NSG 4100 Adult Health III Exam 1 Full Review |2026 Update with
Complete Solutions-Galen College of Nursing
★ UNIT ONE - Complex Elimination (Renal) ★
END-STAGE RENAL FAILURE (CH. 54 p 1581-1589)
What is it?
● Intolerable kidney damage that requires Permanent Renal Replacement Therapy
● Is the 5th Stage (final stage) of Chronic Kidney Disease (also referred to as ESRD).
Pathology
● Declining Renal Function causes UREA to accumulate in the blood.
○ UREMIA (high urea levels) develops & negatively affects every system in the body.
○ Urea = the end product of protein metabolism (a nitrogenous waste).
● Rate & Progression Renal Failure in ESKD is related to:
○ 1) The underlying disorder.
○ 2) Presence of Proteinuria.
○ 3) Presence of Hypertension.
● Stages progresses more rapidly in patients who have:
○ PROTEINURIA (high excretion of protein in urine) or HYPERTENSION (high blood pressure)
Etiology
● Primarily Unknown ; It’s thought that the accumulation of uremic waste products is the probable cause
Clinical Manifestation
● Cardiovascular Disease (MAIN CAUSE DEATH)
● Peripheral Neuropathy
○ weakness, numbness, pain, discomfort.
● Uremic Peripheral Neuropathy
○ Restless Leg Syndrome / Burning Feet (early stages)
Chart 54-6 : Assessing for End-Stage Kidney Disease (p 1582) Chart 54-1 : Stages of Chronic Kidney Disease (p 1569)
NEUROLOGIC GASTROINTESTINAL Normal GFR (90-120 mL/min)
Asterixis Ammonia odor to breath (“uremic fetor”)
Behavior changes Anorexia, nausea, & vomiting STAGE 1 GFR ≥ 90 mL/min/1.73 m2
Burning of soles of feet GI Bleeding Kidney damage with Normal or Increased GFR
Confusion Constipation or Diarrhea
Disorientation Hiccups STAGE 2 GFR = 60 - 90 mL/min/1.73 m2
Inability to concentrate Metallic taste MILD decrease in GFR
Restlessness of legs Mouth ulcerations and bleeding
Seizures
Tremors STAGE 3 GFR = 30 - 59 mL/min/1.73 m2
Weakness and fatigue Symptoms might start MODERATE decrease in GFR
to appear here.
INTEGUMENTARY HEMATOLOGIC
Coarse, thinning hair Anemia STAGE 4 GFR = 15 - 29 mL/min/1.73 m2
Dry, flaky skin Thrombocytopenia Discuss Dialysis SEVERE decrease in GFR
Ecchymosis (bruising)
Gray-bronze skin color
STAGE 5 GFR < 15 mL/min/1.73 m2
Pruritus (itchy)
Purpura Dialysis is Required END-STAGE KIDNEY DISEASE or
Thin, brittle nails CHRONIC KIDNEY DISEASE
CARDIOVASCULAR REPRODUCTIVE
Engorged neck veins (JVD) Amenorrhea
Hyperkalemia (Peaked T waves) Decreased libido
Hyperlipidemia Infertility
Hypertension (control HTN) Testicular atrophy
Pericardial effusion
Pericardial friction rub
Pericardial tamponade
Pericarditis
Periorbital edema
Pitting edema (feet, hands, sacrum)
PULMONARY MUSCULOSKELETAL
Crackles Bone fractures
Depressed cough reflex Bone pain
Kussmaul-type respirations Footdrop
Pleuritic pain Loss of muscle strength
Shortness of breath Muscle cramps
Tachypnea Renal osteodystrophy (uremic bone disease)
Thick, tenacious
Diagnostics (p 1579)
● DECREASED Creatinine Clearance
● DECREASED GFR < 15 mL/min/1.73 m2
● Sodium / Water retention
● Metabolic Acidosis (from the Uremia) ← know how to identify metabolic acidosis with acid/base problems
3 main causes: ↑ acid, ↓bicarbonate, ↓ acid & phosphates secretion
● ANEMIA (Hematocrit less than 30%)
○ Signs & Symptoms → malaise, general fatigue, & decreased activity tolerance.
○ Due to DECREASED Erythropoietin production → EPO stimulates the bone marrow to make RBCs!
● Azotemia (also called Uremia) = high urea & nitrogen levels
● INCREASED Serum Creatinine (More sensitive indicator than BUN)
● INCREASED BUN levels
● Osteodystrophy (brittle bones) → due to calcium & phosphorus imbalance (At risk for falls!
