Transcript for:
Nursing Care and Management for Kidney Transplant Patients

for hello everyone welcome back to our enlex RN review and for those who just joined us we are on the third day of the 90day free enx review classes in this YouTube channel and we will be doing this daily at 12:00 p.m. Eastern Standard Time and so we'll be covering old nursing subjects and rationalization of 2000 anle style questions and today I'll talk about the nursing care and management for a patient with kidney transplant and we'll have some Q&A about the Aki and chronic kidney disease so to get started here we'll talk about the first topic actually the only topic for today which is the kidney transplant and also the care and nursing management and so this is a procedure that involves surgical implantation of a healthy kidney from either a living or a diseased donor into an individual whose kidneys have stopped functioning correctly so basically we're talking of about person that has the endstage renal disease so if the patient does not have living donor they might be added to a waiting list for a kidney maybe from a diseased donor and so the weight time for the diseased donor kidney can vary based on how well you're going to match with the donor and so the length of time that the patient has been on dialysis and the weight list and also the predicted survival after the transplant will be considered and so some of those fortunate individuals can find a match in a few months while others may have to wait several years so that's the reality in the present time now for the kidney transplant there are some preliminary steps preparations in order for this procedure can be started and so the recipient tissues actually will need to be compatible with the donors and the kidney donors can be alive or could be nonheartbeating or could be a disease donor and so there will be some uh compatibility testing it could be the evaluation of the blood type between the donor and their recipient and also hsto compatibility where and it will cover uh human Lucy antigen and also minor antigens and so this is going to determine the successful likelihood of the transplantation without any rejection and so it's going to really match the specific antigens particularly the HLA and this is to minimize the immune response and to ensure that the transplanted tissue or organ is accepted by the recipient's body now for those who are receiving a kidney from a living or let's say a related donor with compatible tissues they are the most uh with the highest likelihood of a transplant success now if the kidney from a disease or let's say a heartbeating donor they must be adequately profused to ensure that the organ is viable during the procedure and the donated kidney is going to be surgically placed in the recipient now at this point we're going to have to talk about the requirements on the kidney transplantation and so the recipient must qualify according to the criteria here and so this is just uh this is not the list really about what's going to disqualify them but these are uh some of the requirements that could qualify them into getting a donor now now one of those is the advanced renal failure uh that maybe you're requiring them to have a dialysis it could be peronal it could be hemo dialysis or as a case with let's say having a endstage renal disease okay or maybe a projected lifespan of at least 5 years so they can qualify if they have that Criterion and also complete uh comprehension of posts surgery instructions in care because they need to be proactive by themselves on actually how to take care of their own a new kidney as well and um to get started here there are also many risk here that you see there's a whole lot of list that will also going to pose a risk to possibly um maybe this would really disqualify them because these are certain conditions that can increase their risk of maybe rejecting the uh kidney and so they have to deal with a whole lot of things especially the surgical procedure itself is already stressful and it is expected that they're going to have to go through a lifelong immunosuppression they have to take lots of those uh immunosuppressive medications and those medications can be toxic to the body as well and so they need to be tested with the drug levels and so this is going to be a bit more stressful um after they get the kidney and also the stress or the risk of having the organ rejection as well now as you see here uh age below 2 years well we're probably going to disregard that right now since we're talking men surge but I'll just include that because for those infants that may need organ transplantation uh they are known to have fragile immune systems and this would really make them very difficult to handle the the complexities of the surgery and also the necessary immune suppression that they need to take at the young age now it's really going to make them very vulnerable to developing so many complications now for those patients that are above 70 years old they are known to developing so many uh Advanced heart disease or maybe some malignant es and um this is really going to increase their risk for developing the complications with the kidney transplant and also they're going to have other health issues um could be cancer or a pre-existing comorbidity that would really put an extra risk to the surgery and will slow down their recovery and so they also need to manage the immunosuppressant medications which they really need to to uh adhere because if they're going to miss taking those immunosuppressant uh medications maybe more than a day or so they can really uh encounter some major problems now another thing is the advanced and treatable cardiac disease that's another issue because if someone has a major cardiac problem the stress of the surgery itself and the effects of the immunosuppressant can be too to much for their heart to handle and this is going to end up with a whole lot of complications as well now also with uh substance dependency or let's say yes substance dependency could be uh it could pertain to the chemical dependency as well and so for those people with this kind of substance abuse they might struggle with sticking to their medication schedule and I'm referring to the immunosuppressant and possibly not able to adhere to the follow-up care that they're supposed to go and this is something that would be really crucial in order for them to avoid any kind of organ rejection and to manage their immun suppression effectively now there's also chronic infections or let's say systemic diseases like HIV Hepatitis B or C um these conditions are actually going to weaken the person's immune system and so balancing the need to prevent the organ rejection with the risk of infections become really challenging for this people because they already have a pre-existing immune uh suppression in the immune system plus the suppression of the immune system that will be caused by the medication then this will really cause a whole lot of major issues for them now another thing is the blood clotting disorders or maybe there is such thing as coagul es or let's say problems in the immune system and so if they have that kind of issue they're at higher risk of bleeding during the surgical procedure and with those certain immune disorders this can also complicate the management uh with the use of the immunosuppressant drug now here we go we have severe or morbid obesity so this is going to bring the patient into higher surgical r risk uh possibly maybe related to infections because of poor wound healing as well and this is going to be much more challenging especially when they're going to be taking the immunosuppressive medications now another here highlighted is diabetes militus and this can make the wound healing slower and I'm not talking just about The Superficial incision that is involved actually it's the wound healing the grass um inside with a newly implanted kidney and it has to be attached to those blood vessels from the body and if there is such wound slow wound healing then it can be at risk to developing some kind of infections and other complications and it would be very difficult for them to control their blood sugars especially that drugs um could be involved like corticosteroids because corticosteroids would be one of those immunosuppressive medications that will be prescribed to them now another thing would be the chronic lung disease um because uh these problems can also lead them to develop breathing issues during and also after the surgery and this will make their recovery much harder and this will increase their risk of developing more complications now another thing is the untreated gastrointestinal diseases so uh I'm referring here to the peptic ulcer disease or a PUD so if a person has an inre GI problem it can also cause problem because the oral medications that they will be taking and these are the immunosuppressive medications there will be poor absorption of those immunosuppressants and also this will cause an increasing risk of GI complications after the surgery so I hope that you're able to recall maybe at least half of these risks um and what you can do to help out in Remembering these information is actually think about those complex medical issues that are very common let's say cardiac disease uh diabetes uh high blood pressure and for those people that are using uh substances like uh maybe alcohol or any of those illicit drugs those are the major um issues that will probably disqualify them or it could lead to so much more complications if they will be able to get that U um donor organ now we're going to talk this time about uh the nursing care directly right now and so we will be requiring you I want you to think as as a seasoned nurse especially when you are taking the enx all right so that's our deal I want to make sure that you're going to do your best to use your clinical judgment in actually applying all these information that you have gained in order that you can synthesize all those problem solving of skills that you have learned all throughout your study in nursing and so there are so many nursing intervention that are highly required