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Impaired structural, neuro, or muscle function. 

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Impaired structural, neuro, or muscle function. 

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Examples: pneumothorax, flail chest, SCI, CVA, Guillian barre, TBI, and COPD

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Tension pneumothorax- tracheal deviation to unaffected side.

Spontaneous pneumothorax- hyper-resonance on percussion

Hemo thorax- dull on percussion.

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Control protein intake based on the client's stage of CKD

Usually low protein diet, protein may be needed after dialysis

Restrict dietary sodium, potassium, phosphorus and magnesium

Provide diet that is high in carbohydrates and moderate in fat.

Restrict intake of fluids

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Add all output (urine, emesis, diarrhea, blood) +

600mL for insensible losses

= 24hr total intake

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excessive drainage (>70 mL/hr)

SaO2 < 90%

eyelets of chest tube become visible

continuous bubbling in water seal chamber (air leak)

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Persistent proteinuria/ albuminuria is the FIRST INDICATION of kidney damage

Estimated GFR is the BEST INDICATOR of overall kidney function

a decreased GFR is a Hallmark sign of progressive kidney disease

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Typically seen with things such as hypotension, hypovolemia, and nephrotoxic agent use

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Influenced by severe; clinical and socioeconomic considerations......

•Availability and convenience

•Comorbid Conditions

•Dialysis center and location

•Pt’s home situation and home therapies

•Method of clinician reimbursement

•Ability to tolerate volume shifts

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Dialysate Solution

Dextrose based solution

Potassium added to prevent low K

Antibiotics added

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Often discovered as a decreased GFR during evaluation and management of other medical conditions

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Improper technique and cleaning

Exit site infection, peritonitis with cloudy drainage

Abdominal pain and increased abdominal pressure resulting in lower back pain and hernia

Outflow problems - dialysate leak

Incomplete recovery of fluid

Check for patency, kinks, closed clamps, catherter displacement

Contraindicated after abdominal surgery

Pulmonary complications - can compromise respiratory system

PD removes protein can vary greatly 0.5-20g/day, may cause malnutrition

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Monitor BG due to dialysate has dextrose

Monitor I&Os with inflow and outflow volume

Color should be clear or light yellow

Warm dialysate prior to instilling

Keep the outflow bag lower than the pts abdomen, drain by gravity

It is slow, time consuming

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Utilizes the peritoneal membrane in the abdominal cavity as the filter to remove toxins and excess fluid from the blood through a process of diffusion and osmosis

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POST:

Monitor VS and lab values (BUN, creatinine, electrolyte, Hct), decreases in BP and labs are common

Compare wt to estimate amount of fluid and procedure removed (1L = 1kg)

Assess - any complications, bleeding, infection at access site, disequilibrium syndrome, hypovolemia, dizziness, tachycardia

Avoid invasive procedures for 4-6hrs after dialysis due to the risk of bleeding as a result of anticoagulation AV fistula and AV graft precautions

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DURING:

Be alert for any changes in condition

Assess, monitor, support, and educate during the tx

Monitor for complications

Clotting, air bubbles, temp of dialysate, regulation of the ultrafiltration

Wt considerations:

Between dialysis txs 2-3kg gain is ideal, more than this will significantly increase the workload of the heart and impact long term survival

Monitor labs

Take BP (q30-60 mins as rapid changes can occur)

Opportunity for nurse to teach about renal diet or reinforce fluid restrictions

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BEFORE:

Assess fluid status (wt, BP, edema, lung and heart sounds)

Condition of vascular access and determine patency (Thrills and bruit)

What meds need to be held

Compare weight difference between last post dialysis and the present pre-dialysis weight

This determines the ultrafiltration or the amount of fluid to be removed

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Method for treating AKI and removes uremic toxins and fluids while acid-base status and electrolytes are adjusted slowly and continuously in a hemodynamically unstable patient. Those who cannot tolerate rapid shifts in fluid or who are hypotensive

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diuretics, Phosphate binders, Ca+ supplements, Vit. D, Iron, Folic acid, Epoetin alfa, Kayexalate and insulin to lower K+

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Disadvantages:

Exchange rate 3-4 hrs

AV fistula takes 6 wks to cure

AV graft ready in 2-4 wks

Stresses a compromised CV system

Does not remove phos

Access may clot

Heparin required

May need dietary restrictions

Dialyzable drugs

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Advantages:

Quick and efficient

Weekly exchanges as an outpatient 3-4x/wk and 3-5hrs sessions

Prolongs life

No limit as to how long one can remain on dialysis

Allows wait for kidney transplant

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Hypotension - N/V, dizziness d/t fluid shifts, diaphoresis, tachycardia

Muscle cramps - usually late in dialysis

Excessive blood loss - If blood lines become separated or needles become dislodged

Air embolism - rare

Chest pain - pt with anemia

Disequilibrium syndrome - too rapid decrease in the BUN and circulating fluid volume. Can cause cerebral edema and high ICP

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When pt uremia can no longer be adequately tx

GFR <15 mL/min

Based on clinical status

Complications with AKI, CKD, drug toxicity, high K+, and fluid retention

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Rids body of excess fluid and electrolytes

Achieves acid-base balance

Eliminates waste products

Restores internal homeostasis

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How do you determine the fluid restriction amount on a patient? 

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How do you determine the fluid restriction amount on a patient? 

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stage 3 is considered CKD

stage 5 is in need of dialysis

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Stage 1: >90ml/min

Stage 2: 60-89 ml/min

Stage 3: 30-59 ml/min

Stage 4: 15-29 ml/min

Stage 5: <15 ml/min or treatment by dialysis (ESRF)

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Extremity Restriction:

Avoid lifting heavy item with access arm

Avoid sleeping on top of extremity

Call provider if: bleeding >30min after holding pressure, no thrill or bruit (poor vascular flow), or signs of infection with fever, redness, or drainage.

Dressing: Maintain the integrity, not get it wet, cover during showers. Do not change it!

Keep HD site clean, protect site and keep it clean and do not wear jewelry, tight clothing

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recovery time for use is shorter for grafts than fistulas, fistulas last longer and have reduced risk of infection and clotting

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AV Fistula: placed in the forearm or upper arm with an anastomosis between the artery and vein, takes about 6-12 weeks to heal and be ready to use

AV Graft: made of synthetic materials, forms a bridge between the arterial and venous supply, higher infection risk, takes about 3-4 weeks to heal and be ready for use

Temporary Double Lumen Venous Catheter:

placed in the IJ when immediate access is required, DO NOT ACCESS LINE, monitor for infection, dislodgement

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GFR decreased, elevated creatinine

Abnormal UA with albuminuria (KEY FINDING)

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Identify the cause and stop the progression

Determining factors:

Poorly controlled diabetes mellitus and HTN

Obesity, heart failure, autoimmune disease, complicated UTI, Kidney mass

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Frequently asymptomatic:

Kidneys are highly adaptive and kidney disease is often not recognized until considerable loss of nephrons

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Presence of kidney damage or decreased GFR for >3mos, irrespective of the cause (this distinguishes it from AKI)

Progressive, irreversible loss of kidney function

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Age is not a barrier to offering dialysis

Less likely to fully recover kidney function

GFR declines with age

More comorbidities and polypharmacy

Aging kidney is less likely to compensate for changes in fluid volume

By age 70, BUN levels increase by 21%, decreased kidney size, impaired renal clearance of drugs, reduced bladder size and capacity

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Assess:

VS, wt, I&Os, urine, general appearance, S/S of dehydration

Monitor:

Kidney function, Fluids and electrolytes, nephrotoxic drugs should be used sparingly with smallest effective dose and shortest time possible

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NSAIDS

Chemo

Aminoglycosides

Vanco

Sulfa

ACE

ARB

Diuretics

Omeprazole

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Initial stage:

onset of injury

Oliguric phase: (UOP <400ml/day; 1-14 days)

Fluid/electrolyte imbalances (high K+, low NA+ and CA+)

Oliguria most common 70%

Elevated BUN and creatinine levels, met acidosis, anemia, cerebral edema

Diuretic phase: (UOP 1-3L/day; may reach 5L)

Caused by osmotic diuresis from uremia and unable to concentrate urine

Hypovolemia and hypotension as a result

pt is dumping urine

Recovery phase: (when GFR improves)

Allowing BUN and creatinine to plateau and then decrease

Improvements may occur in 1-2 weeks but may be up tp 12mos.

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Identify and eliminate the cause!

