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Nephrology Nursing

American Nephrology Nurses Association

www.annanurse.org
This presentation is supported by an unrestricted educational grant provided by the Nurse Competence in Aging Initiative.

Stage 1 - Kidney Damage (Normal or GFR >90)

Action taken by Medical Personnel:
Diagnosis and Treatment Treat comorbid diseases Slow progression of disease through diet and medication

Stage 2 - Mild Kidney Damage (GFR <60-89)

Action taken by Medical Personnel:
Evaluate and treatment

Monitor progression of disease

Stage 3 - Moderate Kidney Damage (GFR <30-59)

Action taken by Medical Personnel:
Evaluate and treat complications Monitor progression of disease

Stage 4 - Severe Kidney Damage (GFR <15-29)

Action taken by Medical Personnel:
Prepare for Renal Replacement Therapies (RRT)

Stage 5 - Kidney Failure (GFR <15)

Action taken by Medical Personnel:
Begin RRT Hemodialysis, Peritoneal Dialysis, Transplant

Chronic Kidney Disease (CKD)

Chronic Kidney Disease (CKD) is a progressive loss of renal function. The etiology of CKD can be from a variety of diseases including but not limited to:

Diabetes Mellitus

Glomerularnephritis

Interstitial nephritis
Chronic pyelonephritis Hypertension

Vasculitis
Obstructive disorders Hereditary disease

Congenital disorders

Cystic disease

The Kidney
The kidneys weigh about 1/2 pound each.
They are located in the retroperitoneal space. They are about the size of an adult fist They are shaped like a kidney bean. They are attached to the blood stream through the renal arteries.

Nephrons

Nephrons are the microscopic functional unit of the kidney.

Functions of the Kidneys

Remove wastes
Remove excess fluid Secrete erythropoietin Regulate bone metabolism Regulate blood pressure Regulate acid-base balance Regulate electrolyte balance

What is Renal Failure?

Acute Renal Failure Chronic Renal Failure

Symptoms of Chronic Renal Failure (Uremia)

Loss of appetite Nausea/vomiting Headache Shortness of breath Itching Bone disease Anemia Proteinuria Weakness, insomnia Hypertension Edema

Symptoms of Chronic Renal Failure (Uremia)

Loss of appetite Nausea/vomiting Headache Shortness of breath Itching Bone disease Anemia Proteinuria Weakness, insomnia Hypertension Edema

Renal Replacement Therapy (RRT) (Used for Patients at Stage 5)

Hemodialysis Peritoneal Dialysis Transplantation No therapy

History of Dialysis
1913 Artificial kidney used in animals. 1935 Heparin purified. 1942 First patient treated with dialysis machine. 1950s Hemodialysis used to treat acute renal failure. 1960 External arteriovenous shunt developed by Drs. Scribner and Quinton. 1965 Internal arteriovenous fistula developed by Drs. Brescia and Cimino. 1972 Medicare ESRD Program established. 1989 - Recombinant human erythropoietin (Epogen) approved by the FDA.

History of Dialysis
1913 Artificial kidney used in animals. 1935 Heparin purified. 1942 First patient treated with dialysis machine. 1950s Hemodialysis used to treat acute renal failure. 1960 External arteriovenous shunt developed by Drs. Scribner and Quinton. 1965 Internal arteriovenous fistula developed by Drs. Brescia and Cimino. 1972 Medicare ESRD Program established. 1989 Recombinant human erythropoietin (Epogen) approved by the FDA.

Types of Hemodialysis Treatments

In Hospital
In-center Self-care Home Nocturnal

Some communities have dialysis center located in the hospital.

Most people on dialysis dialyze in a dialysis clinic. There are some facilities where patients without partners can do their own care in a clinic setting. Patients are trained along with a partner to dialyze at home. Nocturnal dialysis involves dialyzing 5 to 7 nights a week for 8 to 10 hours.

May or may not have partners

Basic Treatment
Hemodialysis removes solutes (waste particles) and fluid from the blood across a semipermeable membrane in a filter (dialyzer).