, Medical Management P. 1583
● Transplant
● Dialysis
○ Decrease the level of uremic waste products in the blood & to control electrolyte balance.
○ Required for Stage 5 CKD
● Nutritional Therapy (p 1584)
○ Monitor Protein Intake ; Must be Lean Protein (dairy products, eggs, meats).
○ Fluid Allowance per Day is:
■ 500 to 600 mL MORE THAN the previous day’s 24-hour Urine Output.
○ Vitamin supplementation = necessary
■ A protein / restricted diet does not provide the necessary complement of vitamins.
Nursing Management
● Assess Fluid Status P. 1585
○ Identifying potential sources of imbalance
○ MONITOR Daily Weights & Fluid Balance
● Nutrition
○ Ensure proper nutritional intake → LOW Sodium & LOW Protein Diet.
○ AVOID HIGH Potassium products. (bananas, spinach, sweet potatoes, mushrooms, peas, cucumbers, citrus fruits, juice).
■ Low potassium (apples, berries, grapes, peaches, cabbage)
● Emotional Support: Encourage self-care & independence.
● Patient Education: Dialysis Education.
Chart 54-7: Plan of Nursing Care - NURSING DIAGNOSIS (p 1584)
● Excess Fluid Volume → Daily Weight, Monitor I/Os, Fluid
Restriction.
● Imbalanced Nutrition → Consult Dietary / Nutritionist.
● Deficient Knowledge
● Activity Intolerance → Conserve energy, Rest breaks, Cluster care
& activities.
● Risk for situational low self-esteem
Medications P. 1583
● Sodium polystyrene sulfonate (Kayexalate)
○ a cation-exchange resin
○ Used to treat Hyperkalemia.
● Calcium Carbonate or Calcium Acetate “Calcium & Phosphorus Binders”
○ Treats hyperphosphatemia & hypocalcemia
○ Risk of hypercalcemia while using meds.
■ If calcium is High or the calcium-phosphorus product EXCEEDS 55 mg/dL
● Give Sevelamer hydrochloride (Renagel) a polymeric phosphate binder
● 1- 4 tablets given with food to be effective.
■ AVOID MAGNESIUM-based ANTACIDS (helps prevent magnesium toxicity). *Key education point.
● Heart Failure & Pulmonary Edema
○ May require treatment: Digoxin, Dobutamine (Dobutrex), or dialysis.
○ BOTH increase the contractility of the heart & Cardiac Output
■ Fluid Restriction
■ Low Sodium Diets
■ Diuretic agents
○ Teacher: DO NOT give these meds / anti-hypertensive meds the day they get dialysis. Dialysis takes fluids out.
● Metabolic Acidosis
○ Kidneys can not excrete increased loads of acid.
○ Elevated acids/ decreased bicarbonate HCO3-
○ Usually produces NO symptoms.
■ If symptoms present → Sodium Bicarbonate or Dialysis.
● Anticonvulsants
○ Benzodiazepine (Diazepam)
○ Hydantoin (Phenytoin)
○ Must monitor for early evidence of slight twitching, headache, delirium, or seizure activity.
○ Seizures or onset of seizure, notify provider immediately
■ IV diazepam (Valium) or phenytoin is usually given to control seizures.
■ Rise side rails and padded to protect the patient.
● Erythrocyte Stimulating Agents
○ Epoetin Alfa ← (SUPPORTIVE TREATMENT)
■ Used to treat ANEMIA (Hematocrit < 30%)
● Target hemoglobin of 12 (normal M 14-18 g/dL & F 12-16 g/dL)
■ Administered IV/ SubQ or Subq 3X per week in ESKD.
■ May take 2 - 6 weeks for hematocrit to rise.
■ Adverse Effects of Epoetin Alfa:
● HYPERTENSION (especially during early stages of treatment)
● Increased clotting of vascular access sites (use heparin to unclog IV lines)
● Seizures
● Iron Depletion (Anemia).
■ Successful Use = Reports of : decreased fatigue, higher/energy levels, increased feelings of well being, better tolerance of dialysis, & improved exercise
tolerance.
Geriatic Consideration P. 1584 & 1589
● OLDER ADULT ESRD CAUSES
○ Diabetes, hypertension, chronic glomerulonephritis, interstitial nephritis, & urinary tract obstruction.
● OLDER ADULT SIGNS & SYMPTOMS:
○ Often non-specific
○ Heart Failure & Dementia
■ Can MASK THE SYMPTOMS of kidney disease.
