Chronic Kidney Disease and Dialysis Management, Exams of Nursing

Download Chronic Kidney Disease and Dialysis Management and more Exams Nursing in PDF only on Docsity! Dialysis Technician notes Kidney position - Located in retroperitoneal space held by connective tissue and adipose fat tissues. Adrenal Gland - On top of each kidney, releases Aldosterone --> retains Na+ --> High blood pressure Nephron - Functional unit of kidney. Each kidney has 1 million of these structures. Think of nephron as a microscopic dialyzer. Each heart beat pumps blood to the kidneys. Nephron composition - Renal corpuscle: Contains the Glomerulus located inside the Bowman's capsule. Also includes the Tubule system. Nephrons start in cortex and end in medulla. 3 primary functions of kidneys - 1) Remove wastes 2) Regulates electrolyte & fluid balance 3) Regulates acid & base balance How does kidney remove waste? - Urea builds up both in intracellular & extracellular space --> When urea levels are very high, kidneys excrete urea --> becomes byproduct of protein metabolism Ureter - Tube that drains urine to bladder from renal pelvis. Urine moves from kidney to bladder via ureter by peristalsis Peristalsis - Smooth muscle contraction which pushes urine toward the bladder 1 | P a g e Bladder - Holding tank before urine is released, has stretch receptors to tell us when to urinate Urethra - Tube delivers urine from bladder to outside of body. Adrenal Glands - On top of each kidney, release hormones such as aldosterone Aldosterone - Affects blood pressure. Secreted by adrenal cortex that results in Na+ retention --> H2O retention --> increase in vascular volume --> Inceasing BP Aorta - Artery with oxygen-rich blood Inferior vena cava - Oxygen poor blood Renal blood vessels - Arteries & veins serve as point of entry and exit of the blood to the kidney. Glomerulus - Ball of capillaries in the Bowman's capsule. Looks like the dilated 'C' portion of the proximal convoluted tubule. Formation/Regulation of urine - Removal of wastes, regulation of electrolytes, fluid balance, regulation of acid/base balance What does urine remove? - 2 | P a g e #1 cause of death = heart disease for people with CKD. #2 cause of death = infections. High risk groups include those with diabetes, hypertension, and genetics. African Americans, Hispanics, Pacific Islanders, and American Indians are at increased for hypertension and diabetes. Tests to detect CKD - Urine albumin and serum creatinine combined with a BP reading. Persistent protein in urine means CKD is present. Stages of chronic kidney disease - Kidney Damage-normal GFR --> Kidney damage-mild decrease in GFR --> moderate decrease in GFR --> severe decrease in GFR --> ESRD (<15 mL/min/1.73 m^2) Stage 2 - Maybe slight elevations of metabolic wastes in blood because not enough healthy nephrons remain to compensate completely for damaged nephrons. Stage 3 - Restriction of fluids, proteins, and electrolytes is needed Stage 4 and 5 - Stage 4 = CKD, Stage 5 = ESRD. Without renal replacement therapy, fatal complications occur Major causes of kidney disease - Type II Diabetes and hypertension are the major causes Diabetes as a cause of kidney disease - High blood sugars injure the capillaries of the nephron. Type I = immune system kills cells in pancreas that makes insulin; Type II = pancreas cannot make enough insulin or the body cannot use what is available. Normal glucose 70-100mg/dL (fasting); among patients = 150-200 mg/dL Hypertension as a cause of kidney disease - High blood pressure in tiny capillaries. 5 | P a g e Diabetic flowchart - High sugar --> increased urine production = kidneys cannot pull fluid back in --> Renin is released --> vasoconstriction and infarct to tissue breaking down tiny capillary beds Blood pressure - Determined by amount of blood your heart pumps and amount of resistance to blood flow in your arteries. The more your heart pumps and the narrower your arteries, the higher your blood pressure Fluid Volume Overload (FVO) - Average daily output of CKD patient = 750 mL. Overload contributes to heart failure, hypertension, and edema. Can only be managed with Ultrafiltration & diet. Many foods have extra water and salt. Diets can be hard to follow. AKA: Hypervolemia, overhydration, FLOV FVO symptoms - HTN, SOB, Edema, CHF, JVD, Pulmonary edema, Pneumonia Uremia - Buildup of urea