Chronic Renal Failure

hi and welcome to the nurse station my name is Maria Mowgli and today we are going to learn about chronic kidney disease as always these videos are for educational purposes only I really hope they're helping you want something you really need to understand about chronic kidney disease first off there's multiple stages it can lead all the way to end stage renal failure or end stage kidney disease we are not physicians we don't diagnose I need you all as future nurses and as nurses that can critically think and catch things early at the bedside to understand this about chronic kidney disease there are so many systems that when the kidneys fail in terms of your body that can be affected your heart tear your lungs to your muscle skeletal though there's risk of fractures when you have chronic kidney disease however mind you all these symptoms might not present in every single client so for these anglich style questions you need to focus on what priority assessment data is given to me and therefore I will act on that problem don't go try to find another problem you act on right here right now problems alright so I'm gonna list everything when I'm sure I miss something in here but a lot of things that can happen to the body related to chronic kidney disease we're really going to talk about if these symptoms present this is your priority action as a nurse and it's also important to understand this because when you take care of chronic kidney disease clients which you will you need to make sure that you can also catch things early in order to intervene and help them have optimal outcomes okay so chronic kidney disease is a GFR glomerular I had a practice that VTS filtration rate less than or equal to 60 MLS per minute for 3 months or longer and of course remember this is what it acts as the filter so our kidneys need that filter in order to excrete the toxins that we went out of our body excrete fluid that we want body we mean the glare list to work so as this number gets less and less and less sixty a miles per minute is not normal that is less than what is normal so when you start seeing a decline let's say they have a GFR of 15 miles per minute it is filtering less everything toxins fluids electrolytes per minute that we need it to so this is your primary definition of course remember there are stages and it can progress all the way to end stage renal disease your causes we already talked about acute kidney injury I have a video on that if you have not been able to watch that yet of course acute kidney injury can absolutely lead to chronic kidney disease diabetes and hypertension you're gonna think any organ that is perfused by vessels which is every organ right we have these vessels that profuse the kidney diabetes glucose starts to get buildup isn't that gonna decrease the amount of oxygen that can get to our kidneys there's there's my Picasso but anything can build up in our vessels in our arteries we need oxygen to perfuse our organs so diabetic clients can have a lot of glucose that start to build up in the lumens of the arteries that are perfusing the kidneys or a hypertension you know your your vessels are vasoconstrictive therefore also not allowing as much oxygen of blood to flow to our kidneys and then infection I'm sure when your teacher talks about kidneys or renal and urinary typically go together you're gonna talk about things like pyelonephritis any infection in the kidney can cause acute kidney injury as well as chronic any dysfunction or disease so those are some primary causes for chronic kidney disease and the assessment of this disease is minimal at first you might not see any assessment data showing you that there's a problem there you're an output could even be normal you need to start to think about any change you need to catch problems early because this is a progressive disease so what we need to start looking for is is that you're infected the organ that filters water electrolytes and toxins how is that starting to present in that clients body what symptoms are starting to occur because of the lack of the ability to filter these things so again it can be asymptomatic at first and then you can start having changes to your an output remember in a healthy adult client we need 30 ml of urine per hour think guys this one little medicine cup of urine per hour to state that hey there at least filtered enough urine for this kidney to be functioning once you get less than that a Liguria by definition is scant amount of urine all the way to an urea which means no urine output are very very minimal you're an output this is the one time with these clients chronic kidney did cry me chronic kidney disease that we might not be calling the physician for urine output less than 30 miles per hour because remember we always gear you in the NCLEX perfect world manifestation verse complication well if our organ that's supposed to produce urine right is not working won't they result won't a manifestation of that be decreased urine output so a lot of times in clinical practice when chronic kidney disease clients get to the point where they're not producing urine that's not something we're calling the physician about that is something that is