■ Can delay or prevent diagnosis & treatment.
, ● Hemodialysis and PD are used effectively in treating older patients with ESKD.
● Transplant is LESS COMMON due to comorbidities (coronary artery disease, peripheral vascular disease).
T/Q (question by teacher):
● What is normal GFR? (90-120 mL/min)
● In ESRD, is potassium going to be high or low? High (hyperkalemia most life threatening of fluid & electrolyte change in kidney disorders)
● What do you teach about fluid status? Fluid restriction, sodium.. P. 1585
○ What do you do while the patient is under your care in the hospital? Strict I&O
○ What can you do to check fluid status? Daily weight
● Nutrition, what would you teach?
○ Protein restriction.
■ Promote high biological value protein (eggs, dairy products, meats). P. 1585
● What would you teach about potassium? Low-potassium snack
● POTATOES DO NOT TAKE HIGH IN POTASSIUM
CRRT “Continuous Renal Replacement Therapies” (CH. 54, p 1594-1595)
What is it?
● Filter blood.
CRRT, Who’s It For?
● For patients with ACUTE or CHRONIC Kidney Disease.
● Who are too Hemodynamically UNSTABLE for traditional hemodialysis (it’s a slower form of dialysis).
● EXAMPLES:
○ Fluid Overload secondary to oliguric (low urine output) kidney disease.
○ Patients whose kidneys cannot handle their acutely high metabolic or nutritional needs.
● Widely used in ICUs.
CVVH “Continuous venovenous hemofiltration”
● Can manage AKI.
● Better tolerated for those with unstable conditions.
● Continuous slow fluid removal (ultrafiltration) = larger volume of fluid removed via convection (heat).
● Replacement fluid added
● Blood from a double lumen venous catheter is pumped through a hemofilter and then returned to the patient through the same catheter
● Critical care nurses must be trained to: set up, initiate, maintain, and terminate the system.
● No dialysate used
CVVHD “Continuous Venovenous Hemodialysis”
● Blood is pumped from a double lumen venous catheter through a hemofilter → dialysate solution removes uremic toxins and fluid then → returns
to the patient through the same catheter.
○ Ultrafiltration and a concentration gradient to facilitate removal of toxins by adding dialysate.
● Fluid replacement are not administered.
● Critical care nurses can set up, initiate, maintain, and terminate the system with the support of the nephrology nursing staff.
**FOCUS ON CRRT** HD CRRT
Indication Hemodynamically STABLE patients Hemodynamically UNSTABLE patients
Solute shift Diffusion Diffusion, convection or both
Blood flow rate >= 200 ml/hr <= 200 ml/hr
Dialysate flow rate >=500 ml/hr <=17-34 ml/hr
Advantages • Short duration (3-4hrs.) Can take 24 hours to complete
• Rapid removal of toxins and low molecular weight Continuous removal of toxins
substances Hemodynamic stability
• Allows for downtime for diagnostic and therapeutic Easy control of fluid balance
procedures Adequate nutritional support possible
• Less anticoagulation
Disadvantages • Cardiovascular instability • Slower clearance of toxins
• Risk of electrolyte disequilibrium with risk of cerebral • Need for prolonged anticoagulation
edema • Patient immobilization
• Technically complex • Risk for Hypothermia
• Requires fresh water supply • Higher risk of infection
KIDNEY SURGERY “Renal Surgery” (CH. 54 p 1602-1607)
What is it?
●
Indications
● A patient may undergo surgery to:
○ Remove obstructions that affect the kidney (tumors or calculi).
○ Insert a tube for draining of the kidney (nephrostomy, ureterostomy)
○ Remove the kidney involved in:
■ Unilateral kidney disease, Renal Carcinoma, or Kidney Transplantation.
● PERI - Operative Concerns
○ Kidney surgery REQUIRES various patient POSITIONS.
○ Three surgical approaches are common: Flank, Lumbar, & Thoracoabdominal
○ Manage altered urinary drainage during surgery → EX: insert a nephrostomy or other drainage tube.
● POST-Operative Complications
○ Hemorrhage & Shock (MAJOR COMPLICATION)
■ Results in hypovolemia
■ Fatigue & urine output <0.5 mL/kg/hr.
■ Cool skin, flat neck veins, change in LOC.
○ Fluid & Blood Component Replacement
■ Immediately post op to treat intraoperative blood loss.
, ○ Abdominal Distention & Paralytic Ileus (common)
■ Are due to a reflex paralysis of the intestines & manipulation of the colon or duodenum during surgery.
