ACUTE KIDNEY INJURY (AKI) Flashcards
❖ FUNCTIONS OF KIDNEYS
→ Responsible for urine formation.
→ Maintains acid-base balance.
→ Activates the Vitamin D so that calcium can be absorbed in the small intestine and will go now to the blood.
→ Hormones
▪ Renin – released if there is a decrease in blood volume.
▪ Erythropoietin – it stimulates stem cells of the bone marrow to increase the production of red blood cells
Is a layer of connective tissue that surrounds and supports the kidneys.
▪ helps maintain kidneys’ proper position and separate from other abdominal structures
Renal Fascia (Gerota’s fascia)
is a thin membranous sheath that
covers the outer surface of each kidney
Renal Capsule
is divided into two parts:
▪ Cortex (outer). It is 1cm wide and contains the ___ which is responsible for ____ formation.
▪ Medulla (inner) It is 5 cm wide.
➢ It contains the _____, ____, and _____ of the juxtamedullary nephrons
Renal Parenchyma
nephrons - urine
loops of Henle, the vasa recta, and the collecting ducts
is a triangular-shaped structure that contain tiny tubes and blood vessels that help filter the blood to produce urine.
▪ Each kidney contains approximately 8 to 18 pyramids.
▪ The pyramids drain into minor calyces, which drain into major calyces that open directly into the renal pelvis.
Renal Pyramid
is the beginning of the collecting system and are designed to collect and transport urine.
Renal Pelvis
→ An abrupt decrease within 48 hours in kidney function
▪ ____ in serum creatinine, ___ than 0.3 mg/dL.
▪ ___ in urine output (___ than 0.5 mL/kg/hr) for more than 6 hours
ACUTE KIDNEY INJURY
Increase - greater
Decrease - less
Normal Urine Output
1-1.5L per day
increased urination
Polyuria
decreased urination
Oliguria
excreting only 50mL/24hrs, kidneys are destroyed.
Anuria
glucose in the urine
Glycosuria
excessive urination due to glucose
Osmotic Diuresis
❖ RISK FACTORS
→ Age 75 or older
▪ Renal function may decline by 50% or more by age 70.
▪ At age 60, there will be less blood supply going to the brain as well as the kidneys.
▪ Prolonged sitting
❖ RISK FACTORS
→ Heart or Liver Failure
▪ If heart is destroyed, there will be less contraction of the heart resulting to less cardiac output. The body will compensate by perfusing the blood to the primary organs and the kidneys will be damagedbecause it is a secondary organ.
▪ If liver is destroyed, there will be a decrease in albumin. Albumin is produced in the liver, and it maintains the oncotic pressure. If fluids leak out there will be less circulating blood volume, and there will be less blood going to the kidneys since it is a secondary organ.
❖ RISK FACTORS
→ Diabetes
▪ It is the No.1 cause of kidney failure.
❖ RISK FACTORS
→ Hypertension
▪ There is high pressure in the blood vessels making the lumen of the arteries smaller causing the blood circulation to be sluggish and less blood will go to the kidneys
❖ RISK FACTORS
→ Sepsis (Multiorgan Dysfunction Syndrome – MODS)
▪ If there is an infection, microorganisms destroy the tissues. Chemical mediators will be released and it will increase capillary permeability; therefore, albumin with fluids leaks out, resulting to less circulating blood volume, and kidneys will not receive blood because it is a secondary organ.
▪ Patient will be hypotensive (less blood in the brain) that’s why IV Fluids are given immediately to increase blood pressure to give more blood to the brain.
❖ 3 MAJOR MECHANISMS
means a decrease of blood supply in the kidneys caused by hypertension, surgery, bleeding, burns.
→ Hypoperfusion (Prerenal AKI)
❖ 3 MAJOR MECHANISMS
chemical mediators are released causing increased capillary permeability, albumin and fluids are released causing a sluggish blood circulation.
