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Module 3 > Acute Kidney Injury&Chronic Kidney Disease > Flashcards

Acute Kidney Injury&Chronic Kidney Disease Flashcards

1
Q

Fluid & Electrolyte Imbalances:In Kidney Disorders

Inadequate fluid – volume depleted

Excess fluid – fluid overload

Monitor:

The most accurate indicator of fluid loss or gain in patients that are acutely ill is _________

A

I & O
Patient weight daily

weight
1 kg weight gain = 1000 ml (retained fluid)

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2
Q

Acute Kidney Injury (AKI)

It is a rapid loss of renal function r/t damage to the kidneys

Depending on severity and duration a wide range of life-threatening complications can occur:

Goal of care:
Minimize complications
Reduce cause of injury
Prevent long term loss of renal function

Criteria for AKI:

A

Fluid & electrolyte imbalances

Metabolic acidosis

-50% or greater increase in serum creatinine above baseline
-Urine volume may be normal or changes may occur:
Oliguria, anuria, Nonoliguria

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3
Q

1 lab to look at for acute kidney injury-

Nonoliguria- anything above

A

serum creatinine

800 ml/day

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4
Q

AKI Causes:

Causes of AKI that reduce blood flow to the kidney and impair kidney function:

A

Hypovolemia

Hypotension

Reduced cardiac output

Heart failure

Obstruction of kidney or lower urinary tract
–Tumor
–Blood clot
–Kidney stone (not very common causes)

Bilateral obstruction of the renal arteries or veins

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5
Q

AKI Classifications:

A

5-point classification system: RIFLE- Risk, Injury, Failure, Loss ESRD (used to identify kidney injury and improve outcomes for patients)

Severity:
Risk
Injury
Failure

Outcomes:
Loss
ESKD (end stage kidney disease)

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6
Q

RIFLE classification table

Risk

GFR Criteria

Urinary output criteria

A

Increased serum creatinine 1.5 x baseline OR GFR decreased >/= 25%

0.5 mL/kg/hr for 6 hours

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7
Q

I (Injury)

GFR

UO

A

Increased serum creatinine 2x baseline
OR
GFR decreased >/= 50 %

0.5 mL/kg/hr for 12 hours

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8
Q

F (failure)

GFR

UO

A

Increased serum creatinine 3x baseline
OR
GFR decreased >/= 75%
OR
Serum creatinine >/= 354 mmol/L with an acute rise of at least 44 mmol/L

< 0.3 mL/kg/hr for 24 hours
OR
Anuria for 12 hours

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9
Q

L (Loss)

A

Persistent acute kidney injury = complete loss of kidney function > 4 weeks

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10
Q

E (ESKD)

A

ESKD > 3 months

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11
Q

AKI Categories:

A

Pre-renal - before the kidneys - hypoperfusion of kidneys
60-70% of cases
result of impaired blood flow that leads to hypoperfsion
(Sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or illness

Intrea-renal-inside the kidneys (actual damage to the kidney tissue)
-Parenchymal damage to the glomeruli or kidney tubules
-Acute tubular necrosis (most common type)
(Direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply)

Post-renal- obstruction to the kidney
(Sudden obstruction to urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury)

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12
Q

AKI Pre-renal failure causes:

A

Volume depletion
Impaired cardiac efficiency
Vasodilation

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13
Q

AKI Pre-renal failure:

Volume depletion resulting from:

A

Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

Hemorrhage

Renal losses (diuretic agents, osmotic diuresis)

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14
Q

AKI Pre-renal failure:

Impaired cardiac efficiency resulting from:

A

Cardiogenic shock
Dysrhythmias
Heart failure
Myocardial infarction

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15
Q

AKI Pre-renal failure:

Vasodilation resulting from:

A

Anaphylaxis
Antihypertensive medications or other medications that cause vasodilation
Sepsis

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16
Q

AKI Intra-renal failure causes:

A

Prolonged renal ischemia
Nephrotoxic agents
Infectious processes

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17
Q

AKI Intra-renal failure:

Prolonged renal ischemia resulting from:

A

Hemoglobinuria (transfusion reaction, hemolytic anemia)
Rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)
Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)

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18
Q

AKI Intra-renal failure:

Nephrotoxic agents such as:

A

Aminoglycoside antibiotics (gentamicin, tobramycin)
Angiotensin-converting enzyme inhibitors (captopril)
Heavy metals (lead, mercury)
Nonsteroidal anti-inflammatory drugs (Aspirin, Ibuprofen)
Radiopaque contrast agents
Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)

KNOW ANTIBIOTICS and NSAIDS!!