■ Abdominal Distention → DECOMPRESSION via NASOGASTRIC TUBE.
■ See Chapter 48 for treatment of paralytic ileus.
■ Low Dose Heparin therapy may be initiated postoperatively to prevent thromboembolism.
○ ORAL FLUIDS are permitted when PASSAGE OF FLATUS is noted.
○ If infection occurs
■ Antibiotics are prescribed AFTER a Culture (which reveals the causative organism / appropriate drug to give).
■ Monitor for Nephrotoxicity (when giving antibiotics).
■ Do NOT give Gentamicin (it’s hard on kidneys).
○ T/note: 3-5 days is where you would most likely see infection at the surgical site.
■ Redness
■ Fever
■ Anorexia
■ Nausea & Vomiting
● T/note: DO NOT GIVE GENTAMICIN (be careful with pts in End Stage Renal Failure)
● T/note: Can use low ...... Heparin based on their status pre and post Op
Nursing Management
● PRE-Operative & Considerations
○ Surgery only after a thorough evaluation of renal function.
○ Ensure optimal renal function is maintained.
○ Encourage Fluids → increases excretion of waste products BEFORE surgery
■ Unless contraindicated because of preexisting renal or cardiac dysfunction.
○ If kidney infection is present:
■ Broad/spectrum antibiotics may be prescribed to prevent BACTEREMIA.
● Extreme caution because many are toxic to the kidneys.
○ Coagulation studies (if history of bruising & bleeding)
■ Prothrombin time, partial thromboplastin time, platelet count
○ Patient is to recognize & verbalize concerns (reduces apprehension).
○ Establish a relationship of trust (reinforces confidence).
○ Patients may think losing a kidney will have to depend on dialysis for the rest of their lives.
○ Educate → normal function may be maintained by a single healthy kidney.
● POST-Operative
○ Respiratory Status
■ Anesthesia INCREASES the risk of respiratory complications.
■ Surgical Incision Location
● Pain on inspiration & coughing.
○ splint the chest wall & take shallow respirations.
■ Auscultate Breath Sounds
○ Circulatory Status and Blood Loss
■ MONITOR
● Vital signs (initially Q 1hr.)
● Arterial Pressure, or Central venous pressure.
● Skin color, Temperature, and Urine Output.
■ Give fluids and blood
○ Pain (major problem)
■ ASSESS Location & Severity of Pain BEFORE & AFTER giving analgesic medications.
■ Abdominal Distention (also increases discomfort).
○ Urinary Drainage (REPORT)
■ Decreased or Absent Drainage → may indicate Obstruction (causing pain, infection, & disruption of the sutures).
○ Pneumonia
■ S/S
● Fever, ↑ heart & respiratory rate, adventitious breath sounds.
■ Prevention
● Incentive spirometer, pain control, and early ambulation.
○ Infection
■ S/S → inflammation, redness, drainage, heat, & pain.
■ Use aseptic techniques → dressing & catheter changes
■ Prevent UTI associated with indwelling catheters.
■ Antibiotics → Serum creatinine & BUN monitored carefully → antibiotics can be toxic (Ex: gentamicin).
○ Fluid Excess
■ Due to: cardiac effects of anesthesia, given too much fluids, decreased urine output.
■ Early signs → weight gain, pedal edema, urine output <0.5 mL/kg/hr, SOB.
■ Treatment → furosemide (Lasix) or dialysis (prevent heart failure & pulmonary edema).
○ DVT prevention
■ Anti Embolism/compression stocking, leg exercises, Heparin.
T/Q:
● What antibiotic is nephrotoxic and would use sparingly? Gentamicin
● For someone who’s had a nephrectomy, what intention could you do for respiratory status? Incentive spirometer, and turn cough deep breathing.
● What would you do for circulatory status? Check vital signs, capillary refill.
● What labs would you follow postoperative who had renal surgery? BUN, GFR, creatinine, WBC
NEPHRECTOMY (Ch 54, Pg. 1575)
What is it?
● Radical Nephrectomy (PREFERED)
○ Removes Kidney, Tumor, Adrenal Gland, Perinephric Fat, Gerota Fascia, & Lymph Nodes.
● Partial Nephrectomy (NEPHRON-SPARING procedure)
○ For patients with BILATERAL Tumors (or cancer of a functional single kidney)
○ Good for small local tumors & normal contralateral kidneys.
○ Used to treat patients with SOLID RENAL LESIONS.
● Depending on Tumor Stage, Nephrectomies may be followed by treatment with chemotherapy agents.