→ Direct Tissue Injury (Intrarenal AKI),
❖ 3 MAJOR MECHANISMS
that cause Renal Inflammation
→ Hypersensitivity Reactions (Postrenal AKI)
In Postrenal AKI, patient will undergo cardiac catheterization (explain)
Nursing Intervention
▪ The patient will undergo cardiac catheterization, a catheter is inserted into an artery, often in the groin or wrist, and advanced through blood vessels to reach the heart. While in the heart, a contrast dye is injected to help visualize the blood vessels and the heart’s chambers. This procedure, known as coronary angiography or angiogram, can carry a risk of kidney injury.
➢ NI: increase fluid intake to help the
kidneys remove the dye
In Postrenal AKI,
▪ Results from obstruction of urine outflow by:
Obstruction (explain)
Tumors, Calculi, and BPH.
➢ Obstruction in the flow of urine can
damage the kidneys because the
urine will go up to the kidneys and
cause damage.
In Postrenal AKI,
▪ Possible Complications:
➢ Benign Prostatic Hypertrophy – can obstruct the flow of urine and can go back to the kidneys, destroying them.
➢ Renal Tumor
❖ PHASES OF ACUTE KIDNEY INJURY
period begins with the initial insult and ends when oliguria develops.
▪ Time when an insult occurs until cell injury.
▪ Last from hours to days.
▪ The GFR is decreased because of impaired blood flow to the kidney.
▪ Urine output at 30mL or less per hour (only 50% of patients are oliguric)
initiation (onset)
❖ PHASES OF ACUTE KIDNEY INJURY
is a decrease in urination, 400-600mL in 24 hours (oliguric), anuric is a UO of 50mL in 24 hours.
▪ 10 to 14 days in Oliguric Patient
➢ Below 400mL/day in 24 hours or 0.5mL/kg/h over 6 hours.
➢ GFR is greatly reduced resulting to Azotemia.
oliguria period (oliguric-anuric)
❖ PHASES OF ACUTE KIDNEY INJURY
is marked by a gradual increase in urine output, which signals that glomerular filtration has started to recover.
▪ In this phase, Kidneys are unable to concentrate urine that’s why specific urine gravity is taken to identify if kidneys can
concentrate the urine.
➢ The urine is whitish in color in this phase.
▪ May last 7 to 14 days.
▪ The tubular obstruction has passed but Edema and Scarring remain.
▪ The urine is able to flow through the tubular space, but the cells cannot concentrate the urine
diuresis period
indicates that there is accumulation of waste products because patient’s urination is decreased.
Azotemia
___ is more severe than ____.
Azotemia - Uremia
In Diuresis Period, because of fluid loss the patient experiences:
➢ Hypovolemia
➢ Hypotension
➢ Hyponatremia
➢ Hypokalemia
The patient must be observed closely for dehydration during this phase; if dehydration occurs, the uremic symptoms are likely to ____, and an elevated _____ and ____ will be noted.
diuresis period
increase
serum BUN and creatinine
▪ It measures the concentration of particles in urine.
▪ To gauge the patient’s hydration status and also the functional ability of the kidneys.
▪ Normal Value: ____
→ Urine Specific Gravity
1.005 to 1.030
❖ PHASES OF ACUTE KIDNEY INJURY
signals the improvement of renal function and may take 3 to 12 months.
▪ Kidney function may return to normal or near normal.
▪ Edema diminishes and the tubular cells begin to slowly resume normal functioning.
▪ GFR that s 70% to 80% normal within 1 to 2 years
recovery period
❖ COMMON TESTS ORDERED BY THE PHYSICIAN IN AKI
→ 24 Hour Urine Collection
→ Creatinine Clearance Test
→ Urinalysis
EXPLAIN
→ 24 Hour Urine Collection
**Specimen:
➢ All urine voided during a 24hr period is collected.
– 1 bottle = 1 urination
➢ Urine is kept chilled on ice in patient’s comfort room.
➢ May need preservative added.
➢ Void to begin test- discard this urine.
➢ Collect for next 24 hours.
**The patient is instructed to void and discard the first specimen (8am-day1).
➢ The patient collects all urine voided in several bottles, including that at 8AM and the following morning (day2).
➢ If any urine is removed or discarded during a time collection, the entire timed collection is invalid.