Manage s/s

Prevent complications

Do NOT force fluids or diuretics

K+ management (most serious complication)

CR monitoring, insulin and dextrose may be infused

Nutrition - renal diet

Adequate perfusion

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UOP of <400mL/day

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Urea - end product of protein metabolism

Creatinine - end product of muscle metabolism (BEST INDICATOR FOR AKI)

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POSTRENAL - blockage of urine

Unable to urinate

Kidney swell and it leads to damage

Causes:

Kidney stones, structural, prostate hyperplasia

*Always treatable, <5% AKI

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less strict diet and can do at home!

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INTRARENAL - direct kidney damage

Acure tubular necrosis, swelling and scaring related to kidney injury

Causes:

Prolonged ischemia, nephrotoxins, glomerulonephritis, infections, meds

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PRERENAL - lack of blood flow

Interferes with the kidneys ability to filter blood

Causes:

Hypovolemia, dehydration, excessive bleeding, heart failure, low cardiac output, med SE, sepsis

*Likely reversible, most common

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Hours to days

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Rise in creatinine and/or reduction of UOP

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PD dialysis solution- What are the components? Why is dextrose added to this solution?

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PD dialysis solution- What are the components? Why is dextrose added to this solution?

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When would a patient need CRRT (Continuous renal replacement therapy)? 

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When would a patient need CRRT (Continuous renal replacement therapy)? 

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Common medications needed for a patient receiving dialysis

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Common medications needed for a patient receiving dialysis

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What are important factors to consider as a nurse before (include meds), during, and after hemodialysis? 

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What are important factors to consider as a nurse before (include meds), during, and after hemodialysis? 

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What are the nursing considerations for HD vascular access sites? (patency, assessments, monitoring, dressing care, limb alert restrictions)

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What are the nursing considerations for HD vascular access sites? (patency, assessments, monitoring, dressing care, limb alert restrictions)

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What is the difference between a AV graft and AV fistula? What would be the reason to place a graft? 

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What is the difference between a AV graft and AV fistula? What would be the reason to place a graft? 

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Describe the different types of hemodialysis access sites. 

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Describe the different types of hemodialysis access sites. 

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What are the deciding factors when deciding on what type of dialysis to use? (Hemodialysis, peritoneal dialysis) 

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What are the deciding factors when deciding on what type of dialysis to use? (Hemodialysis, peritoneal dialysis) 

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Labs- What is usually the first indication of kidney damage? What is usually the first indication or poor kidney function? 

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Labs- What is usually the first indication of kidney damage? What is usually the first indication or poor kidney function? 

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What would a renal diet with restrictions look like?

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What would a renal diet with restrictions look like?

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GFR- What is it considered kidney damage and when is dialysis needed? What values?

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GFR- What is it considered kidney damage and when is dialysis needed? What values?

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What are the stages of GFR for CKD severity?

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What are the stages of GFR for CKD severity?

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CKD- What are lab findings to monitor? What is the best value to determine kidney function?

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CKD- What are lab findings to monitor? What is the best value to determine kidney function?

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CKD- What are the common causes and determining factors?

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CKD- What are the common causes and determining factors?

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Is it easy to detect? At what point do they tend to identify concerns?

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Is it easy to detect? At what point do they tend to identify concerns?

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What is the definition of CKD? Is it reversible?

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What is the definition of CKD? Is it reversible?

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What are some Older adult considerations?

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What are some Older adult considerations?

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What are the common nephrotoxic drugs to avoid?

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What are the common nephrotoxic drugs to avoid?

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What are the phases of AKI and what is the presentation?

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What are the phases of AKI and what is the presentation?

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Tx plan/goals- What should be a priority nursing assessment and what is the outmost important initial interventions to do?

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Tx plan/goals- What should be a priority nursing assessment and what is the outmost important initial interventions to do?

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What is the typical UOP for AKI and helps with the initial dx

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What is the typical UOP for AKI and helps with the initial dx

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Urea and Creatinine - Which one is the end product of protein or muscle metabolism. Best indicator of AKI?

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Urea and Creatinine - Which one is the end product of protein or muscle metabolism. Best indicator of AKI?

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What you see with these? Prerenal, intrarenal, postrenal 

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What you see with these? Prerenal, intrarenal, postrenal 

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Do you usually see it alone or with other conditions? 

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Do you usually see it alone or with other conditions? 

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What are the 2 key AKI clinical presentations you will see?

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What are the 2 key AKI clinical presentations you will see?