Complete Solutions-Galen College of Nursing
★ UNIT ONE - Complex Elimination (Renal) ★
END-STAGE RENAL FAILURE (CH. 54 p 1581-1589)
What is it?
● Intolerable kidney damage that requires Permanent Renal Replacement Therapy
● Is the 5th Stage (final stage) of Chronic Kidney Disease (also referred to as ESRD).
Pathology
● Declining Renal Function causes UREA to accumulate in the blood.
○ UREMIA (high urea levels) develops & negatively affects every system in the body.
○ Urea = the end product of protein metabolism (a nitrogenous waste).
● Rate & Progression Renal Failure in ESKD is related to:
○ 1) The underlying disorder.
○ 2) Presence of Proteinuria.
○ 3) Presence of Hypertension.
● Stages progresses more rapidly in patients who have:
○ PROTEINURIA (high excretion of protein in urine) or HYPERTENSION (high blood pressure)
Etiology
● Primarily Unknown ; It’s thought that the accumulation of uremic waste products is the probable cause
Clinical Manifestation
● Cardiovascular Disease (MAIN CAUSE DEATH)
● Peripheral Neuropathy
○ weakness, numbness, pain, discomfort.
● Uremic Peripheral Neuropathy
○ Restless Leg Syndrome / Burning Feet (early stages)
Chart 54-6 : Assessing for End-Stage Kidney Disease (p 1582) Chart 54-1 : Stages of Chronic Kidney Disease (p 1569)
NEUROLOGIC GASTROINTESTINAL Normal GFR (90-120 mL/min)
Asterixis Ammonia odor to breath (“uremic fetor”)
Behavior changes Anorexia, nausea, & vomiting STAGE 1 GFR ≥ 90 mL/min/1.73 m2
Burning of soles of feet GI Bleeding Kidney damage with Normal or Increased GFR
Confusion Constipation or Diarrhea
Disorientation Hiccups STAGE 2 GFR = 60 - 90 mL/min/1.73 m2
Inability to concentrate Metallic taste MILD decrease in GFR
Restlessness of legs Mouth ulcerations and bleeding
Seizures
Tremors STAGE 3 GFR = 30 - 59 mL/min/1.73 m2
Weakness and fatigue Symptoms might start MODERATE decrease in GFR
to appear here.
INTEGUMENTARY HEMATOLOGIC
Coarse, thinning hair Anemia STAGE 4 GFR = 15 - 29 mL/min/1.73 m2
Dry, flaky skin Thrombocytopenia Discuss Dialysis SEVERE decrease in GFR
Ecchymosis (bruising)
Gray-bronze skin color
STAGE 5 GFR < 15 mL/min/1.73 m2
Pruritus (itchy)
Purpura Dialysis is Required END-STAGE KIDNEY DISEASE or
Thin, brittle nails CHRONIC KIDNEY DISEASE
CARDIOVASCULAR REPRODUCTIVE
Engorged neck veins (JVD) Amenorrhea
Hyperkalemia (Peaked T waves) Decreased libido
Hyperlipidemia Infertility
Hypertension (control HTN) Testicular atrophy
Pericardial effusion
Pericardial friction rub
Pericardial tamponade
Pericarditis
Periorbital edema
Pitting edema (feet, hands, sacrum)
PULMONARY MUSCULOSKELETAL
Crackles Bone fractures
Depressed cough reflex Bone pain
Kussmaul-type respirations Footdrop
Pleuritic pain Loss of muscle strength
Shortness of breath Muscle cramps
Tachypnea Renal osteodystrophy (uremic bone disease)
Thick, tenacious
Diagnostics (p 1579)
● DECREASED Creatinine Clearance
● DECREASED GFR < 15 mL/min/1.73 m2
● Sodium / Water retention
● Metabolic Acidosis (from the Uremia) ← know how to identify metabolic acidosis with acid/base problems
3 main causes: ↑ acid, ↓bicarbonate, ↓ acid & phosphates secretion
● ANEMIA (Hematocrit less than 30%)
○ Signs & Symptoms → malaise, general fatigue, & decreased activity tolerance.
○ Due to DECREASED Erythropoietin production → EPO stimulates the bone marrow to make RBCs!
● Azotemia (also called Uremia) = high urea & nitrogen levels
● INCREASED Serum Creatinine (More sensitive indicator than BUN)
● INCREASED BUN levels
● Osteodystrophy (brittle bones) → due to calcium & phosphorus imbalance (At risk for falls!