Components for Hemodialysis

Access to circulation: need to pull blood from, and return blood to the body, at a speed of 200-500 mL/ min
Dialyzer (artificial kidney) Dialysate (Bath) Dialysis machine Water treatment

Components for Hemodialysis

Access to circulation: need to pull blood from, and return blood to the body, at a speed of 200-500 mL/ min
Dialyzer (artificial kidney) Dialysate (Bath) Dialysis machine Water treatment

Components for Hemodialysis

Access to circulation: need to pull blood from, and return blood to the body, at a speed of 200-500 mL/ min
Dialyzer (artificial kidney) Dialysate (Bath) Dialysis machine Water treatment

Components for Hemodialysis

Access to circulation: need to pull blood from, and return blood to the body, at a speed of 200-500 mL/ min
Dialyzer (artificial kidney) Dialysate (Bath) Dialysis machine Water treatment

Components for Hemodialysis

Access to circulation: need to pull blood from, and return blood to the body, at a speed of 200-500 mL/min
Dialyzer (artificial kidney) Dialysate (Bath) Dialysis machine Water treatment

Caring for the Dialysis Patient includes:

RRT (Renal Replacement Therapy). Diet and fluid management.

Medication regimens.
Rehabilitation services. Community services.

Social support.

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Assessment of the CKD Patient

Assess fluid status
Restrict fluid intake Control dietary intake Properly administer medications Evaluate blood pressure Check access daily Watch for side effects

Potential Problems During Dialysis

Hypotension Nausea Cramping Headache

Potential Problems Between Treatments

Hypotension
Symptoms: Causes: Dizziness, sweaty/clammy, nausea, cramping. Removing too much fluid during dialysis. Co-morbid conditions. Patient may be taking B/P medications prior to dialysis. Take B/P medications after dialysis instead of prior to dialysis.

Prevention:

If the patient experiences nausea and vomiting, report this to the dialysis staff prior to dialysis treatment. Communicate with the dialysis staff if the patient goes to dialysis wearing a nitroglycerin patch.

Potential Problems Between Treatments

Hypotension
Symptoms: Causes: Dizziness, sweaty/clammy, nausea, cramping. Removing too much fluid during dialysis. Co-morbid conditions. Patient may be taking B/P medications prior to dialysis. Take B/P medications after dialysis instead of prior to dialysis.

Prevention:

If the patient experiences nausea and vomiting, report this to the dialysis staff prior to dialysis treatment. Communicate with the dialysis staff if the patient goes to dialysis wearing a nitroglycerin patch.

Potential Problems Between Treatments

Hypotension
Symptoms: Causes: Dizziness, sweaty/clammy, nausea, cramping. Removing too much fluid during dialysis. Co-morbid conditions. Patient may be taking B/P medications prior to dialysis. Take B/P medications after dialysis instead of prior to dialysis.

Prevention:

If the patient experiences nausea and vomiting, report this to the dialysis staff prior to dialysis treatment. Communicate with the dialysis staff if the patient goes to dialysis wearing a nitroglycerin patch.

Problems Between Treatments

Nausea
Causes: Can be due to B/P, medications, uremia, and electrolyte imbalance. Evaluate the B/P to determine if nausea is related to cardiovascular instability.

Potential Problems Between Treatments

Headaches

Leg cramps
Skin integrity

Potential Problems Between Treatments

Hypoglycemia
Symptoms: Causes: Treatment: Shaking, fast heart beat, weakness. Too little food or too much insulin. Test blood sugar.

Hyperglycemia
Symptoms: Causes: Extreme thirst, nausea, blurred vision. Too much concentrated sweets not enough insulin.

Treatment:

Insulin as ordered by MD.

Potential Problems Between Treatments

Hypoglycemia
Symptoms: Causes: Treatment: Shaking, fast heart beat, weakness. Too little food or too much insulin. Test blood sugar.

Hyperglycemia
Symptoms: Causes: Extreme thirst, nausea, blurred vision. Too much concentrated sweets not enough insulin.

Treatment:

Insulin as ordered by MD.

