all are!

which renal dialysis has potential bld loss?

hemodialysis

which renal dialysis may the filter rupture causing bld loss and it's only used in special care units?

hemofiltration (CAVH)

Which renal dialysis requires surg placement of a gore-tex, column-disk or tenckhoff catheter?

peritoneal

UTI occurs at what sites? Normally the urinary tract is sterile, what is most common infcts agent for UTI?

kidney, ureters, bladder (cystitis), prostrate, urethra. E. coli.

Persons at highest risk for UTIs: immunosuppressed, catheterized, preg wmn and what 4 others?

Urinary retention, diabetics, men w/prostatic hypertrophy, elderly women (prolapse)

S/S (5) of UTI that encourage a urine analysis or cystoscopy

Fever & chills; Urin freq, urgency, dysuria; Hematuria; Costovertebral angle tenderness; Elev WBC >10K

What tests dx UTI by determing bladd fxn and bladd/urethral abnorm?

cystogram & cystoscopy

what is cystitis and assoc w/what type of infctn?

inflamm of urinary bladder lining. Usually UTI.

Intvns for UTI: caffeine? What type Rx? Bath? Fluid intake? Void x 2-3 hrs, cotton underwear, monitor I&O

No caffeine (irritates bladder) Antbcs. Shower, not bath. 3L intake.

Urinary tract Obstruction caused by what 4?

1) Foreign body (calculi) 2) Tumors 3) Strictures 4) Functional (neurogenic bladder)

In Urinary tract obstruc urine is retained above pt of obstruction causing what 2 successive complications?

1) Hydrostatic pressure builds dilating organs above obstruction. 2) hydronephrosis can then lead to renal failure.

Urinary Tract obstruction s/s (5)

Pain, Fever & chills; N&V & diarrhea; Abdominal distention (dilatation); Change in void (incontinence, hematuria, dribbling)

Because inc hydrostatic pressure causes dilation of organs in Urinary tract obstruction what will you see in Pt?

Abdominal distention and pain

Flank pain means a stone is where? What if radiates to abbs or scrotum?

Kidney/upper ureter. 2) Bladder/ureter.

Excruciatin; spastic pain sometimes with kidnes stone/obstruction called?

colic pain

During kidney stone attacks (obstruction) is is better to give pain PRN or regularly?

Regularly to prevent spasm.

With Urinary Obstruction give what type meds? (2). Moist heat on pain okay? Fluids?

Narcotic analgesics, Antbcs if infctn. Moist heat usually okay. High fluids to dislodge stone.

Besides I&O monitor, what impt to do with urine when have obstruction from kidney stone?

Strain it for calculi! Send to lab.

Why is follow-up impt after Urinary Obstruction Care? Pt avoid what position?

Stones can recur...esp if still eat same diet that composed calculi. Avoid supine pstn

Cystoscopy, systolitholopaxy, ureteroscopy, Percutaneous nephrolithotomy are used to Dx and tx what?

Urinary Tract Obstruction (percutaneous goes through skin)

What type of Procedure for Urinary Tract Obstruction smashes stones externally via laser, ultrasound, other wave?

Lithrotripsy

Surgical therapies like nephrolithotomy, pyelothitomy, ureterolithotomy & cystotomy used for what dse?

Urinary Tract obstruction

Benign Prostatic Hyperplasia (BPH) in men > __yrs. Intervention req'd if..? Tx?

>40 yrs. If obstruction, intvn req'd. TURP by endoscopy (Transurethral resection of Prostate)

In a man >40 what do the following S/S suggest? Inc void Freq, nocturia, hesitancy, Bladder distention?

BPH. Benign Prostate Hypertrophy

After a TURP for BPH what are general nursing intvns? (6)

Analgesics, Monitor bladder catheter, Color and Content of Urine, Hbg/Hct, increase fluids, avoid intercourse 1 mo.

Color changes to urine after TURP?

Reddish-pink to light pink 24hrs after and yellow by 4th day.

What is abnormal urine output color you want to report?

Bright-red with large clots

Sterility can occur w/TURP. How long will pain last?

1 week post-op.

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