in the blood. Collection of symptoms from a buildup of waste products in the blood. Azotemia - Buildup of nitrogenous wastes in the blood (urea, creatinine) Symptoms of Uremia - Tired, SOB, swelling, lack of concentration, no sleep, dry skin, cramps, nausea/vomiting Anemia - Shortage of RBCs. RBCs get their color from Hemoglobin. Symptoms include fatigue, weakness, feeling cold, SOB, chest pain, difficulty w erections. Most dialysis patients are in constant state of managed anemia. Hemoglobin - increase blood thickness and cardiac risk. 6 | P a g e Reasons for anemia - Decrease in EPO = Tells bone marrow to make RBCs. Vitamin and Iron (Fe) deficiencies, loss of blood during dialysis, loss of blood in GI bleeds CKD and Hypertension - Overlapping and intermingled cause and effect relationship. Increased BP cause kidney function decline. FVO, excess sodium, and Renin = Hypertension and diabetes. Acidosis - Failure to regulate bicarb and Hydrogen in blood. Respiratory diseases can ensue (COPD) = takes advantage of old people since their respiratory system sucks. Renal osteodystrophy & Hyperparathyroidism - Abnormal Ca and P balance. Kidney produces calcitriol (active vitamin D) --> increases intestinal absorption of Ca (while decreasing P levels). Excessive dietary phosphate is normally excreted by kidneys in urine. Parathyroid Hormone (PTH) - Controls amount of phosphate in blood --> tubular excretion of phosphate The effect of bone loss - Patients have reduced phosphate excretion. So phosphate levels increase: Hyperphosphatemia (High P) --> Hypocalcemia (Ca decreases) --> Stimulate parathyroid glands to release PTH --> Ca released from storage areas in bones to oppose P levels --> bone density loss Renal osteodystrophy symptoms - Bone mineral loss, spinal sclerosis, fractures, bone density loss, tooth Ca loss. Unique symptom is skin itching. Excessive Ca crystals may lodge in kidneys, heart, lungs, major blood vessels, joints, eyes. Sodium Imbalance - Increase in Na+ = Increase in plasma volume = Increase in fluid overload = increase in cardiac output = CHF. Dialysis patients restrict salt intake because kidney represents only significant route for excretion of Na+. 7 | P a g e Best way to improve adequacy is more time, or increase blood flow. Uses the Kt/V = clearance * time / volume. CMS goal is >1/5; PSKC HD goal for Kt/V is >1.4 URR - = (pre-urea) - (post-urea) / (pre-urea) * 100. PSKC goal is >70% Relieve hypotension - Temporarily add a little bit of Na+ Barriers to adequacy - Adequacy = Diffusion Inadequate time, bloodflow, dialyzer size, dialysate flow, temperature, heparin, compliance? Barriers to fluid removal (UF) - Anything that interferes with positive or negative pressure. Dialyzer surface area reduces blood clotting. 1) Excessive intake of salt, water follows salt 2) Excessive interdialytic weight gains 3) Patient intolerance, becomes hypotensive-low BP or cramping Aluminum toxicity - Results from exposure to aluminum in dialysis fluid and from ingestion of Al-containing phosphate binders Pre-assessment goals - To conduct physical assessment and identify patient history. Pre-assessment components - Vital signs (sitting BP, pulse, rhythm, temp), lungs, edema, GI history, Access, Weight 10 | P a g e Blood pressure cuff location - 2/3 the diameter of patient's arm, placed 1-2 inches above elbow. If cuff is too small = falsely high reading. If cuff is too large = falsely low reading High BP/Low BP - High = Indicates FVO or HTN. BPs should always be compared to previous treatments to look for trends or new problems. Low = Indicates hypovolemia or cardiac disease Pulse - In patient pre and post-assessments, we do apical pulse to listen for regularity. Low BP, hypovolemia, fever can increase pulse rate. HTN, age can decrease pulse rate. Irregular arrhythmia can be caused by heart disease Temperature - Most dialysis patients have sub-normal 95-98 degree Fahrenheit temps for unknown reasons. Confusion is a major symptom that is usually linked with shallow breathing, rapid heart rate, chills, dry skin, unusual thirst. If >102 degrees, treat for bacteremia. If temperature rises post dialysis = possible reaction to dialyzer membrane. Pyrogenic reaction - Fever gone within 6-18 hrs. Lung sounds - Normal = smooth and even, 12-20/min Tachypnea = shallow, >20/min Bradypnea = <12/min Kussmaul = deep, sighing breaths without pauses, >20/min Adventitious = abnormal breathing sounds Wheezes = High-pitched, musical, wheezes Dialysis patients will frequently have Kussmaul respirations, but the dialysis itself will correct their acidosis. Will endure SOB because of fluid in lungs. 