, Medical Management P. 1583
● Transplant
● Dialysis
○ Decrease the level of uremic waste products in the blood & to control electrolyte balance.
○ Required for Stage 5 CKD
● Nutritional Therapy (p 1584)
○ Monitor Protein Intake ; Must be Lean Protein (dairy products, eggs, meats).
○ Fluid Allowance per Day is:
■ 500 to 600 mL MORE THAN the previous day’s 24-hour Urine Output.
○ Vitamin supplementation = necessary
■ A protein / restricted diet does not provide the necessary complement of vitamins.
Nursing Management
● Assess Fluid Status P. 1585
○ Identifying potential sources of imbalance
○ MONITOR Daily Weights & Fluid Balance
● Nutrition
○ Ensure proper nutritional intake → LOW Sodium & LOW Protein Diet.
○ AVOID HIGH Potassium products. (bananas, spinach, sweet potatoes, mushrooms, peas, cucumbers, citrus fruits, juice).
■ Low potassium (apples, berries, grapes, peaches, cabbage)
● Emotional Support: Encourage self-care & independence.
● Patient Education: Dialysis Education.
Chart 54-7: Plan of Nursing Care - NURSING DIAGNOSIS (p 1584)
● Excess Fluid Volume → Daily Weight, Monitor I/Os, Fluid
Restriction.
● Imbalanced Nutrition → Consult Dietary / Nutritionist.
● Deficient Knowledge
● Activity Intolerance → Conserve energy, Rest breaks, Cluster care
& activities.
● Risk for situational low self-esteem
Medications P. 1583
● Sodium polystyrene sulfonate (Kayexalate)
○ a cation-exchange resin
○ Used to treat Hyperkalemia.
● Calcium Carbonate or Calcium Acetate “Calcium & Phosphorus Binders”
○ Treats hyperphosphatemia & hypocalcemia
○ Risk of hypercalcemia while using meds.
■ If calcium is High or the calcium-phosphorus product EXCEEDS 55 mg/dL
● Give Sevelamer hydrochloride (Renagel) a polymeric phosphate binder
● 1- 4 tablets given with food to be effective.
■ AVOID MAGNESIUM-based ANTACIDS (helps prevent magnesium toxicity). *Key education point.
● Heart Failure & Pulmonary Edema
○ May require treatment: Digoxin, Dobutamine (Dobutrex), or dialysis.
○ BOTH increase the contractility of the heart & Cardiac Output
■ Fluid Restriction
■ Low Sodium Diets
■ Diuretic agents
○ Teacher: DO NOT give these meds / anti-hypertensive meds the day they get dialysis. Dialysis takes fluids out.
● Metabolic Acidosis
○ Kidneys can not excrete increased loads of acid.
○ Elevated acids/ decreased bicarbonate HCO3-
○ Usually produces NO symptoms.
■ If symptoms present → Sodium Bicarbonate or Dialysis.
● Anticonvulsants
○ Benzodiazepine (Diazepam)
○ Hydantoin (Phenytoin)
○ Must monitor for early evidence of slight twitching, headache, delirium, or seizure activity.
○ Seizures or onset of seizure, notify provider immediately
■ IV diazepam (Valium) or phenytoin is usually given to control seizures.
■ Rise side rails and padded to protect the patient.
● Erythrocyte Stimulating Agents
○ Epoetin Alfa ← (SUPPORTIVE TREATMENT)
■ Used to treat ANEMIA (Hematocrit < 30%)
● Target hemoglobin of 12 (normal M 14-18 g/dL & F 12-16 g/dL)
■ Administered IV/ SubQ or Subq 3X per week in ESKD.
■ May take 2 - 6 weeks for hematocrit to rise.
■ Adverse Effects of Epoetin Alfa:
● HYPERTENSION (especially during early stages of treatment)
● Increased clotting of vascular access sites (use heparin to unclog IV lines)
● Seizures
● Iron Depletion (Anemia).
■ Successful Use = Reports of : decreased fatigue, higher/energy levels, increased feelings of well being, better tolerance of dialysis, & improved exercise
tolerance.
Geriatic Consideration P. 1584 & 1589
● OLDER ADULT ESRD CAUSES
○ Diabetes, hypertension, chronic glomerulonephritis, interstitial nephritis, & urinary tract obstruction.
● OLDER ADULT SIGNS & SYMPTOMS:
○ Often non-specific
○ Heart Failure & Dementia
■ Can MASK THE SYMPTOMS of kidney disease.
■ Can delay or prevent diagnosis & treatment.