Potential Problems Between Treatments

Access Site Bleeding
Symptoms: Causes: Treatment: Excessive or prolonged bleeding at dialysis access site. Not rotating needle sites, too much heparin. Manual pressure for 10 to 20 minutes; hemostatic agents may be used; in extreme cases, send the patient to the emergency room.

Vascular Access Types

Internal
Fistula Graft PTFE Bovine Vectra

External
Catheter

Vascular Access Fistula

Check for bruit and thrill daily.

May remove band-aids next morning.

Vascular Access Graft PTFE

Bovine
Vectra

Vascular Access EXTERNAL Catheter

Keep dressing dry.

Call dialysis unit if end caps come off.

Notify unit if dressing has drainage.

Daily Checks of Vascular Access

Inspection of Access
Condition of skin over access
Redness

Palpation of Access
Thrill +/-

Heat
Drainage Swelling Tenderness

Auscultation of Access
Bruit +/ Quality/character

Post-Dialysis Care
Observe for bleeding from cannulation sites. Hold pressure if necessary. If not controlled, immediately notify the nephrologist and continue to hold pressure. Remove tape/bandage within 24hrs after dialysis.

Typical Medications
Vitamins Multivitamins without minerals or vitamin D Phosphate binders

Erythropoietin
Iron Vitamin D Antihypertensives

Typical Medications
Vitamins Multivitamins without minerals or vitamin D Phosphate binders

Erythropoietin
Iron Vitamin D Antihypertensives

Nutrition
Nutrition plays a critical role in the management of the CKD patient. The diet will vary depending on the type of disease, the CKD stage, and the type of treatment chosen.

Dietary Considerations
PROTEIN POTASSIUM 1.0-1.2g/kg/day 50% high biologic value 40-70 mEq (1500-2500mg)/day

SODIUM
CALORIES FLUIDS

750-1000 mg/day

PHOSPHORUS 600-1200 mg/day >35 kcal/kg/day 1 to 1.5 liters/day plus urine output

Dietary Considerations
PROTEIN POTASSIUM 1.0-1.2g/kg/day 50% high biologic value 40-70 mEq (1500-2500mg)/day

SODIUM
CALORIES FLUIDS

750-1000 mg/day

PHOSPHORUS 600-1200 mg/day >35 kcal/kg/day 1 to 1.5 liters/day plus urine output

Social Services
Social services are provided to patients and their families and are directed at supporting and maximizing the social functioning and adjustment of the patient.

Stressors Associated with Dialysis

Actual or threatened loss Distortion of body image Dependency on machines and medical team Fear of death vs. fear of living Patient self-concept

Capacity to control
Helplessness

Communication Between Dialysis Center and LTC Transportation

Family Issues
Financial Concerns

End-of-Life Issues
Assess patient for support systems, emotional status, and perceived quality of life.

Communication
Treatment Communication Long-Term Care Plan Short-Term Care Plan

Coordination of Laboratory Requirements

CKD patients who receive dialysis incenter will usually have monthly lab work drawn at the dialysis center. Some tests, such as H/H and calcium, may be drawn weekly.

Lab Draw Sites

Specific lab draw sites are chosen for the CKD patient. The dialysis staff draws the lab specimen from the blood lines during treatment. For non-dialysis staff: DO NOT perform venipucture from the arm that has the fistula or graft.

Chemistry Values Normal for CKD

Test
Bun Creatinine Sodium Potassium 21 mg/dL 2.5 mg/dL 115 meq/L 3.5meg/L

Low

High
101 mg/dL 14.2 mg/dL 160mg/dL 5.5 mEq/L

Calcium
Phosphorus Glucose Albumin Hemoglobin Hematocrit

9mg/dL
4.5 mg/dL 70 mg/dL 3.5 mg/dL 11g/dL 33%

11 mg/dL
5.5 mEq/L 110 mg 5.0 mg/dL 13 g/dL 39% (if anemic)

Hepatitis Status
Residual Renal Function

Negative for HbSAG

May have some, and amount would be collected and calculated into the urine creatinine clearance equation.