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Indications:

Pneumothorax

postop chest drainage

pleural effusion

pulm empyema

When chest tube is placed at the base, its to drain fluid

When chest tube is placed near the apex, its to drain air

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They are removed when the lungs have re-expanded or there is no more fluid drainage into the pleural space

Upon removing by provider, tell pt to take a deep breath and hold. Less chance with air emboli

Dressing is applied: Airtight sterile petroleum jelly gauze dressing, secure in place.

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Lung sounds

Crepitus around insertion site

Dressing is C/D/I and occlusive

Drainage output, if >70mL/hr, notify provider

Check tubing for any kinks and connections for any concerns

Clamp tubing only as prescribed

Ensure suction is being applied as ordered

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Thoracentesis:

Need decompression in the pleural space for air or fluid

This confirms hemothorax

Chest Tube

Tube placed in the pleural space to drain fluid, blood, or air. Restores negative pressure to reinflate the lung

Can be inserted in an emergency at the bedside, or in the OR through a thoracotomy incision.

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Avoiding long periods of immobility

Wear compression stockings to improve circulation

Don’t cross legs

Frequent anticoagulant blood draws to monitor levels

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Surgical Management

Vena cava filter (avoids reoccurrence)

Embolectomy

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Medication

Anticoagulants

Heparin, Enoxaparin, Warfarin (need to know!)

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Supplmental O2 *(so hypoxic, I place pts non-rebreathers at times)

High fowlers position

Emotional support

Closely monitor RR and VS

Check labs (ABG's) *You will see resp alkalosis with the hyperventilation due to air hunger, but a bad Pa02. This is all about oxygenation issues.

D-dimer (elevated d/t clot formation) *know the diagnostic testing. V/Q scan is another

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Sudden onset chest pressure

Acutely fast severe hypoxia

High HR, RR, and low BP, Sp02 *(severe sudden hypoxia)

Anxious, impending doom

Dyspnea and air hunger

Often not easy to recognize or diagnose, especially if patient is deteriorating rapidly

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*Be able to identify risk factors if I put this on the exam

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*Be able to identify risk factors if I put this on the exam

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Prolonged immobility

Pregnancy

Contraceptives

Smoking

Obesity

Surgery

Trauma

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•As blood glucose increases, the blood in the intravascular space becomes more hyperosmolar.

•Cellular dehydration occurs as the intravascular space draws fluid from intracellular and interstitial spaces.

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**Isn't there more considerations?? If more are needed for the exam, I will let you know.

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**Isn't there more considerations?? If more are needed for the exam, I will let you know.

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Increased prevalence and mortality

Present in 25% over age 65 due to decreased b-cell function, decreased insulin sensitivity, and altered carbohydrate metabolism

Higher rate of death, functional disability, and coexisting illness

More drugs that interfere with insulin action

Many undiagnosed and untreated—signs resemble changes associated with aging

Cognitive decline

Education must be altered to patients needs

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Fever symptoms in the earlier stages

BG can climb very high before the problem is recognized

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*Know definition to understand how to answer questions.

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*Know definition to understand how to answer questions.

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Pulmonary embolisms occur when a substance (thrombus, fat, amniotic, air) enters the venous circulation and forms a blockage in the pulmonary vasculature. Most pulmonary embolisms originate from a DVT (>80%)

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Characterized by

•Hyperglycemia

•Ketosis

•Acidosis

•Dehydration

•Mostly seen in DM I

Clinical presentation

Neuro: Fatigue, malaise, confusion

MSK: Muscle weakness

Resp: Shallow respirations,

GI: Abdominal distension, N/V

CV: Hypotension and weak pulse

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Maintain patient airway and monitor resp status

Mechanical ventilation

Oxygenate prior to suctioning

Labs w/ ABGs and follow each ventilator setting adjustment

Positioning >HOB at least 30 degrees, prone positioning

Infection prevention- oral care q2hrs, VAP (vent associated pneumonia)

Promote nutrition early

Emotional support to pt and family

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As the lungs become inflamed and injured ->harder to ventilate with the increased pressure needed to maintain volumes

Need to change to pressure control ventilation to preserve lung function ->Too much pressure causes further lung injury

ARDS critically needs oxygenation intervention

balance with Fi02 percentages and the amount of PEEP to keep the alveoli open for air exchange.

High PEEP = Decrease venous return and CO

High Fi02 = 02 toxicity.

harder to ventilate *So true unfortunately