expected with this disease especially if they're already to the point of dialysis and other treatment options that we're going to talk about so when we start to see the changes in urine you need to think about what does the kidneys do they have the ability to excrete fluid so when our kidneys fail you need to look for signs and symptoms of fluid volume overload they have the ability to excrete and maintain electrolyte and acid-base imbalances don't forget that your kidneys are a coping mechanism to maintain your pH in a normal range we want the pH of our blood to be 7.35 to 7.45 right from my acid-base imbalance videos your kidneys have the ability to excrete acids such as hydrogen ion if we're in an acidic state your kidneys have the ability to regenerate bicarb to regenerate your base if you're in acidic state so your kidneys have so many ways that it can cope if we're having acid-base imbalances so therefore if the kidneys aren't working don't you need to start looking for acid-base problems and then toxins build up your kidneys are the primary filter in your body of the excretion of toxins so when toxins start to build up in the blood it can result in so many different things we're gonna talk about uremia when your rhenium builds up in the blood it's a toxin it can result in change in behaviors when all these electrolytes build up in the blood it can result in arrhythmias or they can have a risk of seizure so make sure that you're looking at the assessment data for your client cuz I'm going to go through a lot of body systems however every client is not going to present with every single symptom every time so it's important for you on these and click style questions what assessment data is being given to me and I'm gonna find that priority problem and then I'm gonna act on that priority problem okay so let's start with respiratory if your kidneys are not functioning absolutely fluid could start to build up in the body they can start to go into fluid volume overload so if you are retaining more fluids shortness of breath can occur crackles when you auscultate in here crackles fluid is now on the lungs we don't want fluid on the lungs to kitni an elevated respiratory rate coos mom's respirations if the blood is now becoming a right so let's say that they're now going into metabolic acidosis you're going to you can see coos moms to try to get rid of carbon dioxide which is the acid to try to help that problem so these are all potential symptoms that can occur however really think about how you could act on it okay you hear crackles in the lungs we need to get that fluid off your medication choices diuretics if they're short of breath but they're Oh too satisfying you can't give them oxygen but you could if the shortness of breath is occurring with activity slow activity or paced activity right if they're having cruise miles we've really need to be looking at that acid-base imbalances we need to be checking our ABG's to see there are medications we can give to help with for instance the acidic state that's very typical for chronic kidney disease cardiac we already talked about the ability for fluids who absolutely be retained in the body chronic kidney disease clients can have high blood pressure they can have edema from that fluid that is not being excreted from the kidneys they can have risk of heart failure so you start the kidneys now are not excreting water effectively it's going to start to build up in the circulatory system so they can have all those symptoms of edema and now it's starting to back up and our heart can't pump effectively so therefore they can absolutely go into heart failure and all the symptoms that you learn about with heart failure can't present with chronic kidney disease clients if they go into that disorder EKG changes your kidneys excrete water absolutely they also excrete electrolytes your potassium majority of your potassium in your body is excreted through your kidneys I think it's about 80% 80% is excreted through the kidneys and then 20% is excreted through the stool so now the the organ that excretes majority of the potassium out your body is not working well that potassium is gonna start to build up and you all remember hyperkalemia or really low potassium as well can result in arrhythmias so we really need to be checking these clients heart rhythms they are building up potassium in their blood they absolutely are at risk for arrhythmia so we would place them on EKGs we would monitor their electrolytes to ensure that they don't go into arrhythmia because they do we'd have to treat it very quickly neurologically this is the organ that excretes toxins from our body and now it is not coping effectively it can't excrete effectively so therefore toxins will start to build up in the blood think about any disorder you've heard about where toxins build up in the blood liver I'll give you an example liver cirrhosis primary example you start to have for instance ammonia buildup that can absolutely result in a change in behavior it can lead to life-threatening problems well your kidneys are not filtering so we can have a change in behavior they can get fatigued they can have lethargy they have a risk of seizures so when you think about any