EXPLAIN
→ Creatinine Clearance Test
▪ It is necessary to detect changes in renal reserve.
▪ Blood sample and 24-hour urine sample collected are used to measure glomerular filtration rate
EXPLAIN
→ Urinalysis
▪ Protein or cells in the urine may indicate intrarenal damage, such as glomerulonephritis, or kidney infection.
▪ Hematuria, pyuria, or urinary crystals may indicate a postrenal cause.
blood in the urine
➢ Hematuria
pus in the urine
Pyuria
blood can be only seen with a microscope
Microscopic Hematuria
❖ DIAGNOSTIC STUDIES & FINDINGS
→ Renal Ultrasound
→ Renal Biopsy
→ Urine Output
→ Hyperkalemia
→ Progressive Metabolic Acidosis
→ Increased Phosphorus levels
→ Anemia
❖ DIAGNOSTIC STUDIES & FINDINGS
may show renal tissue damage or urinary tract obstruction
→ Renal Ultrasound
❖ DIAGNOSTIC STUDIES & FINDINGS
to investigate possible intrarenal disorders:
▪ Glomerulonephritis
▪ Nephritis
→ Renal Biopsy
❖ DIAGNOSTIC STUDIES & FINDINGS
▪ varies from scanty to normal volume
▪ hematuria may be present
▪ urine has low specific gravity
▪ inability to concentrate urine (earliest manifestations of tubular damage)
→ Urine Output
❖ DIAGNOSTIC STUDIES & FINDINGS
due to decline in the GFR.
▪ When the body breaks down proteins, it releases potassium into the bloodstream causing severe hyperkalemia.
▪ This can cause cardiac arrhythmias and may lead to cardiac arrest.
→ Hyperkalemia
❖ DIAGNOSTIC STUDIES & FINDINGS
occurs because AKI patients can’t eliminate the waste products.
▪ Decreased serum CO2 and pH levels.
→ Progressive Metabolic Acidosis
❖ DIAGNOSTIC STUDIES & FINDINGS
resulting to decreased calcium levels.
→ Increased Phosphorus levels
❖ DIAGNOSTIC STUDIES & FINDINGS
due to reduced erythropoietin production, uremic GI lesions, reduced BC lifespan, and blood loss from the GI tract.
→ Anemia
❖ MEDICAL MANAGEMENT OF AKI
→ Maintenance of fluid balance
→ Adequate renal blood flow
→ Hemodialysis (HD)
→ Maintenance of fluid balance is based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid intake and output, blood pressure, and the clinical status of the patient
→ Adequate renal blood flow in patients with prerenal causes of AKI may be restored by IV fluids or transfusions of blood products
→ Hemodialysis (HD) to remove waste products and excess fluid.
▪ Fluid excesses can be detected by the clinical findings of dyspnea, tachycardia, and distended neck veins.
EXPLAIN: distended neck veins
Auscultate lungs for ___
The high pressure in the lungs due to edema makes the right ventricle to have difficulties in contracting against a high pressure. As a result, the right ventricle loses its elasticity, and blood begins to accumulate in it. This accumulation of blood then extends to the right atrium of the heart. The blood in the right atrium will be pushed to the superior/inferior vena cava resulting to distended neck vein.
▪ Auscultate lungs for moist crackles.
Fluid excess medication ___
▪ Furosemide (Lasix) or Bumetanide may be prescribed to initiate diuresis
Diuresis Nursing Intervention: (5)
- Give it in the morning because it can disrupt the sleep of the patient if given at night.
- Diuretic can cause hypokalemia, so advise patient to increase potassium rich foods.
- Weight the patient (before breakfast, let the patient void first, use the same weighing scale and clothes).
- Check intake and output to determine fluid loss or retention.
- Instruct patients to take drugs with food to avoid GI upset.
EXPLAIN
▪ If AKI is caused by hypovolemia secondary to hypoproteinemia (proteins goes with the urine), an infusion of albumin may be prescribed
➢ If protein goes with the urine, albumin will be low therefore decreasing the circulating blood volume.