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19
Q

AKI Intra-renal failure:

Infectious processes such as:

A

Acute glomerulonephritis
Acute pyelonephritis

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20
Q

Contrast agents- be sure to

A

flush out after imaging- drink lots of fluids

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21
Q

AKI Post-renal failure:

Urinary tract obstruction, including:

A

Benign prostatic hyperplasia
Blood clots
Calculi (stones)
Strictures
Tumors
pregnancy

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22
Q

Phases of AKI:

Four phases

A

Initiation
Oliguria
Diuresis
Recovery

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23
Q

Phases of AKI:

Initiation

A

Begins with initial insult and ends when oliguria develops

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24
Q

Phases of AKI:

Oliguria

A

Accompanied by an increase in urea, creatinine, uric acid, organic acids, and K+ and Mg++

Urine output decreases below 400 mL in 24 hours (or 0.5 mL/kg/hr)

Hyperkalemia develops

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25
Q

Phases of AKI:

Diuresis

A

Gradual INCREASE in urine output…glomerular filtration starts to recover

Lab values stabilize and improve

UOP may reach normal (or even greater than normal) levels

Labs may still be abnormal

Medical/Nursing mgmt. still continuing until the recovery phase

26
Q

Phases of AKI:

Recovery

Improvement of renal function and may take from _____

Labs return to normal (or clients’ baseline level)

____ reduction in GFR may occur; however, is not clinically significant

A

3-12 months

1-3%

27
Q

AKI: assessment & diagnostics:

A

Urine changes:
Urinary output
Urine color, clarity, odor, etc
Hematuria
Specific gravity decreases (one of the earliest manifestations)
Decreased sodium in urine

Renal sonogram, CT or MRI to determine abnormalities with anatomy

BUN and creatinine increase

Hyperkalemia
-may lead to dysrhythmias (VTACH) and cardiac arrest

I&O (folley catheter may be indicated)
Daily weights

28
Q

AKI: assessment & diagnostics: Cont.

Progressive metabolic _____

____ levels increase in blood

_____

A

Progressive metabolic acidosis
-r/t inability to eliminate daily acid-type substances produced in body
-Buffering fails
Decreased serum CO2 and pH levels

Phosphate levels increase in blood
-decreased calcium levels in blood (decreased absorption in the intestines)

Anemia
-r/t reduced erythropoietin production
-uremic GI lesions, blood loss from GI tract

29
Q

AKI diagnostics labs:

A

Decrease:
Specific gravity (one of the earliest signs
Sodium in urine
calcium levels in blood
decreased serum CO2 and ph
progressive metabolic acidosis
anemia

Increase:
BUN
creatinine
hyperkalemia (may lead to Vtach, or cardiac arrest)
phosphate levels in blood

30
Q

AKI: prevention

Continually assess renal function (urine output, laboratory values) when appropriate.

Monitor ____________ of critically ill clients
to detect the onset of kidney disease as early as possible.

Pay special attention to ____, ____ and other precursors of sepsis.

Prevent and treat ______ promptly
_____ can produce progressive kidney damage.

Prevent and treat shock promptly with blood and fluid replacement.

Take precautions to ensure that the appropriate blood is given to the correct client
to avoid severe transfusion reactions, which can precipitate kidney disease.

A

central venous and arterial pressures and hourly urine output

wounds, burns,

Infections

31
Q

AKI: prevention cont.

Provide adequate hydration to clients at risk for dehydration, including:

A

Before, during, and after surgery

Clients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, IV pyelograms), especially older clients who may have marginal renal reserve

Clients with neoplastic disorders or disorders of metabolism (e.g., gout) and those receiving chemotherapy

Clients with skeletal muscle injuries (e.g., crush injuries, compartment syndrome)

Clients with heat-induced illnesses (e.g., heat stroke, heat exhaustion)

32
Q

AKI: prevention

To prevent infections from ascending in the:

To prevent ____ effects

Treat _____ promptly

A

urinary tract
give meticulous care to clients with indwelling catheters
Remove catheters as soon as possible

toxic drug
closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys

hypotension

33
Q

AKI: Medical management

A

Eliminating underlying cause:
Shock (any type); however, sepsis is most common

Maintaining fluid balance
-Daily weights
-Measuring CVPs
-Serum and urine concentrations
-Fluid losses
-Maintaining BP
-Parenteral/oral intake, UOP, gastric drainage, stools, wound drainage, and perspiration are basis for fluid replacement

Avoid fluid excesses
-Dyspnea, tachycardia, and JVD
-Crackles auscultated in lungs
-edema
-Mannitol, furosemide, or ethacrynic acid may be prescribed for diuresis

IV fluids and blood / blood product transfusions
-For prerenal causes

Dialysis to prevent complications of AKI
-Hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema

34
Q

AKI: pharmacologic therapy

A

Hyperkalemia:
-EMERGENCY!!!
-Potassium level greater than 5 mEq/L
-ECG changes (tall, tented, or peaked T waves)
-Irritability, abdominal cramping, diarrhea, paresthesia, and generalized muscle weakness
-Generalized muscle weakness, slurred speech, difficulty breathing, and paralysis
Treatment: Kayexalate

Hemodynamic instability:
-Low BP, AMS, and/or dysrhythmia
-Treatment: IV Dextrose 50%, insulin, and calcium replacement to shift potassium back into cells (temporary…so, dialysis will still be needed)

Renal dosing of medications
-Since many meds utilize the kidneys to filter; pharmacy can adjust medications accordingly
-Common meds: antibiotics, digoxin, phenytoin, ACE inhibitors, and magnesium-containing agents

Sodium bicarbonate:
Since client is typically more acidotic, sodium bicarb may be given; however, dialysis may still be needed for long-term effect

Phosphate-binding agents:
-T-reatment of hyperphosphatemia
-Calcium or lanthanum carbonate decrease levels by decreasing absorption from the intestinal tract

35
Q

CKD: Chronic Kidney Disease

An umbrella term describing
-kidney damage
-decrease in the glomerular filtration rate (GFR) that lasts for _______

Untreated CKD can result in __________
-Final stage of CKD
-Results in retention of ______
-Need for ________________

Damage to kidneys is thought to be caused by _______

Early stages:
There can be significant damage without ___

A

3 months or longer

end-stage kidney disease (ESKD)
uremic waste products

RRT (renal replacement therapy)
Dialysis, or kidney transplant

prolonged acute inflammation

S&S

36
Q

ESKD- need kidney transplant, not reversable, need dialysis

A
37
Q

CKD: Risk Factors / causes

A

Diabetes (primary cause)
-More than 35% of the US population over 20 years of age has CKD
-Leading cause of kidney disease in patients starting renal replacement therapy

Hypertension (second-leading cause)

Obesity

Cardiovascular disease

Glomerulonephritis
Pyelonephritis
Polycystic disorders
Nephorsclerosis
Hereditary disorders
-More than 60
Congenital disorders
Renal cancers

38
Q

Stages of CKD:
Stage I:

A

GFR > or equal to 90mL/min/1.73 m2
Kidney damage with normal or increased GFR

39
Q

Stages of CKD:
Stage II:

A

GFR = 60-89 mL/min/1.73 m2
Mild decrease in GFR

40
Q

Stages of CKD:
Stage III:

A

GFR = 30-59 mL/min/1.73 m2
Moderate decrease in GFR

41
Q

Stages of CKD:

Stage IV:

A

GFR = 15-29 mL/min/1.73 m2
Severe decrease in GFR

42
Q

Stages of CKD:
Stage V:

A

GFR < 15 mL/min/1.73 m2

End-stage kidney disease (ESKD) or chronic kidney disease

43
Q

Stages of CKD:
Stage____ need to be on dialysis

A

3-5

44
Q

CKD: what to expect

A

Elevated serum creatinine levels

Abnormal creatinine clearance

Anemia
Decreased erythropoietin

Metabolic acidosis

Abnormal calcium and phosphorus levels

Fluid retention (edema and CHF)

As the disease progresses:
Electrolyte disturbances
heart failure worsens
HTN more difficult to control

45
Q

CKD: medical management

Treat underlying cause(s)

Keep blood pressure _____

Renal replacement therapies (RRT)
-___ referral

Prevent complications:

A

BELOW 130/80

Early

Controlling cardiovascular risk factors
Treating hyperglycemia
Managing anemia
Smoking cessation
Weight loss
Exercise
Reduction in salt and alcohol intake

46
Q

Dialysis:
Dialysis or renal replacement therapy is indicated when _____ and/or _____ are present.

Dialysis is typically the first-line treatment vs. kidney transplantation

Dialysis is divided into 2 categories:

__________ is a ‘gentler’ form of dialysis that can be done in critical care settings ONLY!

A

advanced uremia and/or serious imbalances

Hemodialysis
Peritoneal dialysis

Continuous renal replacement therapy (CRRT)

47
Q

CRRT can only be done in the:

A

ICU because they are unstable!!