of those things this all falls into safety you need to keep the client safe with any change in behavior risk of seizures are very different from active seizures risk of seizures is safety because they haven't seized yet so you need to think with any risk of seizures or let's say risk of arrhythmia development your priority is to keep them safe we can place them on seizure precautions they can be on medications around the clock to assist to prevent seizures then you have hematological in skin your kidneys create in healthy bone marrow form red blood cells through a wreath ropo in the hormone that is needed for red blood cell formation so now the organ that is in charge of that hormone is not working effectively so we really have to look for I believe you need to look for ecchymosis you need to look for anemia you need to be looking at their their CBC their complete blood count to see if they're starting to show signs of anemia or let's say their hemoglobin hematocrit levels are going low their platelet counts are going low we need to catch all those signs early to try to assist them from actively to try to prevent that this skin we talked about the toxins building up in the body urea which is the byproduct of protein metabolism and other things being metabolized needs to be excreted from the body right so it's a toxin if it builds up in the blood when you start to have that build-up it can absolutely cause skin irritation and dryness it can start to form at very late stages is called uremic frost which looks like little crystals or particles on the skin well chronic renal chronic kidney disease clients can absolutely have a problem with dryness and irritation of the skin a lot of scratching and itchiness can occur so they can be placed on medications to reduce that inflammation and to reduce the itching so look for those signs of bleed look for the changes in skin and then musculoskeletal we're about to talk about electrolytes in one second how our labs will look for our client with chronic kidney disease and one of the electrolytes that affected is calcium so when the kidney fails they cannot excrete potassium we've already talked about clients get hyperkalemic it can't excrete phosphorus clients become hyper phosphate emic well you gotta remember phosphorous and calcium are inverses of one another so if a client and chronic kidney disease has high phosphorus the inverse would be that they have low calcium and remember we want calcium to be in our bones calcium helps to create strong bones it helps prevent and reduce the risk of so when they have hypocalcemia they absolutely are at risk of fractures they're at risk of risk of weak bones so again we'd have to protect the clients from fractures so there's a lot of potential symptoms that can develop and occur with chronic kidney disease it is your priority to look at these symptoms and think about which one will kill them first so I'll give you an example you have a client who has I'm gonna underline a couple things so we can see how we're critically thinking you don't fly it with shortness of breath you have a client with crackles and let's say you have a client with lethargy so let's label these according to Maslow's shortness of breath is that right here right now breathing or risk of breathing and if you say right here right now breathing you're correct but I'm gonna ask you do you know there Oh to staff they can be short of breath and they're oh geez that could be just fine so can we necessarily act on this by giving them oxygen no you cannot give a client oxygen without knowing their Oh to set they can be sure to breath and be in there Oh to set be just fine I'll give you an example as COPD or chronic obstructive pulmonary disease they're short of breath especially with activity but when you check that pulse ox it could be just fine okay so shortness of breath the only thing you can do is maybe stop activity if it is associated with activity you could raise the head at the bed if they had a bed is flat but you cannot give this client oh - yeah let's think about crackles can you act on crackles crackles now means there is fluid in the lungs and remember in these NCLEX style questions if you have an answer choice to give a medication it is assumed you already have the physician order to do so well we have crackles in our lungs fluid that should not be in our respiratory system can you act absolutely you need to diurese them right here right now or you need to do a fluid restriction you need to do something that will help reduce fluid in the body to help prevent and get rid of that fluid especially from a place that's not supposed to be your lungs so you can absolutely act on crackles right here right now between shortness of breath and crackles crackles is your priority all right and let's add lethargy in it lethargy is a change in behavior they're very tired very fatigued right with that change in behavior ever trunk fluid that is right here right now in our lungs it would not you would keep these clients safe but between this the this assessment data the one you should have acted on the one that would be your priority are the crackles okay so that's just a little critical thinking and get together with friends