➢ Albumin is infused through IV as ordered by the physician. There will be high albumin in the blood vessels and fluids will follow into the blood vessels which maintains the oncotic pressure and increases the circulating blood volume; therefore, more blood will go to the kidneys which can increase urine formation.
❖ PHARMACOLOGIC THERAPY
is the most life-threatening (death) of the fluid and electrolyte changes.
→ Hyperkalemia
Hyperkalemia Treatments:
➢ Avoid potassium rich foods
➢ Diuretics (e.g. Furosemide)
➢ Insulin
➢ Sodium Bicarbonate
➢ Dialysis
→ Many medications are eliminated through the kidneys; therefore, dosages must be ___ when a patient has AKI.
reduced
→ In patients with ____, the arterial blood gases and serum bicarbonate levels must be monitored because the patient may require
sodium bicarbonate therapy or dialysis
severe acidosis
→ The elevated serum phosphorus level may be controlled with _____ (e.g., calcium or lanthanum carbonate) that help prevent a continuing rise in serum phosphorus levels by binding with the phosphate from food in the intestinal tract and eliminating it in the stool, thus preventing absorption.
phosphate-binding agents
❖ NUTRITIONAL THERAPY
→ The patient is weighed daily and loses 0.2 to 0.5 kg (0.5 to 1lb) daily if the
▪ If the patient gains or does not lose weight or develops _____, ____ should be suspected.
nitrogen balance is negative.
hypertension - fluid retention
❖ NUTRITIONAL THERAPY
→ Caloric requirements are met with high-carbohydrate meals.
Carbohydrate (Explain)
▪ Carbohydrate is absorbed immediately by the body; therefore, glucose is not enough. So, proteins and fats are converted to glucose by the liver, and it is bad. That is why high carbohydrate meals are given to avoid the conversion of proteins and fats into glucose by the liver because high carbohydrate meals are enough and has reach the demand amount.
❖ NURSING MANAGEMENT FOR AKI
→ Monitoring Fluid and Electrolyte Balance
→ Reducing Metabolic Rate
→ Promoting Pulmonary Function
→ Preventing Infection
→ Providing Skin Care
→ Providing Psychosocial Support
→ Monitoring Fluid and Electrolyte Balance
▪ The nurse monitors the patient’s serum electrolyte levels and physical indicators of these complications during all phases of the disorder.
▪ IV solutions must be carefully selected based on the patient’s fluid and electrolyte status.
▪ The patient’s cardiac function and musculoskeletal status are monitored closely for signs of hyperkalemia.
→ Reducing Metabolic Rate
▪ The nurse takes steps to reduce the patient’s metabolic rate (fever & infection).
➢ NI: Fever
* Tepid Sponge Bath
* Change into light clothes
* Make cold room temp.
* Medications
→ Promoting Pulmonary Function
▪ The patient is assisted to turn, cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection
→ Preventing Infection
▪ Asepsis is essential with invasive lines and catheters to minimize the risk of infection and increased metabolism.
▪ Foley catheter is avoided due to the high risk of UTIs.
➢ Perineal Care
➢ Vitamin C to acidify the urine which lessens the entrance of pathogens.
➢ Lemon Water
▪ To prevent infection: wear mask, cover nose when coughing, limit visitors, hand hygiene technique, and foods should be well cooked.
→ Providing Skin Care
▪ The skin may be dry or susceptible to breakdown.
➢ Epidermis is avascular and gets nutrition in the dermis, if there is edema the water will enter between the epidermis and dermis therefore there will be no nutrition for the epidermis which may result to skin impairment.
➢ Advise patient to eat collagen-rich foods such as citrus, garlic, berry, tomatoes, bell peppers, broccoli, salmon, pumpkin seed, and spinach.
▪ Bathing the patient with cool water, frequent turning, and keeping the skin clean and well moisturized and the fingernails trimmed to avoid scratching are often comforting and prevent skin breakdown.
➢ Do not use soap everyday because it has a drying effect.
→ Providing Psychosocial Support
▪ The patient with AKI may require treatment with HD, PD, or CRRT.
➢ The patient & family need assistance, explanation, and support during this period.
➢ The purpose of the treatment is explained to the patient and family by the primary provider