Positive for HbSAB

Chemistry Values Normal for CKD

Test
Bun Creatinine Sodium Potassium 21 mg/dL 2.5 mg/dL 115 meq/L 3.5meg/L

Low

High
101 mg/dL 14.2 mg/dL 160mg/dL 5.5 mEq/L

Calcium
Phosphorus Glucose Albumin Hemoglobin Hematocrit

9mg/dL
4.5 mg/dL 70 mg/dL 3.5 mg/dL 11g/dL 33%

11 mg/dL
5.5 mEq/L 110 mg 5.0 mg/dL 13 g/dL 39% (if anemic)

Hepatitis Status
Residual Renal Function

Negative for HbSAG

May have some, and amount would be collected and calculated into the urine creatinine clearance equation.

Positive for HbSAB

Chemistry Values Normal for CKD

Test
Bun Creatinine Sodium Potassium 21 mg/dL 2.5 mg/dL 115 meq/L 3.5meg/L

Low

High
101 mg/dL 14.2 mg/dL 160mg/dL 5.5 mEq/L

Calcium
Phosphorus Glucose Albumin Hemoglobin Hematocrit

9mg/dL
4.5 mg/dL 70 mg/dL 3.5 mg/dL 11g/dL 33%

11 mg/dL
5.5 mEq/L 110 mg 5.0 mg/dL 13 g/dL 39% (if anemic)

Hepatitis Status
Residual Renal Function

Negative for HbSAG

May have some, and amount would be collected and calculated into the urine creatinine clearance equation.

Positive for HbSAB

Chemistry Values Normal for CKD

Test
Bun Creatinine Sodium Potassium 21 mg/dL 2.5 mg/dL 115 meq/L 3.5meg/L

Low

High
101 mg/dL 14.2 mg/dL 160mg/dL 5.5 mEq/L

Calcium
Phosphorus Glucose Albumin Hemoglobin Hematocrit

9mg/dL
4.5 mg/dL 70 mg/dL 3.5 mg/dL 11g/dL 33%

11 mg/dL
5.5 mEq/L 110 mg 5.0 mg/dL 13 g/dL 39% (if anemic)

Hepatitis Status
Residual Renal Function

Negative for HbSAG

May have some, and amount would be collected and calculated into the urine creatinine clearance equation.

Positive for HbSAB

References
Gutch,C.F., et al. (1999). Hemodialysis for nurses and dialysis personnel (6th ed.). St. Louis, MO: Mosby, Inc. McCann, L. (1997). Pocket guide to nutrition assessment of the renal patient (2nd ed.) (pp. 9-15). New York: The National Kidney Foundation on Renal Nutrition. National Kidney Foundation. (2003). Kidney disease outcome quality initiative. USRDS. (2001).

U.S. Renal Data System. (2003). USRDS 2003 annual data report: Atlas of end-stage renal disease in the United States. Bethesda, MD: The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
Youngerman-Cole, S. (2003). End-stage renal disease. Boise, ID: Healthwise, Inc. Retrieved September 9, 2003, from http://yalenewhavenhealth.org/library/healthguide/en-us/ support/topic.asp?hwid=aa106246

Glossary
Artificial Kidney (Dialyzer) A device that allows for purification of the blood. During the dialysis treatment, blood and dialysate flow through the dialyzer separated by a semipermeable membrane. The pores in the membrane allow the removal of waste products and excess fluid. Dialysate (Bath) Fluid consisting of treated water, electrolytes, and buffers that can be mixed to the individual patient needs. It passes through the dialyzer to remove waste products and excess water. Diffusion The movement of a substance from an area of high concentration to an area of low concentration. Diffusion is the main transport principle for solute (waste products) in hemodialysis Dry weight The weight a patient is estimated to have with normal blood pressure and no fluid retention. Fistula A surgically created connection between a patients own artery and vein. Graft An implant connecting an artery and a vein. Heparin A drug used in the dialysis treatment to prevent clotting of blood in the dialyzer.

Waste Products Substances formed from the breakdown of proteins, nutrients, etc (urea, creatinine).