you study with pick out assessment data and see which one could you act on right here right now or which one do you have to gather more data for because in chronic kidney disease you fix right here right now problems first according to Maslow's so between diaries and the crapples in the client die recent the client that has crackles in the lungs Barris is trying to find a pulse ox for the client was short of breath do you understand you're trying to find a low - problem but you have a right here right now fluid on the lung problem this is the one you need to fix first that's critical thinking that's Maslow's okay so really look at the system assessment data that the chronic kidney disease client is presenting find the priority of one and that's what you should act on in these NCLEX style questions so now let's talk about our labs of course we have kidney dysfunction so the labs that should always pop to mind for you are b1 and creatinine you will have elevated B you incretin levels with kidney dysfunction look for a 30 Mia or look for the toxin build up in the blood right there urea because we need to monitor for the change in behavior we need to monitor for other associated problems that relate to toxin buildup the blood decrease globular filtration rate you already know that because that meets the criteria or the definition for chronic kidney disease we already talked about anemia because your kidneys excrete every throw eaten so they can have low hemoglobin low hematocrit levels and a lot of changes in electrolytes so remember kidneys of the primary source to excrete potassium from your body and now is not working effectively hyperkalemia potassium starts to build up in the blood hypermagnesemia again magnesium starts to build up in blood because the kidneys aren't excreting magnesium effectively as well along with hyper phosphate emia so your three elevated electrolyte levels high potassium high magnesium high phosphorus and remember phosphorus and calcium are inverse so therefore that's why you have hypocalcemia so really really remember these electrolyte levels because a lot of our treatment that we're going to talk about on the next side of the board is related to these the the symptoms that develop and the labs that present for clients with chronic kidney disease okay I did not put sodium on here sodium could be normal sodium could absolutely be normal sodium could be showing signs of fluid volume overload but just because of the body's ability or inability to excrete fluid effectively a lot of chronic kidney disease clients you see on a low sodium diet because of that fluid volume overload that may present so sodium I did not put on here and typically it can be normal if they are holding on to weight to way too much fluid it could be diluted so it just depends on the symptoms of clients with and an acid-base imbalances your priority acid-based disorder you need to look for is metabolic acidosis this is not a breathing problem we are not going to talk about respiratory anything you can have qu smalls respirations which is a coping mechanism by the body but when you think the kidneys you are thinking a metabolic problem and the metabolic problem you're going to think about is the inability of the kidneys to excrete acid effectively so remember toxins build up in the body with kidney failure well now you're going to think acid is gonna build up as well so they are at risk of metabolic acidosis so the pH would be low would be less than seven point three five and your bicarbonate levels would be low as well they'd have low base you need a monitor for infection for these clients so look at their white blood cell count look for fevers look for any signs and symptoms of infection because of course they're compromised and we already talked about fixing right here right now problems first let's do another one how about let's say gee ugly risk of seizures and to keep Mia three problems alright this will help assist with critical thinking so let's label them to kitten yet is elevated respiratory rate but again I ask you can you prove what they're Oh to set is can you prove the oxygen and their body you can't to keep me on you can't even put oxygen on them yet the first thing you would have to do is assess their pulse ox so we're not going to be able to act on that right here right now risk of seizures again risk of seizures means they have the potential disease but they're not seizing right here right now so your topic for risk of seizures is safety and then you have GI bleed which is a right here right now circulatory problem you should pick sir halation over safety every time so between these three problems your priority is GI bleed you need to start intervening for bleed you can give them fluids you can give them blood products you can give them other medications to assist to reduce bleed or to replace volume okay so look for all those things but again I really watch out a harp on finding the right here right now problem that will kill them first according in Maslow's and that's the answer choice you need to cure yourself towards so let's talk about treatment options a lot of treatment options for a client with chronic kidney disease first things first you have to