11 | P a g e Chest pain - AKA Angina. Related to imbalance of myocardial (heart muscle) O2 supply and demand. Could cause decreased CO, anxiety, impaired gas exchange. Remember that leading cause of death in dialysis patients is cardiac arrest. Ask questions to patient: investigate sweat, paleness, hypotension, irregular pulse Edema - Abnormal accumulation of fluid between cells or excessive interstitial fluid. Can be sign of venous insufficiency or heart failure. Can be localized or generalized. Check face, periorbital, periptheral, shoulders, or perisacral regions. How to check for edema - Press over bony prominence for several seconds and lift finger. Indicated by range of numbers from 1-4. 1+ = slight 2mm edema 2+-3+ = moderate 4-6 mm edema 4+ = severe 8 mm edema Causes of edema - Excessive salt and fluid, hypoproteinemia, heart failure, increased capillary permeability (inflammation). Pitting edema - External pressure leaves persistent depression in tissue occurring because pressure pushes fluid out of area into another. Non-pitting edema - Cells swell instead of tissue or fibrinogen has clotted in tissues preventing free movement of fluid. GI System - 12 | P a g e Low Na diet O2 during hemodialysis Long/frequent hemodialysis treatments to improve UF tolerance Reduce dialysate temperature with less diffusion Elevating Hb (hemoglobin) decreases anemic state, offsetting vasodilation **Summary** for dry weight - Dry weight is a mobile target--changes with appetite/intake-EDW must be systematically and regularly readjusted. Machine modules - Divided into 1) Communication module 2) Blood-handling module 3) Chemical and disinfect module Machine functions - Preps dialysate Circulates dialysate thru dialyzer Heats dialysate Pumps blood and heparin Controls UF Monitors extracorporeal circuit (blood compartment) DIsinfects and cleans itself Fluid delivery system - Monitored for composition, temperature, and flow. Consists of treated water, dialysate, and blood. System is separated into two separate curcuits = blood and dialysate. Circuits operate independently. Proportioning System - Machine proportions water and dialysate in a ratio of 1 part concentrate to 44 parts water 15 | P a g e Bypass system - Machines can divert dialysate directly to drain away from dialyzers. Avoids exposure of blood to unsafe dialysate. Bypass valve is located in affluent dialysate circuit pre- dialyzer. Activated by high/low conductivity, or high/low temperature. Extracorporeal Circuit - Made of 1) Blood pump = works by compression in mL/min 2) Heparin Infusion pump = set amount per hour and pump off time 3) Level (Air/Foam) Detector with In-line clamp = if air or foam is deteced, in-line clamp will immediately clamp the venous blood line and blood pump will stop Correct prescription - Must verify K and HCO3, set all machine parameters to the correct setting ordered by the physician during set up procedure. This is recorded by EMR. Machine testing - Alarm, pressure, and conductivity/pH testing is done prior to every dialysis treatment. Treatment cannot begin until both alarm and pressure tests are complete/passed. If failure, biomed must be called. If not solved, machine needs to be removed & replaced before patient is placed on treatment. Alarm testing - Ensures that blood and dialysate alarms are working Pressure testing - Ensures that ultrafiltration and delivery mechanisms inside machine are working Conductivity/pH testing - Ensures that dialysate is mixed properly and confirms the machines Conductivity testing. Use Phoenix meter to verify conductivity/pH of solution. Should be calibrated every morning. Should be rinsed every evening and between patients. 16 | P a g e Safe conductivity range and pH range - 13.0-14.0 and 7.0-7.5 Patient problems... 1) What happens if prescription is wrong? 2) What happens if conductivity is low/high? 3) What happens if the temperature is too high? 4) What happens if DFR is absent or low? 5) What happens if there is bleach or renalin presence? 