48
Q

Hemodialysis:

Hemodialysis is basically an artificial kidney
-____, ____, _____
-Prevents death, but does not cure kidney disease

A hemodialysis system consists of 3 parts:

During dialysis, blood moves from an artery through the tubing and blood chamber, then back into the body through a vein…this occurs via an ____
Diffusion, osmosis, ultrafiltration
____ is given to prevent clotting during the dialysis circuit

Most persons are dialyzed three times a week for 3-4 hours each time

A

Acute, chronic, ESKD

Blood delivery system
Dialyzer
Dialysis fluid delivery system

AV fistula

Heparin

49
Q

Hemodialysis

Before Dialysis
Assess:

A

Fluid status
-Weight (current & previous)
-Vital signs

Fistula (shunt)
-Feel a thrill (vibration)
-Hear a bruit (swooshing)

50
Q

Deadly complication of dialysis–

S&S

Priority action:

A

DDS (dialysis disequilibrium syndrome)

Restless & disoriented
Vomiting
Headache

Stop or slow infusion, & report to provider
(can happen during or after hemodialysis)

51
Q

Meds to hold for dialysis

A

ABCDD

Antihypertensive
A (ACE & ARBS)
Lisinopril, Losartan
B (Beta blockers)
Atenolol, metoprolol
C Ca Channel Blockers
Nifedipine, Verapamil, Diltiazem
D Diuretics
Furosemide, Hydrochlorothiazide
D Dilators
Nitroglycerin

Antihypertensives will bottom out BP

Do not Give Heparin shot since they filter with heparin

52
Q

Meds that are washed out during dialysis

A

Antibiotics
Digoxin
Water soluble vitamins (B, C, & folic acid)

53
Q

Hemodialysis

Monitor for:

Teaching
No:

A

Infection
Bleeding
Feel a thrill

No restrictive clothing or jewelry
No BP on affected arm
No sleeping on arm
No cream or lotions (infections)
No lifting over 5 lbs. (no purse)

54
Q

Hemodialysis

The 5 P’s

A

Pale skin “pallor”
Paresthesia (numbness or tingling)
Pulses diminished
Poor capillary refill
Pain (distal to shunt)

First 2 P’s are serious and need to be addressed quickly (they can loose their fistula, or worse, their extremeties

55
Q

Vascular access for: hemodialysis and CRRT

A

AV fistula - made by connecting a vein and an artery
Best choice
Optimal blood flow
Lowest chance of infection

Central line?

56
Q

Peritoneal dialysis:

Goals of PD are to remove toxic substances and metabolic wastes to reestablish normal fluid and electrolyte balance.

Treatment of choice for clients with kidney disease who are unable or unwilling to undergo hemodialysis or kidney transplantation.

A typical candidate for PD:

The peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane.

A sterile _____ fluid is introduced into the peritoneal cavity via an abdominal catheter (see next slide).

Once this solution is in the peritoneal cavity, ____ toxins begin to be cleared from blood.

A

Diabetes
Cardiovascular disease
Those at risk for adverse effects from systemic heparin
Clients with other conditions that haven’t been responsive to hemodialysis, will sometimes do well with PD

dextrose dialysate

uremic

57
Q

Peritoneal dialysis cont.

Advantages:

Disadvantages:

A

More freedom
More control over daily activities
A more liberal diet (less fluid restrictions)
Improve BP control

7 days a week
Need to increase protein & K+ in diet

58
Q

Peritoneal dialysis cont

Indications:

Contraindications:

A

-Willingness, motivation & ability to do
-Strong support (family & community)
-Problems with HD (failing access devices, severe HTN, severe anemia, post dialysis HA
-HTN, uremia, and hyperglycemia easier to manage with PD

-Adhesions from previous surgery
-Chronic back pain or disc disease
-Severe arthritis or poor hand strength

59
Q

Peritoneal dialysis Types:

All PD involves a series of exchanges:

A

Acute intermittent peritoneal dialysis:
Not indicated for long term
Usually someone who requires immediate dialysis (referred late in stage of CKD)

CAPD
Continuous ambulatory peritoneal dialysis
Done during the day

CCPD
Continuous cyclic peritoneal dialysis
Done at night while you sleep

Installation of dialysate (by gravity)
Dwell time
Drainage of fluid (by gravity)

60
Q

CRRT: continuous renal replacement therapy

Dialysis that is carried out continuously instead of over 3-4 hours, as in traditional hemodialysis cases

Benefits

Indicated for clients who have acute or chronic kidney disease in the following cases

A

-Can be initiated quickly
-Do not affect hemodynamics as often as traditional hemodialysis
-Used in critical care units

-Too clinically unstable for traditional hemodialysis
-Fluid overload secondary to oliguric kidney disease
-Client with kidneys that cannot handle acutely high metabolic or nutritional needs

61
Q

Avoid fluid excesses
-Dyspnea, tachycardia, and JVD
-Crackles auscultated in lungs
-edema
-_____________ may be prescribed for diuresis

A

Mannitol, furosemide, or ethacrynic acid

62
Q

Dialysis to prevent complications of AKI

A

Hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema

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