treat the trigger if there is one for instance if pyelonephritis infection of which is a kidney infection if that is the trigger that caused chronic kidney disease you need to treat it you need to give them antibiotics let's say it was acute kidney injury related to your related to a urinary obstruction let's say they had a stone in there your reader well you need to ensure to get that stone out or to allow for them to excrete that you're in one way or another so always treat your trigger if there is one and then your nursing interventions and evaluation so now we're going to go back through each system we're going to talk about what we can do for the problems that we mentioned in our assessment data and then also we need to think about how do we evaluate once we intervene on those problems to see if those problems got better okay so starting with your respiratory system oxygen as needed of course if you ever see a local sex level you ever see a low po2 low arterial oxygen your priorities to give oxygen positioning as needed that shortness of breath let's say they were short of breath while laying flat in bed because they have too much fluid on them you need to sit the head of the bed up and then respiratory support as needed y'all need a as always certain diseases in any disease can cause the client to decompensate it might get to the point and stage renal failure that they no longer can breathe effectively on their own they might need to have an endo tape endotracheal tube placed in ET tube and we might need to get mechanically ventilate them for them we might need to breathe for them so respiratory support as needed and just look for that assessment data in your anklet style questions if they get to the point where they no longer can breathe on their own we will assist them to do so okay cardiac EKG monitoring we need to look for arrhythmias we talked about potassium potassium absolutely can cause arrhythmia hyperkalemic can cause arrhythmia but don't forget all the electrolytes that help stimulate and maintain an electrical impulse in the heart potassium magnesium calcium and sodium all help to allow for that electrical impulse to be conducted effectively so yes look for hyperkalemia place the EKG monitor on the clients to ensure they're that they're not an arrhythmia and if the arrhythmia develops you will have to treat that arrhythmia dependent on what type of Ernie it is so EKG monitoring controlling a blood pressure their blood pressure can be so high because the kidneys are not excreting fluid in toxins appropriately so kidney clients with kidney failure can be on antihypertensives they can be on beta blockers calcium channel blockers they can be on ACE inhibitors or they can be on a lot of medications to help reduce blood pressure controlling a fluid volume overload or maintaining fluid volume overload so whenever you think about a client that is holding on to way too much fluid edema jugular vein distension crackles auscultate in the lungs you mean to get that fluid off of them as quickly as you can while maintaining their stability so fluid volume overload can result in diuretic administration you can see furosemide and your lasix given they can be placed on sodium and fluid restrictions so they could be on a sodium and fluid restricted diet if they're having signs and symptoms of fluid volume of flu and then monitoring vital signs monitor and iron OS monitoring and daily weights and heart and lung sounds in order to catch these problems you've had to of assess their respiratory and cardiac status blood pressure you need to be monitoring their vital signs on a routine basis daily weights we need to see are they gaining too much weight on a daily basis then we need a report weight appropriately majority of your resources they report a weight gain of two to three pounds in one day or five pounds in one week so that is how we would monitor if we're giving a diuretic if we're giving us an ID we want to see that they're losing weight on a daily basis because that means they're actually effectively getting rid of fluid if you give a diuretic you mean you want to ask will take long sounds because if you hear it crackles how you know directives working is not by the urine output diuretics increase urinary output we want to know whatever the problem was we hear crackles you administer furosemide we want to ask we'll take clear lung sounds that's showing effectiveness that's evaluating that our treatments working so all these things right here is just a way to assess and evaluate is our treatment working neurologically you need to keep them safe they have a change in behavior you need to ensure that they're not trying to get out of bed by themselves it might even get to the point that they need a sitter at the bedside if they're at risk for seizures you might need a place someone sees your precautions padding the side rails having sections set up at the bedside so when you think no logical change or risk of seizures you need to keep them safe hematological we had you talked about how we need a monitor for bleed GI bleed can absolutely occur with kidney failure think about your anemia that can occur so monitor their CBC hemoccult stools to look for that GI eppley