Renal & Electrolyte Disturbances
Renal &ElectrolyteDisturbances20%6%80%186
RENALI.INTRODUCTIONAACN-CCRN/CCRN-E 6% Chronic Renal Failure Acute Renal Failure Life Threatening ElectrolyteDisturbancesII.RENAL PHYSIOLOGYMajor Functions of the Kidney1.Excretion of Metabolic Wastes2.Urine Formation3.Acid-Base Balance Regulation4.Electrolyte Regulation5.Fluid Regulation6.Blood Pressure Regulation7.Erythropoietin Secretion/Anemia RegulationRenal Assessment1. Blood Work Blood Urea Nitrogen Creatinine Serum Electrolytes Hgb & Hct Serum Albumin Serum OsmolalityBlood Urea Nitrogen: BUN: 5.0 – 25 mg/dLUrea is formed in the liver along with C02 as a waste by product of protein metabolism. It iscarried by the blood and excreted by the renal system. Elevated BUN levels are significant foreither increased protein catabolism or decreased renal excretion of urea. Situations, which wouldincrease protein catabolism, include high protein diets, GI bleeding (protein from blood is brokendown), DKA, burns and cancer. Any pre-renal (shock state, poor renal perfusion) or intra-renalfailure (nephrotoxic medications or kidney diseases) will decrease the GFR and therefore ureaexcretion. The elevation of the metabolic waste products can cause fatigue, muscle weakness, andseizures. Volume status of the patient can also affect the BUN. Treatment is related to the causeof the elevation, which would include hydration, stopping protein catabolism, and/or dialysis.187
Creatinine: 0.6 – 1.5 mg/dL slightly lower in females, children and elderlyCreatinine is a waste product of creatinine phosphate breakdown. Creatinine phosphate is ahigh-energy compound found in skeletal muscle tissue and is released during musclebreakdown. There is no biological use for creatinine so the kidneys excrete it all. Creatininelevel is a reflection of glomerular filtration and a very good indicator of renal function. It willbe elevated in renal disease and muscle wasting disorders (MG, MD, acromegaly), CHF, shock,and rhabdomyolysis. High levels of ascorbic acid and cephalosporin antibiotics may cause afalse positive elevation. Treatment is to restore kidney function or dialysis.BUN:Creatinine Ratio: 10:1 – 20:1Helpful to identify if azotemia is from a renal or nonrenal cause. Elevated creatinine isindicative of renal failure whereas elevated BUN could be caused from a variety of conditionsincluding dehydration.Male: 95 – 135 ml/minFemale: 85 – 125ml/minIndicative of glomerular filtration rate. Compares the amount of creatinine in the urine to theamount in the blood over the same time period.Creatinine Clearance Test:Urine Creatinine X Urine Volume Creatinine clearance rateSerum Creatinine1. Urine Assessment Volume & Concentration Urinalysis (see table) Renal Clearance Studies3. Other Tests KUB X-ray Renal Arteriography IVP CT Ultrasound BiopsyIII.CHRONIC RENAL FAILURE or Chronic Kidney DiseaseAcute renal failure affects many body systems.Chronic renal failure affects EVERY body system.Chronic renal failure (CRF) is a permanent, irreversible condition in whichthe kidneys cease to remove metabolic wastes and excessive water from theblood. (ESRF, ESRD, CRD, CKD)188
Etiology - more than 100 different diseases can cause RF Glomerular Disease Tubular Diseases Vascular Kidney Diseases Urinary Tract Disease Infection (kidney) Systemic Vascular Diseases Metabolic Diseases Connective Tissue DiseasesA.Terms1.Azotemia – Nitrogenous Waste Products in the Bloodstream2.Uremic Syndrome – Systemic and Laboratory Manifestations ofESRD3.Renal Replacement Therapy – Treatment OptionsB.Stages of Renal Failure1.Diminished Renal Reserve2.Renal Insufficiency3.End Stage Renal Disease (ESRD) – Affects every system in thebody Renal AlterationsDisruptions in GRFAbnormal urine production and water excretionElectrolyte ImbalancesMetabolic Abnormalities Metabolic Alterations Urea & CreatinineSodiumPotassiumAcid-Base BalanceCalcium & Phosphate Cardiac Alterations (CV disease is the leading cause of death forESRD pts) Hypertension Congestive Heart Failure Uremic Pericarditis Hematologic Alterations AnemiaDecreased Erythropoietin189