, ● Hemodialysis and PD are used effectively in treating older patients with ESKD.
● Transplant is LESS COMMON due to comorbidities (coronary artery disease, peripheral vascular disease).
T/Q (question by teacher):
● What is normal GFR? (90-120 mL/min)
● In ESRD, is potassium going to be high or low? High (hyperkalemia most life threatening of fluid & electrolyte change in kidney disorders)
● What do you teach about fluid status? Fluid restriction, sodium.. P. 1585
○ What do you do while the patient is under your care in the hospital? Strict I&O
○ What can you do to check fluid status? Daily weight
● Nutrition, what would you teach?
○ Protein restriction.
■ Promote high biological value protein (eggs, dairy products, meats). P. 1585
● What would you teach about potassium? Low-potassium snack
● POTATOES DO NOT TAKE HIGH IN POTASSIUM
CRRT “Continuous Renal Replacement Therapies” (CH. 54, p 1594-1595)
What is it?
● Filter blood.
CRRT, Who’s It For?
● For patients with ACUTE or CHRONIC Kidney Disease.
● Who are too Hemodynamically UNSTABLE for traditional hemodialysis (it’s a slower form of dialysis).
● EXAMPLES:
○ Fluid Overload secondary to oliguric (low urine output) kidney disease.
○ Patients whose kidneys cannot handle their acutely high metabolic or nutritional needs.
● Widely used in ICUs.
CVVH “Continuous venovenous hemofiltration”
● Can manage AKI.
● Better tolerated for those with unstable conditions.
● Continuous slow fluid removal (ultrafiltration) = larger volume of fluid removed via convection (heat).
● Replacement fluid added
● Blood from a double lumen venous catheter is pumped through a hemofilter and then returned to the patient through the same catheter
● Critical care nurses must be trained to: set up, initiate, maintain, and terminate the system.
● No dialysate used
CVVHD “Continuous Venovenous Hemodialysis”
● Blood is pumped from a double lumen venous catheter through a hemofilter → dialysate solution removes uremic toxins and fluid then → returns
to the patient through the same catheter.
○ Ultrafiltration and a concentration gradient to facilitate removal of toxins by adding dialysate.
● Fluid replacement are not administered.
● Critical care nurses can set up, initiate, maintain, and terminate the system with the support of the nephrology nursing staff.
**FOCUS ON CRRT** HD CRRT
Indication Hemodynamically STABLE patients Hemodynamically UNSTABLE patients
Solute shift Diffusion Diffusion, convection or both
Blood flow rate >= 200 ml/hr <= 200 ml/hr
Dialysate flow rate >=500 ml/hr <=17-34 ml/hr
Advantages • Short duration (3-4hrs.) Can take 24 hours to complete
• Rapid removal of toxins and low molecular weight Continuous removal of toxins
substances Hemodynamic stability
• Allows for downtime for diagnostic and therapeutic Easy control of fluid balance
procedures Adequate nutritional support possible
• Less anticoagulation
Disadvantages • Cardiovascular instability • Slower clearance of toxins
• Risk of electrolyte disequilibrium with risk of cerebral • Need for prolonged anticoagulation
edema • Patient immobilization
• Technically complex • Risk for Hypothermia
• Requires fresh water supply • Higher risk of infection
KIDNEY SURGERY “Renal Surgery” (CH. 54 p 1602-1607)
What is it?
●
Indications
● A patient may undergo surgery to:
○ Remove obstructions that affect the kidney (tumors or calculi).
○ Insert a tube for draining of the kidney (nephrostomy, ureterostomy)
○ Remove the kidney involved in:
■ Unilateral kidney disease, Renal Carcinoma, or Kidney Transplantation.
● PERI - Operative Concerns
○ Kidney surgery REQUIRES various patient POSITIONS.
○ Three surgical approaches are common: Flank, Lumbar, & Thoracoabdominal
○ Manage altered urinary drainage during surgery → EX: insert a nephrostomy or other drainage tube.
● POST-Operative Complications
○ Hemorrhage & Shock (MAJOR COMPLICATION)
■ Results in hypovolemia
■ Fatigue & urine output <0.5 mL/kg/hr.
■ Cool skin, flat neck veins, change in LOC.
○ Fluid & Blood Component Replacement
■ Immediately post op to treat intraoperative blood loss.
, ○ Abdominal Distention & Paralytic Ileus (common)
■ Are due to a reflex paralysis of the intestines & manipulation of the colon or duodenum during surgery.
