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GI Kidney key points with patho review, AKI, CKD, etc,.
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Kidney Disease
(^) Prevention (^) Monitor labs BUN, creatinine, ‘lytes (^) Nephrotoxic Meds? Contrast? (^) Fluid and electrolyte management (^) Want equal I&O’s, daily weights (^) Fluid Challenges (^) Give bolus over 1hr to see if UOP increases or if we can help kidneys recover; may also use diuretics (^) Pressors (^) Treat electrolyte abnormalities as necessary (^) Nutrition Therapy (^) Avoid 3 Ps: Protein, Phos, Potassium (^) Low Na (^) Control fluids (^) Medication Management (^) Dextrose & Insulin – lower K (^) Epogen & Procrit – raise RBCs (^) Kayexalate – lower K (^) Sodium Bicarb – help w/ metabolic acidosis (^) Folic Acid & Iron -- supplement (^) Amphojel – lower P (^) Diuretics – improve filtration (^) Lokelma – lower K (^) Renal Replacement Therapy (^) Last resort (^) Continuous Dialysis (CVVH) (^) Hemodialysis (HD)
(^) Progressive, irreversible kidney injury; kidney function does not recover (^) Issues with metabolic & acid-base balance (^) Slow progression (years) (^) Goal: medically manage as long as possible (^) End-stage renal disease (ESRD) (^) High risk factor: DIABETES (^) Will see: Azotemia/Uremia (^) Neurological – Altered LOC, seizures, fatigue, lethargy, depression, coma, weak, dizzy (^) Cardiovascular – HF Sx, HTN, HLD, dysrhythmias, tachycardia, & more (^) Respiratory – pulmonary edema, SOB, pink frothy sputum, tachypnea, crackles (^) Hematologic – anemia, low H&H, low RBC (^) GI – ulcers, anorexia, N/V (^) GU – decreasing UOP, increasing BUN & creatinine (^) Skin – dry, itching, uremic frost, pale, decreased turgor
(^) Progressive; can medically manage (^) Don’t need dialysis right away (^) Reduced glomerular filtration rate (GFR) (^) Stage 1 – GFR > 90; still normal renal function (^) Stage 2 – GFR 60-89; no buildup of waste, kidneys work harder, slight change in Sx (^) Stage 3 – GFR 30-59; see build up of waste, increase in BUN & creatinine, issues with HTN and fluid volume (^) Stage 4 – GFR 15-29; see more build up of toxins and issues with electrolytes, think about HD (^) Stage 5 – GFR < 15; ESRD; severe fluid and electrolyte issues, excessive waste products; start dialysis or comfort cares
Dialysis
(^) Reasons: hyperkalemia, fluid overload, AKI, CKD (^) With CKD, typically go 3x/week (^) Each session being 3-4 hrs at a time (^) Manage fluid overload that kidneys can't handle (^) Manage electrolytes (^) Use dialysate solution to draw waste and toxins out of blood (^) Often use heparin as anticoagulation so blood won’t clot with HD machine (^) Need large needle for access or large enough catheter to filter blood (^) Line options: (^) AV fistula, Mahurkar, or Perm Cath
(^) Arteriovenous (AV) fistula or graft (^) Mesh artery and vein together, use pt own vessels (^) Less clotting risk, less infection risk, more permanent option (^) Usually done in the arm; ensure good circulation (^) Assess if patent by: FEEL the THRILL & HEAR the BRUIT (^) DO NOT use fistula arm for blood pressures, blood draws, or other lines (^) Dialysis Catheter – Mahurkar or Perm Cath (^) Often more temporary; Can be placed while waiting for fistula to mature (^) Can be double or triple lumen (^) Higher risk of infection (^) Complications (^) Thrombosis/Clots – why heparin is used to maintain patency of fistula or catheter (^) Infection – esp w/ catheters; monitor dressing and assess for s/sx infection (^) Aneurysm formation – caused by repeated needle sticks w/ fistula; may need other line or fistula (^) Ischemia – rare; r/t decreased arterial blood flow, will see/feel poor circulation
(^) Before PD: (^) Evaluate baseline VS, weight, laboratory tests (^) Assess glucose because PD dialysate fluid has dextrose in it (^) Monitor patient for respiratory distress, pain, discomfort (^) Monitor prescribed infusion, dwell, and drainage times (^) Observe outflow amount and pattern of fluid (^) Whatever we infuse, we want at least that much coming out, ideally more (^) Want equal I&Os (^) Assess for peritonitis (^) Check for kinks or blockages in tubing; have pt turn side to side to help with flow (^) Ensure drainage bag is BELOW level of catheter insertion on the pt (^) Will NOT see disequilibrium syndrome w/ PD (^) Check for signs of infection (^) Keep catheter site clean and dry; change gauze & tape as needed or per PD nurse orders