Medications
Name a type of medication that would affect the RAAS
ACEs, ARBs, Spironolactone
These are the top two risk factors for developing chronic renal failure
Diabetes & Hypertension
Name 4 functions of the kidneys
•Regulates fluid volume
•Regulates electrolyte balance of body fluids
•Regulates acid-base balance of body fluids in conjunction with body buffer system and respiratory system
•Regulates bone marrow production of RBCs by secreting erythropoietin
•Synthesizes vitamin D into its active form
•Secretes various hormones, such as growth hormone
•Excretes drugs and toxins from the body
•Regulates blood pressure through the renin/angiotensin/aldosterone cycle
Patient is admitted from ED with GI Bleed with history of CKD Stage IV, DM, HTN, GERD and Anxiety.
As a nurse or PCT, I would want to take this into consideration before doing bloodwork.
Vein preservation
Avoiding sticks in the ACs
This type of hemodialysis access is placed in IR, to be used for a longer duration of time and patient may be discharged home with this type of hemodialysis access
Tunneled dialysis catheter or Permcath
Your patient asks why they need to adhere to a diet that limits potassium. You explain...
Normally, the level of potassium in your body is balanced by eating foods that contain potassium and getting rid of excess potassium in the urine, however, when the kidneys do not work well, they cannot eliminate the appropriate amount of potassium. Elevated potassium levels affect the way your heart's muscles work, and can cause your heart to beat irregularly.
A patient with Stage 5 CKD is experiencing extreme pruritus and has several areas of crystallized white deposits on the skin. As the nurse, you know this is due to excessive amounts of what substance found in the blood?
Urea.
The patient is experiencing uremic frost that occurs in severe CKD. This is due to high amounts of urea in the blood being secreted via the sweat glands on the skin. The patient will experience itching as well.
DD- Your nephrologist orders the hyperkalemia protocol on your patient who has a potassium of 5.8. He orders 10 units regular insulin IV, 50mL D50W injectable IV, and 1000mg calcium gluconate IVPB. Blood glucose is 123. In what order will you administer the medications?
1) Calcium gluconate
2) Dextrose
3) Insulin
Name 3 causes of Acute Renal Failure
–Damage to the kidneys
–Hypotension
–Drugs
–Blockages
This enzyme is released from the kidney in response to decreased perfusion to the kidney and/or decreased salt delivery to kidney tubules
What is renin
HD patient is admitted with acute on chronic renal failure. What 3 nursing orders would you anticipate that the nephrologist would enter for this patient while they are in the hospital?
Daily standing weights, strict I&O, renal dialysis diet with fluid restriction
This type of hemodialysis access can be placed for emergent or acute use and must be removed prior to patient discharge
Non-tunneled temp cath or Quinton Cath
You are discharging home a patient who was admitted with AKI. Patient states "Thankfully I'm healed and this is all behind me." What would you want to make sure the patient has a clear understanding of?
They need to stay vigilant with hydration/fluid balance, diet, and reporting signs of decreased urine output and electrolyte imbalances to provider since their kidneys are still healing.
Your patient with chronic kidney disease is scheduled for dialysis in the morning. While examining the patient's telemetry strip, you note tall peaked T-waves. You notify the physician who orders a STAT basic metabolic panel (BMP). What result from the BMP confirms the EKG abnormality?
A. Phosphate 3.2 mg/dL
B. Calcium 9.3 mg/dL
C. Magnesium 2.2 mg/dL
D. Potassium 7.1 mEq/L
D. Potassium 7.1 mEq/L
A normal potassium level is 3.5-5.1 mEq/L. This patient is experiencing hyperkalemia, which can cause tall peak T-waves. Remember in CKD (especially prior to dialysis), the patient will experience electrolyte imbalances, especially hyperkalemia.
After completing your admission assessment and OMR, you note that your patient is on Prograf post kidney transplant. They have not had a dose since early this morning before they arrived to the ED and are due. You Halo the on call provider to let them know that you've completed the medication review and medications are ready to be reconciled, but they tell you that the Hospitalist who comes on for dayshift the next morning will take care of it.
Reach out to the provider to let them know that the patient is on Prograf and has a dose due. If no response, escalate through appropriate chain of command (charge nurse first).
What blood pressure goal should a patient with CKD maintain in order to slow the progression of the disease related to HTN?
BP less than or equal to 130/80
This is the most immediate life-threatening imbalance seen in Acute Kidney Injury
Hyperkalemia
DD- You are discharging a new dialysis patient home with orders to continue HD. They currently have a temp cath and are asking you what will need to be done before they can leave. What 3 nursing considerations should be arranged before this patient can discharge?
Do they have a dialysis clinic/chair time and transportation to and from dialysis clinic? Do they have orders for a permanent catheter placement? Temp cath must be removed by validated RN (with orders) prior to discharge. Patient education provided on hemodialysis, any new medications, vein preservation, daily weights, and diet/fluid restriction.
