renal patients

KatieMI, BSN, MSN, RN · Apr 6, 2015

- if patient has acute BUN elevation, the first question will be "what happened with him within last 12 -72 hours" and then proceed from there. As the most common reason for acute BUN elevation among patients with normal - moderately affected renal functions is either dehydration, drugs or their combination, the typical expected orders are hydration and meds reconciliation. Get him drinking. Start IV fluids, increase TF flushes. Call cardio and tell them politely that 80 mg of Lasix q6h may not be so splendid an idea. Call ID and ask if they could change gentamycin for something else.

If patient has known renal disease and suddenly turned worse, in addition to all things above we need to find out if he was compliant with treatment or if he suddenly started to eat too much protein. Dietary orders need to be checked; if patient is on tubefeeding of TPN, formulas should be reviewed. VSs monitoring should be advanced in frequency/quality, as overdose of HTN meds, some painkillers and development of infection are common reasons for acute decline of altered renal functions.

In either case, these patients should be on strict I/O count (with Foley, if needed) and labs must be checked regularly. Sometimes urine needs to be collected for special tests like 24 h/random lytes excretion, protein excretion, cell count.

- Patients with elevated BUN are literally poisoned from within as kidneys cannot excrete waste products of protein metabolism, excess of organic acids, etc. These products start to be excreted by alternative, and not effective, means such as sweat, mucus, through skin and mucus membranes, through breathing (CO2 as attempt to compensate metabolic acidodis). Because all this, these patients frequently feel nauseated, have no appetite and generally feel really bad.

I do not fully understand what do you mean by "decreased intake/output". Patients with renal failure, except for some special situations, most commonly have low urine output for obvoius reason of not having any kidneys to make it.

- I never saw anyone but dialysis RN flushing dualysis ports or even changing dressing on them. I heard that in critical circumstances such as code and absence of any other access dialysis ports can be flushed and used as any other central line port but it should obviously be an exclusion. Check your place policies before doing anything with dialysis cath.

calivianya, BSN, RN · Apr 6, 2015

KatieMI had a pretty good summary there.

I would be more worried about acutely elevated K+ levels than the rest of the toxins. Those are uncomfortable but the elevated K+ can cause fatal arrhythmias, so I see more treatment for the K+ level than anything else. The patient with a high K+ level may get emergently dialyzed or they may just have to drink a ton of kayexalate or have it as a retention enema. You may also give some IVP insulin and d50w because insulin drives potassium back into the cells but you don't want the IV insulin to tank the patient's blood sugar.

If BUN is elevated in a non-dialysis patient and the creatinine is not also elevated, I would suspect a GI bleed and take a real close look at whatever they are vomiting or pooping out. The GI tract digesting blood leads to re-absorbing the urea from said blood, raising the BUN. You would be looking for IV protonix/sandostatin drips to help with the GI bleed in that case.

If both are elevated, it may just be related to dehydration or low blood pressure. The kidneys are pretty finicky so when someone gets hypotensive from sepsis, as an example, they may go into acute renal failure even if they didn't have kidney problems to start with. In that case the physicians may play it conservatively and wait to see what the kidneys do. They may give some fluid boluses to try to stimulate the kidneys. If they are not making much pee on their own after a few days, diuretics will probably be ordered. If the kidneys don't respond to that, the patient may need dialysis either temporarily or permanently. It sucks when you see a patient walk into the hospital with healthy kidneys and walk out in end-stage renal failure.

I wouldn't use a dialysis port at all unless you've double-checked with the physician. They usually have a heparin dwell, so if you do have to use them, remove some blood and waste it before you hook anything up. You don't need to flush that heparin into the patient.

EmergencyRN22 · Apr 6, 2015

The others have answered everything quite well.

Ive only used the venous dialysis port during codes.

Any other times, big no no.

westieluv · Apr 6, 2015

I used to be a dialysis nurse. Normally, if a patient has no history of renal failure, the doctor will monitor the BUN and Creatinine and will not initiate dialysis unless the elevated level is sustained and there is no apparent medical reason for it other than acute renal failure brought on by another condition. However, as a pp pointed out, if the K+ is elevated or if a patient has extreme fluid overload that is compromising his cardiac function, they will initiate dialysis.

You should never access a dialysis port, even to draw labs. In every hospital that I performed dialysis in, they had very strict protocols governing this. The pp is also correct that there is either a heparin or a sodium citrate dwell in the catheter between treatments to prevent it from clotting off, and this needs to be removed per protocol by the dialysis nurse only.

schnookimz · Apr 6, 2015

Just throwing in, around here when I worked in acutes, no one locked with heparin anymore due to HIT. We just lock with .9

iluvivt, BSN, RN · Apr 8, 2015

HD Catheters are still locked with heparin...1000 units per ml to equal the priming volume. So if it has a volume of 1.9 ml it will be 1900 units of heparin in that lumen. It is a big deal to lose your HD line and it you must be able to get good flow rates so even a sluggish catheter will be problematic and must be kept patent and not positional or kinked and tip should be in RA .

Lennonninja, MSN, APRN, NP · Apr 8, 2015

Our dialysis catheters are locked with sodium citrate. Don't touch them, they're literally the patient's lifeline!