in alpha we can administer the hormone we can give iron replacements we can give blood products as needed if anemia or bleed is a concern for our clients skin avoid irritants avoid scratching at the skin anti critics can be administered to help calm the itchiness to help calm the inflammation that can occur especially related to that urea that's built up risk of infection monitor fresh signs and symptoms of infection and of course as we would do with any client we need to maintain a sepsis with with procedures we need to make sure that any invasive procedure that's done for instance a client is could be a candidate for dialysis well access Mac's essing the fistula or the perm cath or making sure that everything is being maintained in a sterile fashion even the dressing for a perm cath when we talk about hemodialysis and peritoneal dialysis in another video needs to be maintained in a sterile fashion so really maintain an aseptic with invasive procedures monitoring for the scientific ssin and all your labs we have so many medications we can give for abnormal electrolyte imbalances so we're going to start with potassium high potassium of course we'd monitor their heart rhythm but let's think about the medications that can help reduce potassium in the blood sodium Palestine aka kayexalate helps bind to potassium so it can be excreted from the body luke diuretics of course furosemide is a gold standard for excreting potassium along with other electrolytes from the body IV regular insulin when you give insulin and this is IV insulin IB regular insulin it to a client and helps to push potassium from the blood so here's where I'm contacting my blood back into the cell okay but remember especially if they're a non diabetic client if we're given IV regular insulin of course would always monitor blood sugar checks blood glucose checks to make sure that we're not causing hypoglycemia but you might need to be given dextrose along with this to ensure that we don't make them bottom out in terms of their glucose so we can give IV regular insulin we can give calcium gluconate to help prevent arrhythmia formation in terms of increased magnesium our gold standard is luke diuretics again if roast mite is a great thing to help reduce potassium and magnesium in the blood increase phosphorus you need to think phosphate binders medications that will bind to phosphorus and excrete it or because phosphorus and calcium are inverse of one another if we have high phosphorus and low calcium we start to administer calcium and calcium starts to increase if they are inverse of one another what's going to start to happen this will start to decrease so all these medications are either phosphate binders your self Amir of course is the phosphate binder and also we have the ability to give calcium because it's inverse to help bring down those phosphorus levels for low calcium you of course would do calcium and vitamin D supplementation you would protect them from fractures you would increase activity especially weight-bearing activity to try to help push the calcium that we have back into the bone and permit fracture so with low calcium you'd give calcium and vitamin D supplementation and then low pH if we are in an acidic state typically when you address the trigger it helps resolve pH balances but we have the ability to give sodium bicarbonate which is the base when we are in an ecstatic state to try to help improve acidosis and then your diet we need to think low protein diet your body's organ that helps filter toxins is not working effectively and a lot of toxins are from the byproduct of protein metabolism okay so we need to have a low protein diet just because the components that protein breaks down into may not be able to be filtered from the body effectively and then built up as toxins and then you also have to think about what electrolytes are being presented at this time if they are hyperkalemic they need to be on a low potassium diet if they're in fluid volume overload they need to be on a sodium restricted fluid restricted diet so also think about what other assessment data is being presented and then of course last but not least dialysis is absolutely a potential option for clients and chronic kidney disease it depends on the GFR it depends how how much the disease is progressing but douses is a potential option for these clients along with kidney transplant so be on the lookout for analysis video that differentiates hemodialysis along with peritoneal dialysis but I think the big takeaway from this video is you can see how many different symptoms can present with chronic kidney disease clients but it is your job as a nurse to catch them early and also intervene on the priorities so please remember and ingest this knowledge but also think about how you're going to best break down those and click style questions so I hope this helped we are better together nurses so help someone else and good luck on those tests take care

Channel: Maria Mobley, MSN, BSN, RN

Views: 3,496

Rating: 4.9574466 out of 5

Keywords: ESRD, Renal Failure, Chronic renal failure, dialysis, hemodialysis, AKI, NCLEX prep, nurse nclex prep

Id: Be3HFT35oKM

Length: 34min 8sec (2048 seconds)

Published: Wed Jun 05 2019