Decreased RBC SurvivalIron and Folic Acid DefBleeding Gastrointestinal Alterations Mouth Inflammation (ulcers)AnorexiaNauseaVomitingHiccupsUremic ColitisDiarrhea or Constipation Neurologic Alterations Lethargy and Daytime DrowsinessDecreased Attention SpanInsomniaWeakness in ExtremitiesParenthesesSeizures and Coma Pulmonary Alterations Respiratory Effort Changes – Kussmaul’s BreathingBreath Smells Like Urine – Uremic HalitosisDeep SighingYawningShortness of Breath Integumentary Manifestations C.Skin Oils and Turgor DecreasedPruritus (itching)Ecchymoses (bruises)Purpura (purple patches)Uremic FrostTreatment: Renal Replacement Therapies Medications Hemodialysis Peritoneal Dialysis Renal Transplant190
IV. ACUTE RENAL FAILURE: Acute Kidney DiseaseA. Pathophysiology: a sudden deterioration in renal function usually associatedwith the loss of the kidney’s ability to concentrated urine, as well as theretention and accumulation of nitrogen wastes. Decreased Glomerular Filtration Rate Interstitial Inflammatory Changes Tubular Lumen Obstruction Oliguric, 400 mL/day Non-Oliguric, Large Amt of Dilute UrineB. Common Etiologies Severe Hypotension (all forms of shock) Heart Failure Dehydration Nephrotoxic Agents Complication of Infection Severe HypertensionCategoryCause/ConditionsVolume: DehydrationPre RenalThe problem is not actually with thekidneys but with perfusion (blood flow) tothe kidneysIschemia: hypovolemic shock, cardiogenic shock,septic shock, hypoxemia, low cardiac output,heart failure, severe hypertensionHemodynamic instability, multisystem organfailure, traumaPost RenalUrethral: Stricture, Prostatic HypertrophyThe problem is not actually with thekidneys but after the kidneys.Urethral: fibrosis, calculi, blood clotsBladder: neurogenic problems, neoplasms/cancer,obstructionTraumaRenalThe problem is in the kidney itselfeffecting function. Kidney diseasesGlomerulus: acute glomerulonephritis, acutecortical necrosis, hepatorenal syndromeTubule: acute tubular necrosis, acutepyelonephritis191
Nephrotoxins: heavy metals, antibiotics,radiographic contrast media, anestheticsPigments: hemoglobin, myoglobinTrauma, intravenous hemolysis, rhabdomyolysisC.Differentiating Pre-Renal From Renal Diagnosis for ATNAssessmentPre-RenalRenal(Hypoperfusion)(Tissue Damage)Urinary Sodium 20mEq/L 20 mEq/LBUN:Creatinine Ratio 20:110-20:1 (normal)Responds (increase in UO) Positive ResponseNo Responseto volume or diureticsD.Phases of ARF Onset Phase BUN & Creatinine Rising Urine Output Dropping Diuretics Still Working Acidosis Beginning Oliguric Phase Alteration in Electrolyte Balance Potential for Infection Alteration in A-B Balance Alteration in Nutrition Status Uremic Syndrome Alteration in Pulmonary Status Alteration in GI Function Diuretic Phase Fluid Loss Goal is to maintain adequate fluid balance and regulateelectrolytes Alteration in Electrolytes Recovery Phase Goal is Supportive Care Prevent Further Insults Assessment of Renal Function192
Keep patient well hydrated and free from infection Prevent Further InsultsE.Systemic Response to Acute Failure Hypertension Tachycardia Decreased UO Lethargy Pulmonary Edema Depends on Type Very Similar to Chronic FailureF.Nursing Care Needs Ensure Hydration Fluid Challenges Diuretics Monitor Fluid Status Weigh Daily & I & O Monitor Electrolyte Imbalance Support Renal FunctionG.Treatment Options/Alternatives Drug Therapy Diet Therapy Renal Replacement Therapies (CVVH, Hemodialysis,Peritoneal Dialysis) Renal TransplantH.Support Therapy for ATNPt ProblemExtracellular Volume OverloadHyponatremiaHyperkalemiaMetabolic AcidosisTreatmentRestrict NaCl and H20DiureticsDialysisRestrict Oral H20Restrict Hypotonic IV SolutionsRestrict K intakeDialysisK Binding ResinsGlucose/InsulinEliminate K Supplements NaBicarb Ca GluconateNa BicarbDialysis193