for a kidney transplantation before the procedure is done and so we're going to focus on so many several key areas and this is very exciting but also complex and make sure that you also put yourselves in the nurse's shoes that you're actually going to play a very critical role in preparing the patient for the surgery and so at this time we're going to deal first with the nursing actions before we actually send the patient for the surgery and so during this time the recipient the patient who's needing the new kidney they're going to be receiving a blood transfusion and the blood is coming from the living donor and so this is something that can really help in several ways in order to improve the matching between the donor and the recipient and it will also help in uh reducing reducing the risk of rejection and also will enhance the survival of the transplanted kidney now another preparation here is to um have the hemodialysis within one day after the kidney transplant so I'm saying that it's part of the preparation because they need to know that this is something that has to be done right after so they need to be compliant that hey I thought that I would not be doing any more dialysis once I have the kidney no that's not true uh the dialysis actually will be done even after the kidney transplant because there are some uh changes in the body probably the the kidneys are still kind of trying to adjust with a new environment and also the other um processes that has taken place and so there is a need to do the dialysis for a few sessions right after the transplantation and so this is also a practice shortly after a kidney transplant because this will also remove excess waste products and also exess fluids until the new kidney will start to function completely because you're not really going to expect the new kidney to work 100% no it has to deal with the new environment new host actually and so um yeah this is the reality and make sure that you are including that in your patient education so your patient will comply with the dialysis after the transplantation now at this time we're really going to focus into the real nursing action so at this point we're going to be responsible in arranging uh the schedule of the preop lab test and I've listed here so many and one of those is the blood chem and this is going to assess the kidney function the current kidney function of the patient and also their electrolyte levels and also other metabolic processes or parameters so we can identify and also correct any of those imbalances that they have all right so if there are some major imbalances in their electrolytes or maybe um uh a drop in the calcium that needs to be corrected before they can experience any complications during the surgery they have to be at least close to the normal range now for the complete blood count or the CBC that should include the differential count and this is intended to check for the anemia also to see if there is such kind of an infection maybe an elevated uh blood uh what do you call this white blood cell count or for the surgical procedure okay now another is coagulation studies this is very important guys because the kidney transplant is a major bloody uh procedure this is uh the organs are actually um supplied with so many blood vessels and this patient can possibly bleed out if they probably have some um coagulopathies wherein there is probably a deficiency in their cling Factor or maybe uh their playlet count is probably dropping so we need to keep an eye into these studies to make sure that they're going to bleed out during the surgical procedure now another is urine culture why we need to take a look into the urine culture we have to detect if there is an existing urinary tract infection that needs to be treated before the transplant because this can also reduce the risk of postop in action again focus on the urine culture don't just focus on one so you have to think about all these lab studies that I listed here now another is blood typing and crossmatching well this is to help us out in confirming the compatibility between the donor and also the recipient in order to reduce the risk of organ rejection all right so I hope that this is going to give you a little bit more of idea aide of what their role is so we're not just going to uh arrange the schedule and making sure that they're going to show up to their appointment at the lab Center but you really need to pay attention into the lab results as well once you retrieve those lab information and make sure that you're going to relay it to the medical provider as well and also to the healthcare team involved in the care of the patient so everyone will be alerted and at least they would be able to uh point out some major problems before things can go out of hand all right now at this point we also need to uh administer some preup medications and I'm not talking about sedatives or Antics no I'm talking about preop medications that will be needed uh in order to prevent any infection and also to prevent rejection and so these are the two classifications that I'll be talking about um these are your prophylactic anti-infectives or antibiotics so the reason for that is to prevent infections due to the immunosuppressive therapy that the patient will receive so there are always disadvantages to any kind of medication because the immunosuppressant will help prevent major immune response by the patient that can possibly cause rejection but they need to take the immunosuppress and in order that they will not be rejecting that donor tissue but in order for us to protect the patient from a possible opportunistic infection to have to occur then we need to prevent that from happening by administering them the prophylactic anti-infectives okay and so we want to make sure that the patient is going to receive the correct appropriate dose so that we can monitor for any kind of adverse reaction as well all right so I really want you to think ahead and use your clinical judgment it's not that because the doctor has ordered it that it will be okay no you have to use your brain because some of these medications are going to be weight based and also according to the laboratory studies so if this medication is probably like a standard dose this might not be applicable to this patient that we'll be receiving a kidney transplant it could be toxic for their system and so you want to make sure that you're really going to do your diligent study make sure that you are going to also question what the doctor has ordered because they can make mistakes as well and it has happened several times we nurses are actually covering their butts and so the next classification here are the immunosuppressant medications um so we listed here are your corticosteroids cyclosporin ziprin we also have the mtor or the mamalian target rapin Ramin mtor Inhibitors and the uus so it doesn't mean that we're going to have to give all of these medications we are just listing here the different possible uh immunosuppressant that can be prescribed to the patient but most often these medications will be given in combination to really uh have that that um much more effective uh therapeutic effect into the patient now we're going to the corticosteroid so what is this classification well we know that corticosteroids are your synthetic um or could be your external source of the glucorticoids because our body really produced the corticosteroids right or the glue corticoids and so at this point the body will or the patient will be needing an outside Source in order to really reduce the inflammation and the immune response that the patient might be um developing and so we are going to educate the patient about the potential side effects of the corticosteroids so I'm throwing it question right now so what do you think are the commonly known adverse effects of glucocorticoids I'm giving you a second right now all right right giving you the answer so one of those adverse or side effects is weight gain because the corticosteroids can actually cause sodium and water retention it can also cause mood swings so you really have to properly assess your patient before during and after glucorticoid therapy because this can alter their mood some of these patients might go into um psychotic behavior or mood changes that would be too extreme and another side effect here is the increase of the blood sugar level it can cause hyperglycemia so for those patients that are already diabetic and they have to go through with this process of premedication or pre-op medication you really have to think ahead what can I do for this patient in order to prevent more complication especially that they're already diabetic and so think ahead maybe the dose of this patient's insulin will be increased according to the physicians's order so this is something that you need to think ahead um because the medication the the pre-existing dose of insulin that they might have at the current time might not be able to control the hyperglycemia when they're taking the corticosteroids all right so that's how I want you to think think ahead diligently and also be careful in your judgment you want want to make sure that you're reading back into the literature because sometimes you can make mistakes as well now we're going to have to talk about the cyclosporin um and also the as a thoin so these are also immunosuppressants that can be used as a pre-up medications but we are going to have to monitor um regarding the blood levels and also the labs of the patient like uh the renal function even though they already have the end stage but we also need to monitor on to the other uh lab values okay now this can also affect the liver function so that's why I want you to go over the different lab studies because it can alter the liver function and it can also cause some problems in the blood cell count or the complete blood count all right so think ahead now another is the melean target of Ramy or the mtor inhibitor so what are these uh medications in this category so we have the example um of that um so this is in a group of medications that can prevent or actually it will interrupt the t- cell signaling helping prevent the rejection and so this is going to suppress the effect of your tea cell which is one of the forms of a white blood cell uh to fight off the the donor kid so it will suppress the immune system especially the the white blood cell the te cells from attacking the possible donor tissue and so what we're going to do here is to uh monitor the patient for possible side effects let's say dry mouth or uh ulcers in the mouth their wound healing will be delayed and also some metabolic changes so I hope that you're writing down all those um other information that I did not show in or not include in the PowerPoint because those are the things that actually are possibly going to be asked in the enlex now the other one is the monoclonal antibodies so what are these medications we have the examples the dumad and also the basad um these medications will Target the tea cells to prevent the activation and so our role here as nurse we are going to educate the patient about the necessity of adhering uh to really comply and taking the medication all throughout the regimen and we're going to have to monitor for any infusion reactions because this is going to be given through an infusion and we also have to monitor them for any appearance or any manifestations of infections all right so I hope that you're able to digest those kind of heavy information inform there you really need to have that you need to get used to have some heavy information so you will be able to handle the exam now at this point we're going to have to look into the next uh role that we're going to have we're going to have to educate the patient before the kidney transplant and so we are going to explain to them um possible questions or possible uh items that they did not understand and so our role here is to be a support as an advocate in order that the patient will be able to participate in the entire regimen and so they will be compliant with the treatment as well now how are we going to promote the patient education at this point they're already overwhelmed with a surgery um thinking about the possible um complications that they might have they already stressed out that's why we really have to step in here patient education can really calm the nerves that's right and so one of those things is to help um explain to them the process of the transplant procedure so we are going to walk them through the whole process from the preop to the postop so they will know what to expect so it's just not about verbal um conversation um at this point so part of the education here is actually providing them some printouts um let's say pamphlets that are going to be available in the institution because most of the institutions in the US are actually um mandated to make sure that we are providing them education before we're going to um give them some treatments or any kind of procedures or any medications we are mandated to educate them okay that's part of the care it's just not about verbal teaching no that's only part of it and so we have to make sure that they have a um that kind of information that is easily understood in their own language because we can provide them with different languages translations of the pamphlets and something that can be easily understood not something that would require knowledge as an RN no that would not help them and so we need to uh walk them through the information uh make sure that they are uh reassured that they are open to uh they are can ask questions if they still do not understand those um information that they have now another thing is to explain to them or present to them the risks and the benefits okay I'm not not talking about the initial conversation that should take place between them and the medical provider or the surgeon because they are the primary um professionals that should be going through with the patient about the the risk and the benefits but we can support the medical provider in actually um uh we are going to what do you call this support we're going to have to at least uh smooth out those possible um and clear uh sections um and so what we can do here is to explain to them the risk and the benefits we want to make sure that the patients are fully informed and we have to break down the pros and the cons of the transplantation versus the dialysis so that they can really make the best decision for themselves because this is something that could really affect their lifetime this is a long-term commitment now at this point we have to participate in counseling the patient and also support services so even so if we're not really going to be the main person to provide the formal counseling what we can do here is we can offer and probably we can refer them or connect the patient to uh the counselor or any support groups that can help them out so they can uh listen to them actively with empathy and make sure that they can also provide encouragement to these patients now another thing is peer support so this is very important in this journey because we need to explore some more ways to connect to our patients and with others who have been through it and so they really need to have this kind of uh sense of belonging connection with the same patients so that they can share the experiences and how they were able to get through the difficult time and um another thing is we're going to have to teach them stress management techniques and this is something that will help manage their stress and so part of it will be to go over some deep breathing exercises guided imaginary and also relaxation techniques that will help them to stay calm and centered now we need to also set realistic expectations with a patient and to make sure that we have to keep it real with our patients do not give them false reassurance we want to make sure that we are clear of what's possible and what is not so we will discuss to them the transplant process honestly and talk to them about the possible challenges that they might face along the way and this is going to be uh helping them to have that realistic expectation as well and we can help them with a much more prepared um deis and also um they probably would not be blaming us in the future future how could they do that to me they didn't tell me anything about this and so we want to make sure that we can support uh them just as much as possible now another thing is we can encourage our patient to ask questions and also have that open communication so that we can also chat about um um maybe if they had any uncomfortable questions so they would be opening up to you um and also share their concerns so as nurses it's part of our job to create a safe space for them to do just like that okay so I don't want to go too deeper here because that's not going to be my role but this is the reality I've been a nurse for over 24 years and there are so many things that were not taught in nursing school there are so many things that I've learned way much more in the clinical area and this is one of those things being empathetic to your patient now what are we going to do here next is we're going to have to deal with the patient during or after the surgical procedure so at this point we're going to have to go deeper into the nursing care plan for a patient after the surgical procedure so again I want you to think critically as a seasoned nurse when taking care of this patient with the new kidneys and so the IM immediate postoperative area this is the busiest part of your care to this patient so if you are in the recovery room or let's say the ICU or let's say the medical surgical unit um think about just getting ready to take care about this busy patient to start your shift and it can happen probably in the middle or maybe towards the end of your shift so you got to be behave be prepared now during the immediate posttop our nursing care right after the surgery is to make sure we are monitoring the vital signs every 15 minutes initially then every 4 hours so this is not really going to be applicable on all different nursing uh levels if it's the recovery room they're probably going to be doing this a whole lot more in ICU um this is something that we can probably do in maybe a step down unit or Telemetry or Med search right especially if you are just uh meeting this patient but most often this the the frequency of the vital signs checking and also checking for the other um what do you call this observations it would require much more frequency here and so what we're going to include is going to check also the intake and output so most of these p patients or all of these patients will be coming back to the unit or let's say the pacu or the recovery room or the ICU most of these patients will going to end up possibly with a urinary catheter I'm talking about that indwelling um catheter and so we're going to be required to do an hourly eyes and O's measurement I'm talking about diligently measuring all the output that you had emptied from the urinary bag or let's say measuring the JP drain or whatever hemovac that's collecting the drenage because the patient has a wound and also checking into the IV intake you got to be diligent in measuring this because if you going to fail in measuring accurately this will really cause problem to your patient it will return to you you're going to get busier if you're going to fail doing this and so we are going to to monitor the urinary output of the patient so it is expected at this point that at least we have to have that goal that they need to urinate at least 30 MLS an hour nothing below that because if it is less than 30 that is very significant it simply means that maybe there is a problem in the surgical site maybe there is thrombosis there could be a uh an obstruction or it could be there's an ongoing rejection of the new kidney yes it can happen as early as within an hour and so when this happen if our intake and output states that hey my patient is not really putting out 30 an an hour this is something that you really need to notify to The Physician or the surgical team or the doctor all right so you have to also check on the urinary appearance make sure that you have at least a documentation of what the color of the urine is right after you received the patient is it bright red is it pinkish is it kind of just blood tined or maybe it was light pink when you receive the patient but let's say 30 minutes later on it went to a bright red well that's something that should be addressed right away there is an active bleeding going on so any kind of urinary color change that you can see to the in this patient make sure that you report immediately to The Physician or the medical provider surgical team so that this patient will be sent back into the OR okay now we're going to have to also check for the organ rejection as early as right after they are sent out to the PAC you they need to be checked for a possible organ rejection and so the organ rejection can be um it can't possibly occur right there and then it could be a hyperacute type of organ rejection that can occur within the 48 hours after they receive the new kidney that is just bad right or it could be acute which can happen within months or actually one to uh two years okay or actually that would be the chronic and months to two years rather is the acute and The Chronic is one to two years so I accidentally uh reversed that one so forgive me so the acute is actually the kind of rejection that can happen um let's say months after the surgical procedure up to maybe a year whereas The Chronic would be uh something that can occur during the first to two years after the procedure now why is this acute hyperacute um rejection occurring well this is something that could be possibly be brought about by the antibody mediated response that could possibly cause formation of the blood clots uh into the transplanted kidney and this will include the the vessels and this will cause massive cellular distraction and I'm referring to the kidney the new kidney and so this is a process that is revers not reversible I should say so again I will say say this is irreversible so when this happened it has to be dealt with accordingly now what expect as a recovery room nurse or the ICU nurse taking care of this patient well one of those signs would be fever that is the early yes sign that there is rejection and part of that would be hypertension then there is also pain at the transplant side or the graft and there is also Al of the blood Uria nitrogen and also the creatinin can you imagine that you were expecting really that you're happy that your patient is now getting a new kidney and all of a sudden everything went back It reversed your patient now was an elevated bu and creatinin how disappointing is that and so this is one thing that you need to um anticipate just don't expect uh way too much expect the worse so you won't get disappointed that's what that's how I do it and so I always prepare for the worst to happen in my patient even though I do my diligent care I always think about the the worst possible complication to happen so I'm ready to fight whenever I get to encounter those complications now we also have um elevation of the white blood cell well because that's part of the inflammatory process right there will be lucyisanerd process going on and of course that is part of the the rejection process and there's also edema okay and why why is there edema well of course the new kidney is not working and so what's going to happen there is poor filtration so again let's go back into the original picture of a patient having a chronic Kitty disease or let's say yeah chronic Kitty disease wherein they have fluid volume overload and so the same kind of classic manifestations that they had during the CKD is pretty much the same manifestations that you will be seeing in this patient with a rejection maybe not all of the manifestations will be uh completely similar but some of these manifestations will be at least 75% um similar okay now the what is going to be done here when there is immediate or hyperacute rejection well this is going to require immediate removal of the donor kidney yeah disappointing right you have you as a patient probably have dealt way so much you have to pay for all the expenses and now this kidney is not working for you how bad is that very disappointing and so yeah it will be removed right away or else the body will do some more Havoc into the other systems now we're going to have to talk of course yeah as soon as you're going to encounter these assessment findings you're going to have to notify the doctor asap I'm talking within 15 to 30 minutes as soon as you assess this patient with all these rejection signs notify them right away do not wait more than an hour do not wait for the next shift that's going to be a neglect of care okay I'm just telling you right now whenever there is a critical manifestation or a critical lab result that will come back to you we are mandated to notify the physician within 30 minutes and in the hospital that I work with in the past usually we are to notify the medical provider within 30 minutes for Sam laboratory findings that are abnormal critical Labs I should say I'll just critical Labs we are supposed to call the medical provider with in 15 minutes upon receipt of the news upon we we have uh read the abnormal or critical laboratory in the computer system as soon as we get that news or as soon as we read that laboratory result we document that in the nurses notes the time exactly we receive the information and then we have to document as well the time when you notify the physician because the quality assurance department will be tracking in how you are dealing with this serious situation you have to be timely in delivering your care and also your notification I'm getting serious right yeah because I'm one of those nurses that actually do Char checks now um another thing that we're going to have to do here is to actually um administer the immunosuppressive meds so this is something that will be more applicable to the acute and The Chronic kind of rejection this administration of immunosuppressive Ms like right after after the surgical procedure um this is something that would be more applicable to the acute and chronic the and I'm telling you that because with the hyperacute remember that the kidneys had the kidney that was donated will be removed right so it will not stay in the the recipient's body and so right up the surgical procedure and so if the patient has acute or chronic um rejection to the new tissue they're going to proceed with take the immunosuppressant medications aside from taking the preliminary or the preup so they're going to continue taking the corticosteroids the cyclosporin and also the monoclonal antibodies and this one right here the removal of the D kidney uh this is indicated for the patient that had the hyper acute I just don't have any way to put it there so yeah and just to make sure clarifying things right now and so another thing that you're going to have to do at this point uh post stop is to monitor the patient for infection and this is a common CA of first transplant year morbidity and also mortality again infection is a big deal and so what we're going to do here as the Paco nurse or the ICU nurse or even Med search nurse we're going to have to detect for any early signs of infection so what are those early signs of infection this will come back probably several times in any enlex question the reason for that is to measure your judgment if you're able to capture those possible risks that could really cost more complications the enlex will test you how well you're going to be able to capture even the subtle manifestations because if you're not able to capture then then you're not worthy to become an RN that's the honest response right there you really need to be able to detect those potential um side effects or complications abnormal findings so that we can notify the physician we can intervene about it and we can prevent complications and so again back to the uh infection here what are we going to expect or what are those signs of infections that we are going to look for well of course disia that's one there's also fever right and also abnormal discharge from the surgical site there is now a different or there is increasing drainage coming from the surgical site the dressing is getting much more like soaked it's watery or it could be purulent maybe there is now an going odor or the patient has a trend in their temperature there is now an elevation of the temperature guys I've seen so many nurses just telling me and that's okay that's still within normal limits I know it's still with a normal limits but when you're going to look into the trend make sure that you're really following into how is this trend going is it going down is it going up if it's going up then that's not good even though it's normal because it simply means that something is going on let's say when you were on Chef yesterday and the patient's temperature was 97.8 de F and the night shift documented maybe 98.2 de fah and the after or the morning shift documented maybe a temperature of 98.9 and the mid shift nurse documented maybe 99.1 yeah all those lab or all those temperature readings are normal right but look into the trend are they going up are these readings going up this is not a good sign this this is something that should give you a red flag in order for you to prevent a much more uh destructive complication now at this point we really need to uh keep an eye out for these signs immediately okay um some of these uh manifestations can also accompany um redness into the surgical site um some of these would be uh fatigue General discomfort those are the accompanying early signs of an infection okay now I want you to really stress the importance of be being a critical thinker here because as we know the patient is already taking immunosuppressant medication so that means they will not be able to fight for any infection and another thing is that their immune system will probably impair our defenses let's say some of these patients probably will not develop any fever right so it's kind of messed because of the immunosuppress so you don't assume that the patient doesn't have an infection because they don't have a fever that's just not the uh clue that we are looking for there are so many things and so with that uh immunosuppressor it does really make things much more complicated in capturing the infection all right so other than that maybe white blood cell count being elevated uh a left shift and so at this point as nurses what we're going to need to do here is to notify the provider ASAP once we encounter these assessment findings we have to make sure to educate the patient the family the spouse in order that they're going to be able to also report for any possible signs of infection they're going to be your helper and I actually um like to educate my patients family members because they're actually going to be able to help you as well to to tell you if something is going on with their family member and so many times I encourage them to do that in order that I'll be alerted although it sometimes can be so annoying because they can overdo it but you have to deal with it I mean they're part of the care as well um part of that would be to encourage them to do frequent hand hygiene that's very important all right um avoiding crowds and this is just like a general patient education not just about uh applying this into the acute care setting but also when the patient gets discharged right and they need to uh was themselves for any signs of infection so they need to avoid crowded areas avoid sick people especially for those with active infections um uh what else those people that might have had a recent chickenpox or vaccinations with uh live virus yep that's part of our precautions we need to tell them that um and also make sure that they wear face masks if they're going to be out in the public if it's unavoidable they have to be out there um but as much as possible they have to U avoid big crowds to prevent any opportunistic infection to occur now part of the care to fight of infection is to administer anti-infective medications antibiotics okay and yeah antibiotics and we have have to monitor the patient as well let's say for example they really develop the infection and so there will be follow-up appointments as well make sure that they are some resolution if they have some kind of respiratory infection then they need to have a follow-up visit to the medical provider's office to see if they're positive still in their blood cultures or maybe their sputum exam then there's going to be ongoing um care to this patient now another complication or a possible risk that can occur in a patient with a uh kidney transplant would be the Hemorrhage this is very common as well the kidney is a highly vascular organ and during the procedure there is a break in the continuity of the tissues and so uh Hemorrhage is something that you should anticipate so what are we doing here we are going to check the surgical dressing for any signs of bleeding all right not just the dressing you have to carefully look into the amount of drenage for example if the patient has an accompanying uh wound vacuum let's say like Jo those JP drain or hemovac then you have to um use your judgment is this drainage way too much for this acute face Post stop is this 200 mls an hour or is this just maybe 10 s 10 CC's per hour so maybe that's acceptable but maybe your patient has an ongoing massive bleed then you really need to notify the doctor if the the bleeding is way too much and if as much as possible if there's probably no other way of telling no no measurement or no device to measure um what you can do is to estimate the blood loss maybe use uh to maybe weigh the the dressing that would be helpful as well to estimate the amount of blood that has occurred um during the bleeding episode and at this point we really need to also encourage transitioning the oral fluid intake or let's say from IV to fluid oral fluid intake in order to um help them hydrate and also this is something that we need to be careful make sure that you're offering oral fluids is ordered and make sure that the bowel uh function has returned there's already peristalsis okay so if the patient is Toler uh tolerating uh some sips of clear liquids then go ahead now if the provider has or not provider the patient has significant blood loss significant I'm telling you significant blood loss that you really need to notify the provider right away it's a critical finding again notify the doctor as early as possible 15 30 minutes okay maybe 30 minutes is even like late already 15 minutes would be much more ideal now administer Avy fluids this is something that would help restore the circulating fluid volume to counteract the effect of the hypovolemia and another problem really with the Hemorrhage when there is a fluid loss or volume loss it can compromise the circulation not just into the body system but also it will compromise the blood supply into the new kidney so imagine that you have a brand new toy not really I'm just should I to say toy or if you have a brand new organ inside your body you want to make sure that you're taking care of it right that this organ should be getting enough blood supply that it should get at least 20 to 25% of the total cardiac output right that's what I said during the introduction of my lecture so if there is now a hypovolemia decrease circulating fluid volume then expect that this kidney will also be dysfunctional if the bleeding is prolonged now we really need to administer the fluid BSIS or maybe there's a need for us to administer pack red blood cells if there is a significant blood loss a significant drop of the red blood cells or the hemoglobin count we want to make sure that we are going to do that and and we have to uh do our prompt assessment as well intervention to prevent more complication at this point now urinary elimination what is this this is going to be something that we need to really keep an eye on because maintaining a urinary output is what we are looking at because if there is a decreased urinary output then simply there is something wrong with a new kidney probably there is a rejection or could be a thrombosis and a possible removal of the kidney we don't want that now part of the Care um in posttop face because the patient would really need an ongoing Ino measurement strict intake and output measurement so most of these patients will come back to you or will be admitt it to the pacu or the recovery room they mostly will have a urinary catheter and the reason for that is to help uh us to measure the output accurately and also to allow checking of the urinary output if there is let's say uh what do you call this uh an assessment let's say there is presence of cluts in the urinary output this is already concerning because if there is cluing in the drainage tube then some something is possibly going to happen in the next hour it can possibly obstruct the outflow all right and so we have to anticipate administering the continuous bladder irrigation which is actually going to require a three-way uh catheter okay not the two-way because if you are going to use or yeah if you're only going to expect to two-way catheter then it's only going to compose of the inlet for the balloon um in order that you can inflate the balloon and the other one is for the what the drainage uh bag right and so this is not going to allow you to do the irrigation so most of these patients will be uh sent to the pacu with a three-way catheter so most of these patients will come back already with the CBI The Continuous bladder irrigation that's something that we'll be discussing as well in the next uh Topic in the prostectomy in the bladder or the B9 prostatic hypertrophy and so with that uh part of the Care is to make sure we are going to um irrigate the bladder in order to prevent any oclusion and also there will be optimal urine flow and once the flow of urine is somewhat more stable there's no more active bleeders um the removal of the catheter will be done as early early as possible and the reason for that is to prevent complications in the US it's very strict as far as insertion of the or maintenance of the urinary catheter as soon as the patient is going to be able to ambulate po upop if there is an a pre-existing urinary catheter if there's no need for that then it has to be removed um because urinary catheters can cause urinary tract infections I just say ascending urinary tract infection now another uh issue that we need to uh deal with is IGA okay so what is this this is a possible complication because possibly there is an obstruction so again this is going to be uh detected through proper intake and output measurement we need to notify the medical provider right away and so as much as possible we notify them as early on because there are so many things that we can do for them uh such as as the administration of the diuretics and also possible dialysis okay and why are we giving diuretics at this point um diuretics let's say the manitol thides the furosemide and again there's so many more information right so I hope that you're writing notes so for the manal this is a osmotic diuretic that will actually help preserve the urine flow and it will reduce the risk of acute kidney injury so the manal here is applicable in this scenario it's not needed for a cerebral edema again this is this is intended for the igua status poost um kidney transplant so the filtered manal will actually draw the water into the nefron of the kidney and it will promote diuresis that's why we are going to expect this medication to be ordered um and some doctors might be a little bit more cautious that's why thyoides and furosine will also be ordered but not all of these right okay don't expect to give all these different classes because um we don't want to cause way too much fluid loss we only want to initiate diuresis we don't want to overdo it so for the thide and the furosemide they are considered like less effective um in promoting the filtration rate that's why they are the secondary and the tertiary uh modality here okay now also the dialysis is going to be ordered by the medical provider um after the kidney transplant in order to um facilitate the filtration because the kidney at this point probably is not doing its 100% yet and so this will help remove the body waste and also to lessen the burden into the new kidney we want to help we want to assist the new kidney in filtering those waste products and also to remove those extra fluid from the body until the new kidney will be able to function 100% okay so I hope that you're able to capture all those explanations that I have given now at this point we're going to have to also keep an eye on excessive diares so extremes are not good right so at this point if there is excessive urination polyurea I'm talking about 4 L 5 lers in 24hour Period that is way too much for it out from the system and so this can happen after a successful a um kidney transplant and so we want to make sure that we are expecting a yeah we are going to expect really that the kidney will work better right uh but the excessive diuresis can also occur and the reason why um why this happens it's because the sudden restoration let's say for example the body is now hey we got a new friend here we got a new newbie that is really a hardw worker uh brand new and so the body will be adjusting to the new organ right and so probably at this point the kidney will be overwhelmed and also the the interplay of the body hormones the anttic hormone the aldosterone um surprised by the new friend and so with all these changes occurring at the same time this can lead to the excessive diuresis and however though the diuresis can be a problem it can really cause hypovolemia again this will require us to call the medical provider ASAP all right because when there is uncontrolled hypovolemia and low blood pressure it will also decrease the blood flow to the graft the same mechanism when there is hemorrhage and so that's why we are going to call the doctor right away and so we have to promptly address it by possibly administering fluid basis of normal saline uh in order to counteract the hypotensive effects now constipation yes that's also part of it U this is something that can occur possibly because of the B manipulation during the surgical procedure and also possibly the effect of the anesthesia okay it can slow down the peristalsis and possibly from the analgesics that we are providing or that we are giving to the patient post up right because our patient would need pain medication you don't want our patient to be in pain in agony you really have to control their pain and so the the drawback is the constipation and so what we're going to do is to monitor for the bowel sounds and to also monitor the bowel movements closely and part of the Care is to administer stool softeners could be laxatives um increasing their fiber in the diet and also to uh I would probably not say increase fluids yet because we are still in the process of uh restoring the fluid volume at this point we don't want to overwhelm the system but we want to start with at least softening their stools now also fluid electrolyte imbalances can occur during the postop phase and we are going to monitor the intake and output as well um and also the electrolytes this is very critical we got to measure the daily weights as well because the daily weight will really um give us a the information if the patient is gaining weight maybe the patient now is emitus from the accumulated fluid because the kidney the new kidney is not working well and so we want to make sure that we are doing our diligent documentation in order for us to to notify the medical provider make sure that our assessment also guide our uh treatment plan now again we're going to have to notify the medical provider ASAP for any electrolyte and fluid imbalances so we can correct them right away so at this point you probably would be needing to U replace IV uh electrolytes as well if there is such an imbalance um o sorry um and so at that point when you are looking into the laboratory and usually this is going to be it daily there will be daily renal function tests looking into the creatinin The Bu the complete blood count the electrolytes sodium potassium mag also phosphorus uh chloride and so we have to really pay attention if there's any um Rapid or abrupt changes from the previous assessment okay always do that assessment is actually going to help you in passing the test if you have a good assessment skill you have a higher chance in passing the enlex because the enlex is actually asking the most basic questions yep that's true most basic questions now at this point we're going to have to promote again that Stan Coast is offering the 90 days of free enlex training classes so we are doing this daily so please don't Mis uh misconstrue that we are actually doing this daily so I really want you to um tell your friends who are trying to uh pass the enlex make sure that they are going to grab this perk and also make sure that they are going to attend to the classes they can also review Into the recorded videos uh that will be posted in the actually it will be uh posted right away as soon as the live session is done and again we're going to cover the nursing subjects and also we're going to do some rationalization of about 2,000 intile questions and so we want to make sure that you are going to subscribe and also like this video and on top of that we're going to also promote the um the course that we are offering in the website ww uh stanos and class coaching.com we have there so many perks as well so there will be 10 hours of animated videos there's also lots of on demand video recorded lectures uh 20 plus practice questions and there's also audiobook ebook and Mac testings and this is accessible 24/7 uh for 6 months with your subscription of course and this will also include the 200 plus ngn questions and this will be self-paced and you also have about 70% discount for this month only so I really want you to grab this opportunity and if you have any more questions you can ask in the the um conversation thread um in this video and also look into the description below so you will be able to click on those links to uh go into our website to check our website directly so that's it we're going to continue our lecture here and again now we're going to continue with the Q&A so here we have our scenario the question is about a 58-year-old man was recently diagnosed with enage renal disease secondary to chronic kidney failure he has initiated hemodialysis oop sorry click that one he has initiated hemodialysis treatment to manage his condition and given the risk of disequilibrium syndrome in patients new to hemo dialysis the nurse diligently monitors the patient uh during the dialysis uh session for any signs of symptoms suggestive of this disequilibrium Syndrome again the question States a 50 year 58-year-old man was recently diagnosed with endstage renal disease secondary to chronic kidney failure he has initiated hemodialysis treatment to manage his condition given the risk of disequilibrium syndrome in patients new to dialysis the nurse diligently monitors the patient during the dialysis session for any science of symptoms suggestive of this disequilibrium syndrome so what are these uh symptoms is it a restlessness irritability and weakness B we have elevated blood pressure rapid heart rate and fever we also have headache for C confusion Fusion muscle twitching and D we have low blood pressure slow heart rate and decreased body temperature okay I want you to pick your choice right now choice so what is your answer I'm giving you at least a few seconds all right so time is up we're going to have to go through each item here or each option okay now at this point we have letter A restlessness irritability and weakness now this uh group of symptoms may occur in our patient um having a dialysis right but they are not specific to the disequilibrium syndrome and they can be indicative of other conditions or maybe other complications that could be not related to the rapid solute removal and brain swelling so we are going to eliminate that what we are looking for here are those manifestations that is closely associated with the disequilibrium syndrome now B what is this elevated blood pressure rapid heart rate and fever what do you think about that again these manifestations can also happen in a patient with a disequilibrium syndrome but again they are not specific to the disequilibrium syndrome um the elevated blood pressure actually um the rapid heart rate and also the fever they can be um manifested by other issues maybe fluid volume overload or maybe electrolyte imbalances uh and so with a fever it is associated with so many other um disorders maybe Associated directly with infection and so we are going to eliminate that because it doesn't really suggest about the disequilibrium syndrome now we'll talk about the C here headache confusion and muscle twitching well sounds like fancy right so this is a possible answer um we're going to have to recall here that during the dialysis especially the Hemo dialysis U for those patients that are newly diagnosed um they just started the hemodialysis session and so they are at a higher risk to developing the disequilbrium syndrome okay please take note of that they are at higher risk to develop this because they're body is not used to the change in the osmolality um with the dialysis treatment okay they are used uh their body is already used to elevation of the blood Uria nitrogen most of the time and so if there is now a filtration removal of the blood Uria nitrogen at a certain rate their brain will respond to it like very differently it can cause some changes in the central nervous system and it can cause headache it can cause confusion it will lead to muscle twitching okay and the the other neurological symptoms that is also associated with a disequilibrium syndrome is um the um what do you call this the osmotic uh changes in the brain cell so when The Bu the high level of blood Uria nitrogen is removed from the body in the vascular compartment it will cause osmotic changes into the brain cells due to the shifting of the fluid and it will cause brain cell swelling all right so there will be an increase also in the intracranial pressure potentially our patient will go into seizure okay aside from having intracranial increased intracranial pressure so add that to your notes increasing ICP and also possible seizure now our goal here as nurses is to make sure that we are assessing the patient uh for this specific neuro uh manifestations especially during the dialysis session not just the brand new dialysis station so that we can recognize early on the management also to treat the problem so it's not limited only to new dialysis patient but it can also have happen even the the uh chronic dialysis patients if the dialysis nurse is rapidly removing the urea or let's say the the rate of removal is way too fast the patient can go into this problem disequilibrium syndrome so we have that as our potential answer okay now for letter D what is this low blood pressure slow heart rate and decreased body temperature what is this so similar to the other options uh these symptoms are not really characteristics of the disequilibrium syndrome and so the low blood pressure itself the slow heart rate the Brady cardiac they potentially can happen during the dialysis and also same thing with the uh low temperature okay but they are not again specific to the disequilibrium syndrome they can also be found in other disorders now again we're going to have to go through so our answer here is letter C okay now at this point we're going to have to point out the different uh the different test taking strategies that you need to apply so again what we're going to do here is to identify the key concept what is being asked in the scenario okay is it asking for the manifestations the signs and symptoms and specific to that is that we are being asked about the disequilibrium syndrome okay so narrow your um let's say narrow your decision making at this point as far as like with the assessment findings you have to kind of pick this common manifestations associated with this problem so we are also going to have to eliminate those obvious incorrect options so what are those obvious incorrect options these are those answers those non-specific symptoms okay I'm I'm talking about symptoms that are not directly uh pertaining to the disequilibrium syndrome that's why I started eliminating that one same thing with letter b and also with letter D so always answer by elimination do not look for the correct answer because if you're only looking for the correct answer you're gonna easily miss it so answer by elimination look for those uh options that are not related to the problem that we are looking at we have to look for those um options that can potentially delay the treatment or could POS uh potentially harm the patient and so this is how you're supposed to answer when you are answering for let's say SATA or select all the apply or a multiple choice or even with the Matrix multiple choice the same thing applies you have to answer by elimination now another tip here is to recall the disequilibrium syndrome and what it primarily affects so the system that will be involved here is the central nervous system because of the rapid solute removal during the dialysis so restlessness irritability and weakness yeah this can be associated with some other electrolyte U imbalances low blood pressure it doesn't really correlate with CNS problem elevate blood pressure not so you have to narrow down your options here twitching is one there is actually irritability in the uh meninges at this point the patient is going to go possibly into a seizure episode confusion that is because the patient has an increasing ICP that is causing edema uh the edema causing ICP I should say and the headache CA by the influx of the solvent or the water into the brain cells that's why they're going to have that headache now let's move on into the next question here we have the situation it's a female client is admitted for a treatment of chronic renal failure or um yeah which is a condition characterized by the gradual loss of kidney function over time so as a nurse you know that this disorder increases the risk of is it a metabolic as alkalosis as a consequence of hydrogen ion retention is it B increasing serum calcium levels due to kidney failure or is it C retention of water and sodium due to a significant decrease in the glal filtration rate or is it D decreased serum phosphate levels stemming from kidney failure I'm going to give you a few seconds here to select your option all right I hope that you were able to pick your answer so let's go through the choices here let's have letter a first okay what is being asked really a female client is admitted for a treatment of chronic renal failure condition characterized by the gradual loss of kidney function over time as a nurse you know that this is order increases the risk for so what we're actually looking at right now is the complication that a chronic renal failure can possibly have okay we're looking for the complication that is what this question is wanting us to do so is it a metabolic alcalosis is a consequence of hydrogen ion retention is it true that when your hydrogen ions are retained in the bloodstream that it will cause a osis hydrogen ions well let's go through the kidneys actually is going to play a big role in the normally functioning body it will be responsible to excrete the acids the hydrogen ions produced by the body's metabolism however in the chronic kidney disease or the CRF the kidneys have already lost their ability to adequately excrete the acids so what is going on it will cause accumulation of those hydrogen ions now another thing that we are um going to talk about is that the ammonia production in the kidneys supposedly in the normally functioning body it will be able to help buffer the acids because the ammonia is going to be converted into an ammonium and this will be excreted in the year urine okay now in The Chronic Kitty disease it will reduce its ability in excreting the ammonia that is why there is that metabolic acidosis not alkalosis now also in CKD there is a bicarbonate loss because the kidney has already lost its function in uh producing bicarbonate um bicarbonate and so it will not be able to buffer the effects of the metabolic acid dosis so we are crossing this one out because this is what makes it wrong should be acid doses now let's take a look into letter B increased serum calcium levels due to kidney failure now I've talked about this during our introduction that the kidneys are supposed to what synthesize activate the form of vitamin D into calcitriol right from cidial to citrio and Recall now your concept about the involvement of vitamin D in the absorption of calcium right and it will actually lead to hypocalcemia if there is deficiency in vitamin D so we are going to cross this out because it's saying increase there is no increase in the calcium level in chronic renal failure it will decrease okay now another reason that it will the patient will have hypocalcemia is that the um in in CKD itself there is also a secondary hyper parathyroidism wherein the parathyroid gland will become overactive due to the low active vitamin D and calcium levels and this will cause the parathyroid uh gland to secrete the uh hormone to stimulate the release of the calcium ions from the bones now this is really not going to be sufficient to maintain the normal calcium levels and so that is why the patient will end up with hypocalcemia so we are going to remove that one xx and letter C let's find out retention of water in sodium due to significant decrease in the glal filtration rate well at this point there is a possible potential or there is really a retention of water in the and also the sodium in the body because of a significant decrease in the gluma filtration rate okay now the patient at this point is really at risk for fluid imbalance they're going to usually come into the hospital with the difficulty of breathing cardiac dismas these are the main complaints why they are seeking help because of the shortness of breath but we'll know more when we look into their lamps it's just not about the shortness of breathing it's going to be electrolyte imbalances that can affect their cardiac function and also the brain function so at this point the patient will actually have um have some problem to concentrate the urine and that's why there's also fluid retention um at this point okay now this is a possible correct answer so now let's check letter D decrease serum phosphate levels stemming from kidney failure uh before we go to letter D let me just uh look here real quick retention of water and sodium due to a significant decrease in the glome filtration yes okay and so this is actually pertaining to hypernatremia right okay guys I want to emphasize right now that in chronic renal failure it's either hyponatremia and hyperia what I emphasized during my lecture was hyponatremia okay um I've researched this very deeply and the reason why I chose hypon netri IA because most of the population um with a chronic renal failure that is admitted during the acute phase will manifest hyponatremia more than hypernia I said either of the two can happen but most of the population admitted with chronic renal failure will usually manifest holia and the reason for that is again the inability of the kidneys to concentrate so they will have that kind of like delusional type of hyponatremia all right dilutional type that's why um there is uh either hyper or hypo in CRF now uh let's move on to letter D decrease serum phosphatase levels well let's check the facts well in hyp um in chronic renal failure or CKD there is actually going to be a high phosphate level levels because we know that calcium and phosphorus are inversely proportional they are actually the exact opposite so if there is Hypoglycemia what you're going to expect here is the the phosphorus levels will Elevate and this is going to become a toxic to the system and this is associated as well with the the dysfunctional mechanism of the parathyroid gland uh because the body is sensing that there is significant hypocalcemia so the release of the parathyroid hormone is an attempt to also equalize the amount of calcium however at this point the filtration rate is already Disturbed so the the calcium is actually not going to be at the normal level it will be readily uh it's not going to be stabilized the body will not be able to compensate that low low pot low calcium and so the hyponatremia cannot be mitigated by The increased uh resorption of calcium from the bone structures what can happen though is that the phosphorus instead will be elevated at this point okay now what would be our testing strategy here in order for you to properly uh correctly answer this question well we again we're going to have to read through the question and make sure that we are uh reading through the case is it about identifying the risk associated with a chronic renal failure yes there we are being asked about the potential complication here so that is your key and another is we're going to have to eliminate those incorrect options so look for those options that are clearly incorrect based on what you had learned your stocked knowledge and also in and the information that you were uh able to collect from the scenario so for examples we have letter A and D this can be easily eliminated because in chronic renal failure uh typically the patient will end up with metabolic acidosis not alkalosis okay and then you're also going to eliminate letter D it's because it said decreased well in CRF it's over always increased increase phosphorus so you have to get rid of those two immediately now another is you're going to have to recall the picology in the chronic renal failure and also the changes that will take place and once you recall those um p uh changes the what do you call this the pathological changes I should say U we want to make sure that we are aligning with the manifestations that are presented in the options so in this scenario The Chronic Ral failure will lead to the decreased glal filtration and that is why the person will end up with retention of water it will cause the dilutional type of hypo netria okay that is why we're going to select letter c as our correct answer letter D is wrong now let's move on to the next okay I'm going to do one more question before we're going to end okay we have a question here Mr Smith a 55-year Old feem Miss Smith a 55-year-old female presents with complications related to ureia necessitating renal replacement therapy due to the difficulties encountered with the Hemo dialysis peronal dialysis has been any appreciated as the chosen mode of treatment which of the options below um signals a significant problem during Miss Smith's baronial dialysis procedure okay let me read that question one more time Miss Smith a 55-year-old female presents with complications related to uremia necessity renon replacement therapy due to the the difficulties encountered with hemodialysis peronal dialysis has been initiated as the chosen mode of treatment which of the which of the following findings signals a significant problem during Miss Smith's peronal dialysis procedure we got options a hematocrit of 34% B white blood cell count of 22,000 cubic millim and we have letter C potassium level of 3.5 Mill per liter and D blood glucose level of 210 milligrams per deciliter so what is being asked here is that which of these findings could contraindicate the peronal dialysis what could pose a problem into continuing the peronal dialysis that's what this question is implying giving you a few seconds to answer all right time up now let's go back into the question again our patient has been using the peronal dialysis because she had some issues with the Hemo dialysis right or some difficulties and now we are tasked to identify those findings in the options that could contraindicate that could become a problem while the patient is going to go through a heronia dialysis so let's go go to letter a himatic rate level of 34% now I want you to recall the normal level of the hematocrit count especially in the females so this is something that you really need to re be to remember okay so at this point we have to uh talk about the normal range for the female pic count so for females adults the usual range will usually fall between 30 6 to 46% and for the males it will be 38 to 50% again for females that is let me put my pen in here 36 to 46% and there might be some slight variances with what laboratory has been used for the testing um for the for the males it will be around 38 to 50 okay and again it can vary it might be some there might be some slight differences but this would be our reference for now um and so looking into the range here our patient has a low hematocrit but does it contraindicate the use of the peronal dialysis probably not uh we understand that it is low right um the hematocrite will give us us an idea how the red blood cells is compared to the amount of the plasma so this will tell how diluted the blood is or how concentrated the blood is with regards to the red blood cells to the plasma so at this point the the reading is lower 34 so it looks like our red blood cell count is lower compared than the normal range and so there is more solvent um in the system compared to the red blood cells now um it's still kind of like considered as an acceptable range it's not normal but this will not contraindicate the use of the peronal dialysis because considering that our patient would need some regular blood sampling so there will be blood draws that could also um yeah their counts would be decreased right if there is regular blood draw and so this is an expected finding but however it's not going to uh contraindicate the use of PD this is an expected finding the patient has chronic renal failure they don't have much erythropoetin to produce or to stimulate the kidney uh to stimulate the red bone marrow to produce the red blood cell that is why our patient has anemia now let's take a look at letter B white blood cell count of of 22,000 per Cub mm well what do you think what is the normal why blood cell count range in adults well simply recall that would be around 5 to 10,000 per cubic millimeter okay that would be my usual range um in some cases some uh scenario would EXA up to 11,000 so anything above 11,000 would be very significant but I usually would narrow down my limits here like 5 to 10 just going to have a little bit more or less room for error and so um with this it actually suggests that there is a presence of infection at this time and again go back into the scenario the patient is dealing with a peronal dialysis and remember about the very common complication which is peritonitis as I have discussed yesterday this is a complication that can easily occur when there is um unsafe practice in the insertion of the peronal catheter poor hand hygiene unsterile technique um so peritonitis can really set easily to this patient it will compromise the peronal membrane and also decrease its ability to filter the solute so it will become an ineffective dial is all right so we are going to possibly put this in the parking lot as one of the as the correct answer a is already wrong um because hematocrit really is not going to um prevent us from proceeding with the PD now let's take a look at letter C potassium level of 3.5 what do you think about potassium 3.5 is it normal yeah it is normal the range that we have discussed is 3.5 to 5.0 MOS per liter and so this is something that we are not going to worry about we're going to x that out it's unnecessary it's just a distractor it doesn't cause any problem to continuing PD now let's take a look at letter D blood glucose of 210 milligram per deciliter this is a high blood sugar reading right it is elevated it indicates hyperglycemia we know that but this is not uncommon in patients with CKD particularly for those diabetic CKD patients and so this is something that we need to manage accordingly but it does not signal an acute or specific problem with the peronal dialysis procedure like I have said yesterday about the PD that one of the possible complications would be hyperglycemia right and I said something about managing it with a dose of insulin that this is this is something that can be easily managed but will not contraindicate in proceeding with the next session of PD all right so we are left with letter B that is our correct option and so for now the the testing strategies at this point is again to understand the context so the question is about identifying the significant problem during the PD so we need to recognize that the complication associate with a PD can include the infection especially peritonitis so it really pays to uh for if you are really listening to the discussion it would really help you quite a lot now again the next uh testing strategy here is to eliminate those clearly incorrect options incorrect for letter A also letter C is incorrect and letter D is also incorrect those are obvious um reasons that will not um hold us into doing the next dialysis session now another is that we're going to have to uh focus on the critical findings so what which is critical here is 34 percent a critical finding heck no what about the potassium it's not is the blood glucose 210 milligrams per diesel liter critical for this patient no so we are left with again letter B 22,000 is way way way above the upper limit which is the 10,000 and so this is a serious complication of PD and peritonitis again is a major concern that we need to deal because this can cause a major sepsis into our patient it will readily cause Havoc into our patient systems now we are going to also apply the knowledge that you had gained regarding the complications of the dialysis we need to understand or recall that peritonitis is a very common and serious complication and again it is associated with an increase in the white lso count and we have to recognize that the question is testing knowledge of recognizing the signs of infection and also the complication specific to the PD so this is where're going to end our discussion today I will see you again tomorrow for the next topic um we will be talking about glone def fridus in adults and so I hope to see you again tomorrow and again please don't forget to like this video and share with your friends so they will be able to uh participate or the next session tomorrow or the succeeding days so thank you so much for your time you have a great day you have a happy