Who can remove a non-tunneled dialysis catheter with an order?
PICC Team or validated 7th floor Charge RNs
DD -Your patient asks you for 4 examples of high potassium foods to limit. You respond...
Citrus/citrus juices, banana, avocado, potatoes, beans, spinach, brussel sprouts, prunes/prune juice, fish, melons, tomatoes, milk, nectarines, bran, chocolate, lentils, chicken, beef, low-sodium cheeses
A 55 year old male patient is diagnosed with CKD. The patient's recent GFR was 25mL/min. What stage of CKD is this known as?
Stage 4.
GFR for this stage is 15-29mL/min.
You are administering morning medications for a hemodialysis patient prior to sending them to HD. Their blood pressure is 108/68 and they have several blood pressure medications ordered with no specific hold parameters. What are your next steps?
Reach out to provider/HD nurse for clarification. Medications may need to be held or administered after dialysis treatment, but nursing may not hold or administer medications without an order.
Which blood test and which urine test gives us the greatest indication that patient has CKD?
Serum creatinine and Urine protein
DD-This test compares the creatinine in a 24 hour sample of urine to the creatinine level in your blood to show how much waste products the kidneys are filtering.
Creatinine Clearance
Your AKI patient is complaining of abdominal pain. You note that only 200ml of urine output has been documented in the last 12 hours. Before reaching out to the provider, what 2 things would you want to do first?
Assess your patient (palpate bladder for distention, ask about urination, review I&Os) and bladder scan (does not require and order). Retention should be considered in patients with acute or chronic renal failure, especially in the presence of reduced urine output.
DD- Your PD patient was admitted to the hospital with fluid overload after missing several days of PD treatments. He tells you that his sister, who normally handles his PD treatments, has become increasingly forgetful and unable to help him. No one has been able to get in touch with her since he was admitted yesterday, and the patient states he has no other family. What type of discharge planning concerns would you want to discuss with the nephrologist?
Is the sister's problem acute or chronic? Is this patient appropriate for PD if he cannot handle administering treatment on his own and the sister is unable to continue to assist? What other needs does the patient's sister help with (diet, mobility, etc.)? Does the sister need to seek medical attention?
Your new HD patient asks why their whiteboard states they have a fluid restriction? You explain...
Because your kidneys can no longer remove excess fluid from the body effectively, limiting fluid intake is important to prevent fluid overload, swelling in the extremities, shortness of breath, heart failure, and fatigue.
A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of uncontrolled hypertension and coronary artery disease. You're assessing the new medication orders received for this patient. Which medication ordered by the physician will help treat the patient's hypertension along with providing a protective mechanism to the kidneys?
A. Lisinopril
B. Metoprolol
C. Amlodipine
D. Verapamil
A. Lisinopril
The two types of drugs that can treat hyperension and protect the kidneys in patients with CKD include ACE Inhibitors and ARBs.
Patient is prescribed Epogen during dialysis treatments. He asks for 2 benefits and 2 risks associated with this medication prior to administration.
Benefits: decreased levels of fatigue, increased feelings of well-being, better tolerance of dialysis, higher energy, improved exercise tolerance
Risks: HTN, increased clotting of vascular access sites, seizures and iron depletion
DD -Name 3 hormone imbalances present in CKD
Decreased erythropoeitin
Increased Angiotensin II/Aldosterone secretion - RAAS activation
Increased parathyroid hormone
True or False. During the diuretic phase of an acute kidney injury, a return to normal urine output signifies that renal function has returned to normal.
False. While glomerular filtration will improve urine output, renal function can still be abnormal in this phase.
DD -Your patient with ESRD on hemodialysis complains of constant chest pain, 9/10 on pain scale, in middle of chest that is worse upon inspiration. You complete a set of vitals: BP 98/56, HR118, R 24, T 100.9, SpO2 98% on RA. You activate the chest pain protocol. In the meantime, you complete a physical assessment and hear a creaky sound that is louder at end of exhalation.
What are you suspecting?
Pericarditis
This is required to be done on each patient with a temp or perm cath on each shift in order to reduce risk of infection
CHG baths
When reviewing the Chronic Kidney Disease stoplight tool, you want to ensure that your patient looks out for 4 of the following yellow zone sign and symptoms.
Swelling in extremities, fever greater than 101, weight gain more than 3lbs in 2 days or 5lbs in 3 days, increased fatigue, dizziness, or trouble thinking, inability to perform daily activities, trouble urinating, less urine output than normal, or blood in urine.
DD -A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery.
Which findings by the nurse should prompt immediate action to prevent acute kidney injury?
(Select all that apply)
a. Urine output of 100 mL in 4 hours
b. Urine output of 500 mL in 12 hours
c. Large amount of sediment in the urine
d. Amber, odorless urine
e. Blood pressure of 90/60 mm Hg
A, C, E
The low urine output, sediment, and blood pressure should be reported to the provider.
Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal