Nursing Field Notes / Renal + Fluid · Pathophysiology Course

Renal Failure 🩺
Care · Diet · Drugs

Acute vs. Chronic — part 3 of 3 · what the NURSE actually does

NG-266 Renal + Fluid ADHD-friendly visual edition

THE DO-IT PAGE. Nursing interventions, the renal diet food-by-food, and every drug you give vs every drug you avoid. This is where the HESI and Kaplan food questions live. Sisters: NG-047 = master overview & causes · NG-264 = 4 phases & 5 stages · NG-265 = labs & symptoms.

📄 Simple Nursing original — opens in Drive →

⚖️ 1 kg = 1 LDaily weights are the #1 fluid assessment. 1 kg gained = 1 L retained.

🚫 NSAIDs · MOM · Vanc · Gent · DyeThe five things that finish off a kidney.

🍏 Apples = BEST choiceLow potassium. The classic right answer on food questions.

🧂 NEVER a salt substituteSalt substitute = potassium chloride = dangerous K⁺.

🩺

NURSING INTERVENTIONS

STEP 1 · MONITOR & PROTECT

Two jobs, all day long: measure the fluid, and stop anything that would hurt the kidney further.

⚖️ Daily weights — 1 kg = 1 liter of fluid retained

Answer first: the scale is a more reliable fluid measure than I&O, because nobody forgets to record a weight the way they forget a urinal.

🧠 “A kilo is a carton of milk 🥛.” One kilogram, one liter, one carton. If she gained two cartons overnight, that fluid is sitting in her lungs — assess breath sounds first.

✅ Procedures — the daily checklist

⚖️ Daily weights — same time, same scale, same clothing. 1 kg = 1 L.

💧 Strict I&O — every mL in and out, including ice chips, IV flushes and med volumes.

🚰 Fluid restriction — commonly the previous day's urine output plus about 500–600 mL. Amounts vary by facility & provider — follow the order.

🫁 Assess lungs, edema, JVD & BP every shift — this is how overload announces itself.

🫀 Cardiac monitor whenever K⁺ is over 5.0.

🧪 Track the labs — K⁺, Na⁺, phosphorus, calcium, BUN, creatinine, H&H, pH.

🦠 Infection prevention — uremia suppresses immunity; infection is a leading cause of death in ESRD.

🤲 Skin care for pruritus — cool water, gentle soap, moisturize, keep nails short, no scratching.

🧠 “Weigh · Watch · Write · Warn.” Weigh daily · Watch lungs & edema · Write every mL · Warn the provider when the numbers move.

🩸 Hemodialysis — the machine version of the kidney

Source definition: the machine version of the kidney, used to wash the blood. It is only used for a number of years until a kidney transplant is available.

🖐️ Assess the access every shift: feel the thrill, hear the bruit. No thrill/bruit = clotted = report immediately.
🚫 Never take BP, draw blood, or start an IV in the fistula arm
⚖️ Weigh before and after every treatment — that difference is the fluid removed.
💊 Some meds (especially antihypertensives) are held before dialysis to prevent hypotension — follow the provider's order; practice varies.
📉 Watch for hypotension, cramps, headache during and after treatment.

Go deeper: NG-248 hemodialysis · NG-261 peritoneal dialysis · NG-267 transplant & biopsy.

🧠 “Thrill & Bruit — the fistula's pulse and purr.” If you can't feel the buzz or hear the whoosh, the lifeline is clotted.

🍽️

THE RENAL DIET

STEP 2 · FOUR LOWS

Low sodium · low potassium · low phosphorus · protein adjusted to the stage. Every food question on the exam comes from these four lists.

🚦 The renal food traffic light

NCLEX TIP Renal diets are individualized to the patient's labs and stage by a renal dietitian — the lists above are the ones these exams test.

🧠 “An apple a day keeps the potassium away 🍏.” When a food question involves a high potassium level, look for the apple — it's the answer more often than any other food on the NCLEX.

🧂 NO SODIUM — and NEVER a salt substitute

🥫 No canned / packaged foods
🌭 No processed meats — deli meat, bacon, hot dogs, sausage
🧂 No salt shaker; season with herbs, lemon, garlic, vinegar
🚫 NO salt substitutes — they are potassium chloride

Why: sodium drags water with it → more edema, more hypertension, more work for the heart.

HESI Statement that shows a need for further education: “I should reduce my sodium intake by using a salt substitute.” ❌

🧠 “Salt substitute = Secret Potassium.” The label says salt-free; the bottle is full of K⁺. In renal failure that swap can stop a heart.

🍌 NO POTASSIUM — the food list

🥬Leafy veggiesspinach

🥑Avocados

🥕Carrots

🍅Tomatoessauce & juice too

🍓Strawberries

🍊Oranges& orange juice

🍌Bananasthe classic

🍏APPLESBEST choice ✅

HESI Q: Best food choice for a potassium of 6.5? A: Apple slices or apple juice — low K⁺.

🧠 “Bananas, Oranges, Potatoes, Spinach — BOPS your potassium up.” Anything that BOPS — skip it. Reach for the apple.

🦴 LOW PHOSPHORUS — NO dairy

🥛 No milk · 🍮 no pudding · 🥣 no yogurt NCLEX TIP
🧀 Cheese, ice cream — same problem
🥤 Dark colas, nuts, seeds, whole grains, dried beans

Why: phosphorus rises → calcium falls → itching, muscle cramps and brittle bones (renal osteodystrophy).

🧠 “Phosphorus and calcium ride a seesaw 🎢.” Phos up = calcium down. Cut the dairy, take the binder, save the bones.

🥩 LOW PROTEIN — and the exception

KAPLAN Rationale for a low-protein diet? → to preserve renal function. Protein breakdown makes urea — less protein in, less waste for a dying kidney to filter.

KAPLAN Teaching is effective when the client says: “I will eat red bell peppers and avoid red meats.” ✅

⚠️ The exception: once a client is on dialysis, protein needs go UP — dialysis pulls protein out with the waste. Pre-dialysis = restrict; on dialysis = replace. Exact grams are set by the renal dietitian and vary.

🧠 “Before the machine, keep protein lean. On the machine, feed the protein.” Same disease, opposite answer — read whether they're dialyzing.

🍽️ The four lows on one plate

Restrict	Say NO to	Because
Sodium 🧂	Canned/packaged food, processed meats, salt shaker, salt substitutes	Water follows salt → edema, HTN, heart failure
Potassium 🍌	Bananas, oranges, strawberries, tomatoes, avocado, carrots, spinach, potatoes, salt substitutes	K⁺ >5.0 stops the heart
Phosphorus 🥛	Milk, yogurt, pudding, cheese, dark colas, nuts	Phos up → calcium down → itching & brittle bones
Protein 🥩	Red meats (pre-dialysis)	Less urea to filter — preserves renal function
Fluid 💧	Free water beyond the order — ice chips count	Prevents overload, crackles, hypertension

🧠 “Salt, Sweet-potassium, Milk, Meat.” Four cuts, one plate. If a food answer choice contains any of the four, it's probably the wrong choice.

💊

DRUG THERAPY

STEP 3 · AVOID & GIVE

First the five drugs that finish off a kidney — then the ones that replace what the kidney stopped making.

🚫 AVOID: the top drugs that can cause kidney failure

🧠 “No More Very Good Dye” — NSAIDs · Milk of Magnesia · Vancomycin · Gentamicin · Dye. Five words, five ways to finish a kidney.

☢️ Before contrast dye — what the nurse does

🧪 Check the creatinine / GFR first
💧 Hydrate before and after per order — IV fluids protect the kidney
🩸 Ask about metformin and any nephrotoxic meds
🐚 Ask about iodine / shellfish / prior dye reactions
📈 Recheck creatinine after — contrast injury shows up in 24–72 hours

🧠 “Cement in the washer.” Picture pouring wet concrete into a washing machine — that's contrast dye in a fragile kidney. Flush it out with fluids or it sets.

⚠️ Other drugs to watch

💊 Magnesium- or aluminum-containing antacids — the kidney can't clear them
🧂 Potassium-sparing diuretics & K⁺ supplements — no pee, no K
❤️ ACE inhibitors / ARBs — protective in chronic proteinuric CKD, but they raise K⁺ and are usually held in acute injury. Monitor K⁺ and creatinine.
💓 Digoxin and many others are cleared by the kidney → doses must be reduced; watch for toxicity

🧠 “Renal dose everything.” A normal dose in a failing kidney becomes an overdose by tomorrow.

💊 GIVE: replacing what the kidney stopped doing

Problem	Drug	Nursing pearl
Anemia 🩸	Epoetin alfa / darbepoetin + iron	Replaces missing erythropoietin. Monitor BP — it can rise. Hgb is titrated to a target, not maxed out.
High phosphorus 🦴	Phosphate binders — calcium acetate, sevelamer	Give WITH meals — they bind the phosphorus in the food. Given between meals they do nothing.
Low calcium / vit D ☀️	Calcitriol (activated vitamin D)	The kidney normally activates vitamin D; now it can't.
High potassium 🫀	Sodium polystyrene sulfonate (Kayexalate); insulin + D50; calcium gluconate	Full priority order is on NG-265. Expect diarrhea with Kayexalate — that's how K⁺ leaves.
Fluid overload 💧	Loop diuretic — furosemide	Only works if nephrons still function. Watch for hypokalemia & ototoxicity (push slowly).
Acidosis 🧪	Sodium bicarbonate	For pH below 7.35; adds a sodium load — watch fluid status.
Hypertension 🩸	Antihypertensives per order	BP control is the #1 way to slow CKD progression.

🧠 “Binders with Bites 🍽️.” Phosphate binders go with the food — no food, no point. It's the most-tested timing question on this page.

🍽️ Phosphate binder timing — see it once, never miss it

🧠 Binder = a net 🥅. You only catch fish while the fish are swimming by. No meal = no fish = no point.

📚 Teaching she can hand the patient

⚖️ Weigh yourself every morning, same scale, same clothes — call for a gain of 2–3 lb in a day or 5 lb in a week (threshold varies — use your provider's number)
🧂 Read every label for sodium, potassium, phosphorus
🚫 No OTC ibuprofen/naproxen — ask before any new medicine or supplement
🩹 Protect the fistula arm — no BP cuffs, no blood draws, no tight sleeves or jewelry
💉 Keep vaccinations current; report fever early
🗓️ Never skip dialysis — missed sessions are how potassium reaches 8.0+

🧠 “Scale, Label, No-Ibuprofen, Save the Arm.” Four sentences the patient must be able to repeat back before discharge.

⚡

QUICK RECALL

SAY IT OUT LOUD

⚖️ 1 kg = 1 LDaily weight, same time, same scale, same clothes

🚫 “No More Very Good Dye”NSAIDs · MOM · Vancomycin · Gentamicin · Dye

🍏 Apple = the answerLow potassium — apple slices or apple juice

💊 Binders WITH mealsNo food = no phosphorus to bind = no point

🎯 Cover & check — 7 rapid-fire questions

Q1: A client gains 2 kg overnight. How much fluid is that, and what do you assess first?

2 kg = 2 liters retained (1 kg = 1 L). Assess breath sounds and respiratory status first — that fluid goes to the lungs. Then edema, JVD, BP.

Q2: Name the top drugs to avoid because they can cause kidney failure.

NSAIDs · Milk of Magnesia (magnesium antacid) · antibiotics vancomycin and gentamicin · CT contrast dye ("thick cement in the washer — contrast kills the kidney!").

Q3: HESI — best food choice for a potassium of 6.5?

Apple slices or apple juice — low potassium. Avoid bananas, oranges, strawberries, tomatoes, avocado, carrots, spinach and potatoes.

Q4: HESI — which statement shows a need for further education?

"I should reduce my sodium intake by using a salt substitute." Salt substitutes are potassium chloride — dangerous in renal failure.

Q5: Kaplan — what's the rationale for a low-protein diet?

To preserve renal function — less protein means less urea for the failing kidney to filter. Note the flip: once on dialysis, protein needs increase because dialysis removes protein.

Q6: Kaplan — which statement shows nutrition teaching was effective?

"I will eat red bell peppers and avoid red meats."

Q7: When are phosphate binders given, and why?

WITH meals — they bind dietary phosphorus in the GI tract so it leaves in the stool. Given between meals there is nothing to bind. Also teach: no dairy — no milk, yogurt or pudding.