ionDrug DosageV.Restrict PHO4DialysisPhosphate Binding AgentsCalcium CarbonateCalcium GluconatePhosphate Binding AgentsDialysisD/C Mg Containing AntacidsDialysisHigh ProteinEnteral or Parental NutritionAdjust Doses Around GFRAvoid NSAIDS, ACE I, Dye, Nephrotoxic AbxRenal Replacement TherapiesGoal – to remove body waste and fluids in the presence of acute orchronic renal failureA. Terms – Diffusion: movement of particles from an area of greater to anarea of lesser concentration. During dialysis diffusion results inthe movement of urea, creatinine, and uric acid from thepatient’s blood in the dialysate Osmosis: the movement of water across a semi-permeablemembrane from an area of lesser to an area of greaterconcentration (osmolality) of particles. During dialysis osmosisresults in extra fluid from the patient being removed. Ultrafiltration: the movement of fluid across a semi-permeablemembrane as a result of an artificially created pressure gradient.More efficient than osmosis for the removal of water. Dialysis: involves the movement of fluid and particles across asemipermeable membrane. It is a treatment that can helprestore fluid and electrolyte balance, control acid-base balance,and remove waste and toxic material from the body. It cansustain life successfully in both acute and chronic situationwhere substitution for or augmentation of normal renal functionis needed.194
B. Insurance Coverage – in 1972 the Congress enacted legislation thatprovides for people with ESRD to receive Medicare regardless of age.This is not true in all countries.HEMODIALYSISGoal – involves shunting the patient’s blood from the body through adialyzer in which diffusion and ultrafiltration occur and then back intothe patient’s circulation. Requires access to the pt’s blood, a mechanismto transport the blood to and from the dialyzer (where exchange of fluid,electrolytes, and waste products occur). HD can be used in the treatmentof acute and chronic renal failureAccess – five different types of access can be used Arteriovenous Fistula Arteriovenous Graft External Arteriovenous Shunt Femoral Vein Catheterization Subclavian Vein CatheterizationContraindications - Causes rapid fluid shifts Labile Cardiovascular States Recent MI HypotensionComplications Hypotension Air Embolism Arrhythmias Infection Disequilibrium Syndrome -Rapid shifts in osmolality betweencerebral spinal fluid and blood can lead to cerebral edema Coagulopathies - Heparin used during dialysis to preventclotting of blood outside of bodyChronic Care Needs – Patients are typically hemodialyzed 2-3 times a week for 2-4hours Require many medication195
Encounter multiple acute and chronic health risks as a resultof the renal failure and dialysis Have dietary and fluid restrictions Safety concerns regarding access sites Assessment requirements for access sitesPERITONEAL DIALYSISGoal – The goal is the same as above but a machine is not used toperform the “cleaning of the blood.” The dialyzing fluid is instilled intothe peritoneal cavity, and the peritoneum becomes the dialyzingmembrane. PD is used for acute and chronic renal failure and can bedone in the hospital or at home.Access – an abd catheter is inserted into the peritoneal space. In chronicuse this catheter remains in place permanently and only changedperiodically should problems arise.Procedure – Approximately 2 liters of sterile dialysate is instilled intothe peritoneal cavity and allowed to dwell for a period of time. Duringthis time osmosis and diffusion of particles takes place. The catheter isthen reopened and the fluid is drained from the patient (entire process iscalled an exchange). This process is done repeated during a 24 hr period.Contraindications Peritonitis Abdominal Surgery Abdominal Adhesions PregnancyComplications Peritonitis Respiratory DistressChronic Care Needs – PD can be done independently at home and theindividual can lead a fairly normal schedule. Not as many risks asHD. Most common problem is infection of abd catheter. Continuous ambulatory peritoneal dialysis (CAPD) – 4 –5exchanges are done a day. Continuous cyclic peritoneal dialysis (CCPD) – exchanges aredone with the use of a machine to control the infusion, dwelland drain times and patients can set up before going to sleep196
and have their PD occur automatically whale they sleep. Theyare completely independent the rest of the day.CONTINUOUS RENAL REPLACEMENT THERAPYGoal - CRRT provides continuous ultrafiltration of extracellular fluidand clearance of uremic toxins. Only done in the critical care setting.Access – Arterial and venous cannulation sites are required or twovenous cannulation.Procedure – the blood leaves the patient and flow through a hemofilterwhere the ultrafiltration takes place and removal of water and waste(collected into standard urine bag) and then the blood is returned to thepatient via the venous access. The flow gradient to move the bloodthrough the filter is the patient’s own blood pressure. There are severaltypes of processes that are used in the critical care setting for CRRT. Notnecessary to learn this year. It will be covered in your acute care coursenext fall.Contraindications: Inability to tolerate extracorporeal circulation Hypercoagulability Inability to tolerate anti-coagulation therapy (heparin) Fluid, electrolyte and acid-base shifts are less severe than withhemodialysis and usually better toleratedComplications Fluid Imbalance - Hypo/Hypervolemia (Depends onultrafiltration rate and intravascular volume requirements) Electrolyte Imbalance - Hypokalemia, Hyponatremia,Hypocalcemia, and Hypomagnesaemia Metabolic Acidosis - Bicarbonate readily removed Drug removal - Potential for removing most drugs Hemorrhage - Heparin used as blood leaves body to preventcoagulation Thrombosis/Infection Hypo/HyperthermiaVI.RENAL TRANSPLANTATIONVII. SUMMARY197
Fluids & ElectrolytesI.INTRODUCTIONFluid and electrolyte monitoringare an essential component of patientassessment. These factors regulatemost physiological functions and theacid base balance.II.FLUID BALANCEA. Total Body Water – 60% of body weight (approximately 40L)1. Intracellular – 67% of total body H20a. Primarily made up of intracellular electrolytes2. Extracellular – 33% of total body H20a. Plasma Water – 8%, Water, proteins and lipidsb. Interstitial Fluid & Lymph – 20%, Fluid bathing the cellsc. Transcellular Fluid – 7%, Pleural, pericardial, peritoneal,synovial and fluids in secretions (GI, respiratory, salivary)B. Osmolarity – the concentration of particles within a solution1. Plasma osmolarity avg. 290 5 mOsm/kgNa is the primary regulator of extracellular osmolarityK is the primary regulator of intracellular osmolarity2. Calculated osmolarity 2(Na) BG BUN182.8C. IV Fluids:The most common IV solution used in Med/Surg is D5.45NS w20KCL because if is most “like” normal fluid in the human body.Typically at 125ml/hr – 3L a day1. Isotonic Fluids Normal Saline & Lactated Ringers 275 -295 mOsm/L Volume Expanders Tend to stay in intravascular space2. Hypotonic Fluids198
.45% NS or lessLess than 275mOsm/LSevere Dehydration with Dry TissuesLeak out of vascular space into tissues3. Hypertonic Fluids 3% NS and above D5WLR D5 .9%NS Greater than 290 mOsm/L Volume Expanders Stay in intravascular space PULL fluid from interstitial space and tissuesIII. ELECTROLYTE BALANCEA. Physiology:Electrolytes are particles or solutes found throughout the body influids. They carry an electrical charge and are essential for fluid andacid base balance within the body. The cations (positively chargedions) are sodium (Na ), potassium (K ), magnesium (Mg ), andcalcium (Ca ). The anions (negatively charged ions) are chloride (Cl), bicarbonate (HCO3-), sulfate (SO4 ), and phosphate (PO4-).The four major functions of electrolytes are:1. Regulate Acid Base Balance2. Maintain Fluid Balance and Osmolarity3. Distribute the Body Fluid and H20 Between the Compartments4. Promote Neuromuscular Function/IrritabilityB. Distribution:Electrolytes are found in the intracellular and extracellular fluid. Theyare concentrated in one of these two compartments and exert osmoticproperties within that compartment. Electrolytes help to maintaintotal body fluid balance and also help to regulate fluid movement inand out of the cell. For example K is the major intracellular ion andNa is the major extracellular ion and they each play a significant rolein maintaining homeostasis within each of their compartments. Eachelectrolyte serves a unique physiologic function and concentrations199
above or below the “normal” range can affect homeostasis or specificorgan function detrimentally.ELECTROLYTE TION(plasma or intravascular)Sodium (Na )Extracellular135 – 146 mEq/L10 – 15 mEq/LPotassium (K )Intracellular3.5 – 5.5 mEq/L140 - 150 mEq/LCalcium (Ca )Extracellular0 - 2 mg/dLMagnesium (Mg )IntracellularT 8.5 – 10.5 mg/dLI 4.0 – 5.0 mg/dL1.5 – 2.5 mEq/LPhosphate (PH04 )Intracellular100 mEq/LChloride (Cl-)Extracellular2.5 – 4.5 mg/dL1.7 – 2.6 mEq/L96 – 109 mEq/LBicarbonate (HC03-)or Serum C02Extracellular22 – 26 mEq/L4 – 10 mEq/L200INTRACELLULARCONCENTRATION30 – 40 mEq/L1 – 4 mEq/L
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ECG Changes: Hypokalemia Depressed ST segments Flat or inverted T wave, Presence of U waves Dysrhythmias, ventricular Cardiac arrest Hyperkalemia Tall, peaked, tented T waves Flattened or absent P waves Widening QRS AsystoleHyperKalemia Treatment: Three-Part Therapy1. Cardiac Protect: 10ml of Calcium Chloride or Calcium Gluconateslow IV push. Renders the myocardium less excitable by decreasingthe effects of excess extracellular K .2. Shift K into the Cell: 1 amp Sodium Bicarbonate 5-10U Regular Insulin 50ml Bolus 50% Dextrose Albuterol 10 – 20mg inhalation or intravenous (beta2adrenergic agent – stimulates B2 receptor in the pancreas torelease more insulin).3. Removal of K : Loop Diuretic Sodium Polystyrene Sulfonate (Kayexalate) a cation exchangeresin given orally or by retention enema. Oral administration ismore effective. Each 1gm will lower the K 1mEq with orallyadministration, and 0.5mEq with rectal administration. Sorbitolprevents constipation. Dialysis can also be utilized to remove K from the body.203
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CalciumHypocalcemiaExcess LossInadequate IntakeDecreased IonizedGI/Bone AbsorptionAlkalosisHypercalcemiaExcess IntakeLoss from BonesMobilization from BonesAcidosisNeuro: Tingling ospasmCV:Dysrhythmias,Cardiac Arrest,Bruising,BleedingGI: IncPeristalsis, N/V/DMus/Sk:Osteoporosis Fractures, AbnDeposits of Ca inBody Tissues,Muscle Spasm,ECG ChangesHypo: STsegment, QT,Tetanytorsades de pointes, HRHyper: Short ST/QT, Heart Blocks205Neuro: DecReflexes, Lethargy Coma, SeizuresCV: DepressedActivity,Dysrhythmias,Cardiac ArrestGI: Dec GI TractMotility, N/V,ConstipationGU: KidneyStones, Flank PainMus/Sk: MuscleFatigue,Hypotonia, BonePain,Osteoporosis,Fractures
RENAL I. INTRODUCTION AACN-CCRN/CCRN-E 6% Chronic Renal Failure Acute Renal Failure Life Threatening Electrolyte Disturbances II. RENAL PHYSIOLOGY Major Functions of the Kidney 1. Excretion of Metabolic Was
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Anatomy of the kidney Figure 11.3 The anatomy of a human kidney. 11.2 Kidney Structure renal artery renal vein ureter a. Blood vessels renal cortex nephrons b. Angiogram of kidney renal cortex renal medulla renal pelvis c. Gross anaomy, photograph d. Gross anatomy, art renal pyramid in rena
The high stiffness of the optical bench readily transmits disturbances through the structure. To attenuate high frequency disturbances to the Earth-observing instruments, including reaction wheel disturbances, gimbal disturbances, and disturbances from the sun-pointed instruments, the . force and torque
1. Prerenal (75- 80%) 2. Intrinsic renal (10-15%) 3. Postrenal (5%) Persistence of insult can convert pre renal or post renal failure to intrinsic renal failure. However, there is an increasing awareness that even moderate decrease in renal function is important in the critically ill and contributes significantly to morbidity as well as mortality.
Protocol Electrolyte Protocol [X] Electrolyte Protocol [X] Electrolyte Replacement Protocol: Critical Care (ICU/PCU) RN to order specific medication needed based on lab result. If creatinine greater than 2 mg/dL and/or documentation of Renal Failure or Dialysis, contact ph
Fluid and Electrolytes & Renal Disorders Topics for the Day Fluids and Electrolytes: review of normal physiology * Fluid imbalances * Electrolyte Disturbances * Beginning acid -base imbalance * Renal Disorders Fluid Types * Electrolytes Solutes that form ions (electrical charge) Cation (
Renal Disease Dr CPhilip Masson Advanced Trainee, Renal Medicine Royal Prince Alfred Hospital, Sydney April 7th 2008 Overview Aetiology, pathophysiology, clinical signs and symptoms of acute (ARF), chronic (CRF) & end-stage renal failure (ESRF) Renal Replacement Therapy: CAPD, APD, Haemodialysis, Transplantation, o ns er v a ti M gm
Korean as a second language (L2). This study quantifies such correspondence at the syllable level by calculating the degree of correspondence in Korean-Chinese syllables. The degree of correspondence between Korean and Chinese syllables was examined. Results show that among the 406 Chinese character families in Sino-Korean words, 22.7% have an average correspondent consistency lower than 0.5 .