6) What happens if there is a high bacterial count? - 1) Electrolyte imbalances, cardiac arrhythmia, cardiac arrest 2) Low = Hemolysis --> Death; High = Hyper-osmolar coma --> Death 3) Hemolysis --> Death 4) Absent = no dialysis; Low = inadequate dialysis 5) Bleach and renin = Hemolysis --> Death 6) Mild to severe pyrogenic reaction Rinsing the machines - Purpose is to enable internal cleaning and disinfection of machine. PSKC uses vinegar, high heat, and bleach. Every time machine is disinfected, staff member should document on disinfection log. Vinegar - (Mon-Fri) Used as cleaning agent to help remove acid and HCO3 precipitate from the machines --> Heat disinfect (85 C) after vinegar has been used --> document Bleach - (Only Sat nights) Breaks down fibrin and clots in the blood leak detector and other areas of the fluid pathway. Can kill spores and resistant viruses. Must always be rinsed from machine because of highly corrosive effect on parts of machine 17 | P a g e Dialysate alarm - Float drops (silver ball), dialysate shunted down drain (bypass), blood pump continues Arterial pressure alarm - **UNDER INCREASED RESISTANCE** Needle sucks up blood against wall of access Involuntary vessel spasm Patient moved access limb Patient is hypotensive Needle comes out **UNDER DECREASED RESISTANCE** Clotted dialyzer Needle is out and blood pump is pumping air Venous pressure alarm - **UNDER INCREASED RESISTANCE** High reading Needle not aligned within vessel causing increased resistance as blood return Patient moved access limb Needle has infiltrated...blood is going into tissue Needle is coming out **UNDER DECREASED RESISTANCE** Needle is out, blood pump pumps blood into chair Severe hypotension Transmembrane pressure monitor - Low reading = transducer protector at venous drip chamber is full and not reading pressure. High reading = over 400, access or clotting issue 20 | P a g e Level venous drip chamber - If level is too low and in-line clamp and blood pump will stop Temperature alarm - Machine is over 39 C...if machine fails to go into bypass, you must stop pump and clamp line Access issues - Each year people die since they run out of access sites. Continues to be biggest challenge to success of Hemodialysis. Hemodialysis access - EIther via fistula, graft, or central venous catheter. Must sustain adequate blood flow. Arteries - O2 rich blood from heart and lungs to rest of body. Deep below skin and hard to access. Risk of infection, and disfigurement from frequent cannulation with 15-16 gauge needles. Veins - Bring oxygen poor blood back to heart and lungs. Easier to reach, small, thin-walled. AV Fistula - Permanent. Surgery that connects artery and vein allowing arterial blood to flow through the vein causing dilation. The vein arterializes. Both this and a graft should be placed on non- dominant forearm. AV Graft - When Fistual is not possible. Prosthetic material that is implanted subcutaneously between artery and vein. Prone to stenosis, infection, and shorter lifespan. To determine arterial side of loop graft, you compress loop and listen/feel for stronger pulse. Catheter - 21 | P a g e Meant to be temporary. Tunneled under skin. Cannot have fistula or graft. Prone to infection, and increased hospitalization. CAn access blood quickly through percutaneous non- tunneled or subcutaneous tunneled catheter. Anastomosis - Actual spot of surgical attachment for fistula. Must be straight, healthy, easily visible. Thrill - Sensation or vibration that the blood makes through the entire length of the gistula and can be felt with fingers or hand. Fistula maturation - Vein becomes arterialized and walls of vein hypertrophy in response to high blood flow. Thickening of walls = maturation. It has to mature to withstand repeated cannulations as well as pressure that occurs in hemodialysis. Long-term complications of fistula - Stenosis, Thrombosis, Aneurysm, Steal syndrome Stenosis - Narrowing of blood vessel Injury causes scarring and turbulence (overgrowth of muscle cells) High pitch or louder bruit, pounding pulse, less thrill Swelling of access arm Thrombosis - Most common reason for grafts to fail Blood clots. Blood naturally uses clotting proteins and platelets to seal off injury. Any factor causing slow flow through fistula causes thrombosis due to stasis of blood Absence of bruit/thrill, absent blood flow from fistula, high venous pressure, high TMP Aneurysm - 22 | P a g e