■ Abdominal Distention → DECOMPRESSION via NASOGASTRIC TUBE.
■ See Chapter 48 for treatment of paralytic ileus.
■ Low Dose Heparin therapy may be initiated postoperatively to prevent thromboembolism.
○ ORAL FLUIDS are permitted when PASSAGE OF FLATUS is noted.
○ If infection occurs
■ Antibiotics are prescribed AFTER a Culture (which reveals the causative organism / appropriate drug to give).
■ Monitor for Nephrotoxicity (when giving antibiotics).
■ Do NOT give Gentamicin (it’s hard on kidneys).
○ T/note: 3-5 days is where you would most likely see infection at the surgical site.
■ Redness
■ Fever
■ Anorexia
■ Nausea & Vomiting
● T/note: DO NOT GIVE GENTAMICIN (be careful with pts in End Stage Renal Failure)
● T/note: Can use low ...... Heparin based on their status pre and post Op
Nursing Management
● PRE-Operative & Considerations
○ Surgery only after a thorough evaluation of renal function.
○ Ensure optimal renal function is maintained.
○ Encourage Fluids → increases excretion of waste products BEFORE surgery
■ Unless contraindicated because of preexisting renal or cardiac dysfunction.
○ If kidney infection is present:
■ Broad/spectrum antibiotics may be prescribed to prevent BACTEREMIA.
● Extreme caution because many are toxic to the kidneys.
○ Coagulation studies (if history of bruising & bleeding)
■ Prothrombin time, partial thromboplastin time, platelet count
○ Patient is to recognize & verbalize concerns (reduces apprehension).
○ Establish a relationship of trust (reinforces confidence).
○ Patients may think losing a kidney will have to depend on dialysis for the rest of their lives.
○ Educate → normal function may be maintained by a single healthy kidney.
● POST-Operative
○ Respiratory Status
■ Anesthesia INCREASES the risk of respiratory complications.
■ Surgical Incision Location
● Pain on inspiration & coughing.
○ splint the chest wall & take shallow respirations.
■ Auscultate Breath Sounds
○ Circulatory Status and Blood Loss
■ MONITOR
● Vital signs (initially Q 1hr.)
● Arterial Pressure, or Central venous pressure.
● Skin color, Temperature, and Urine Output.
■ Give fluids and blood
○ Pain (major problem)
■ ASSESS Location & Severity of Pain BEFORE & AFTER giving analgesic medications.
■ Abdominal Distention (also increases discomfort).
○ Urinary Drainage (REPORT)
■ Decreased or Absent Drainage → may indicate Obstruction (causing pain, infection, & disruption of the sutures).
○ Pneumonia
■ S/S
● Fever, ↑ heart & respiratory rate, adventitious breath sounds.
■ Prevention
● Incentive spirometer, pain control, and early ambulation.
○ Infection
■ S/S → inflammation, redness, drainage, heat, & pain.
■ Use aseptic techniques → dressing & catheter changes
■ Prevent UTI associated with indwelling catheters.
■ Antibiotics → Serum creatinine & BUN monitored carefully → antibiotics can be toxic (Ex: gentamicin).
○ Fluid Excess
■ Due to: cardiac effects of anesthesia, given too much fluids, decreased urine output.
■ Early signs → weight gain, pedal edema, urine output <0.5 mL/kg/hr, SOB.
■ Treatment → furosemide (Lasix) or dialysis (prevent heart failure & pulmonary edema).
○ DVT prevention
■ Anti Embolism/compression stocking, leg exercises, Heparin.
T/Q:
● What antibiotic is nephrotoxic and would use sparingly? Gentamicin
● For someone who’s had a nephrectomy, what intention could you do for respiratory status? Incentive spirometer, and turn cough deep breathing.
● What would you do for circulatory status? Check vital signs, capillary refill.
● What labs would you follow postoperative who had renal surgery? BUN, GFR, creatinine, WBC
NEPHRECTOMY (Ch 54, Pg. 1575)
What is it?
● Radical Nephrectomy (PREFERED)
○ Removes Kidney, Tumor, Adrenal Gland, Perinephric Fat, Gerota Fascia, & Lymph Nodes.
● Partial Nephrectomy (NEPHRON-SPARING procedure)
○ For patients with BILATERAL Tumors (or cancer of a functional single kidney)
○ Good for small local tumors & normal contralateral kidneys.
○ Used to treat patients with SOLID RENAL LESIONS.
● Depending on Tumor Stage, Nephrectomies may be followed by treatment with chemotherapy agents.
