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NSG 478 > Acute Renal Failure/ Acute Kidney Injury > Flashcards

Acute Renal Failure/ Acute Kidney Injury Flashcards

1
Q

Goal of Acute kidney injury (AKI)

A

Minimize long term loss of renal function, prevent chronic kidney failure

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2
Q

Mgmt of AKI

A
  • Replace renal function temporarily
  • Minimize potentially lethal complications
  • reduce potential causes of increased kidney injury
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3
Q

Common pt with AKI

A

Pts who are hospitalized or in outpatient settings

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4
Q

Acute kidney injury

A
  • Occurring for under 7 days
  • Rapid loss of renal function due to dmg to kidneys
  • High mortality rate
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5
Q

Criteria for AKI

A
  • 50+% increase in serum creatinine above baseline
  • Urine volume: Normal or changes
    • Non-oliguria
    • Oligura
    • Anuria
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6
Q

Normal urine output

A

1 mg/kg/hr
30 ml/hr is minimum

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7
Q

Nonoliguric

A

Normal, greater than 800ml/day urine output

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8
Q

Oliguria

A

Less than 0.5 ml/kg/hr of urine output

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9
Q

Anuria

A

Less than 50 ml per day of urine output

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10
Q

Normal creatinine

A

Depends on the hospital
* 0.8-1.2
* 0.6-1.4

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11
Q

Is AKI reversible

A

Yes

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12
Q

Reversible causes of AKI

A
  • Hypovolemia
  • Hypotension
  • Reduced CO
  • HF
  • Obstruction of kidney or lower urinary tract by tumor, blood clot or kidney stone
  • Bilateral obstruction of renal arteries or veins
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13
Q

First organ to be damaged if there is issues in the body

A

Kidneys , 25% of CO goes to the kidneys

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14
Q

First sign of AKI

A

Reduced urine output

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15
Q

Risk factors for AKI/ARF

A
  • Major surgery
  • Major trauma
  • Nephrotoxic meds (IV contrast/mycin antibiotics)
  • Elderly (Decreased renal function)
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16
Q

Categories of AKI: Prerenal

A
  • Hypoperfusion to the kidneys
  • Caused by
    • HF, Decreased CO
    • Bleeding
    • Dehydration
  • Impaired blood flow leading to hypoperfusion of kidney, decreased GFR (Renal artery stenosis)
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17
Q

Common causes of AKI: Pre-renal

A
  • Volume depletion, burns, hemorrhage, GI loses (Vomiting, diarrhea, NG suction)
  • Hypotension and vasodilation (Sepsis, shock , anaphylaxis)
  • Impaired cardiac (Cardiogenic shock, dysrhythmias, HF, MI)
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18
Q

Categories of AKI: Infarenal

A
  • Damage to the actual kidney
  • Glomeruli or kidney tubules
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19
Q

Causes of AKI: Infrarenal

A
  • Acute tubular necrosis Damage to the kidney tubules
  • Hemoglobinuria vs hematuria
  • Rhabdomyolysis/ myoglobinuria (Trauma, crush, injuries, burns)
  • Infectious processes: Acute glomerulonephritis, acute pyelonephritis
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20
Q

Hemoglobinuria vs hematuria

A
  • Slight differences but for the purposes for this exam, it’s just blood in the urine
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21
Q

Types of kidney injury

A

Prerenal
Intrarenal
Postrenal

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22
Q

Phases of AKI (IODR)

A
  • Initiation: Initial insult to when oliguria occurs
  • Oliguria period: Decreased urine output, can last 10-14 days
  • Diuresis period
  • Recovery period
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23
Q

Phases of AKI: Diuresis period

A
  • Gradual increase in urine output
  • GRF recovers
  • Renal function: Still abnormal due to uremia
  • Observe for dehydration
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24
Q

Phases of AKI: Recovery period

A
  • Signals improvement in renal function (3-12 mo)
  • Lab values return to normal level
  • Permanent 1-3% reduction in GFR, not clinically significant, due to dmg
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25
Q

AKI Assessment and diagnostics findings

A
  • Varies from scant to normal volume
  • Hematuria
  • Low specific gravity
  • Renal sonogram/ MRI/ CT, can show anatomical differences
  • BUN serum creatinine increased
  • Decline in GFR, oliguria, anuria
  • Hyperkalemia, may lead to dysrhythmias (VT) cardiac arrest
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26
Q

Normal specific gravity

A

1.010-1.025

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27
Q

Why is there hyperkalemia in AKI

A

Body cannot excrete it properly

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28
Q

AKI Assessment and diagnostics findings: metabolic acidosis

A
  • Associated with decreased serum CO2 (Form of compensation)
  • Decreased PH levels
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29
Q

AKI Assessment and diagnostics findings: Blood Phosphates

A

May be elevated, coming from nutrition

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30
Q

AKI Assessment and diagnostics findings: Calcium

A
  • May be low due to decreased absorption of Ca in the intestine and due to increased blood phosphate
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31
Q

AKI Assessment and diagnostics findings: Anemia

A
  • Erythropoietin is produced in the kidney, in AKI it is not produced leading to a decrease in WBC
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32
Q

If Ca increases what happens to P and Mg

A
  • P decreases
  • Mg increases

Ca and P are inversely related

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33
Q

Factors that influence mortality AKI

A
  • Increased age
  • Comorbid conditions (Diabetes and HTN)
  • Pre-existing kidney and vascular diseases
  • Resp failure
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34
Q

Best way to treat AKI

A

prevention

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35
Q

Preventing AKI: Renal function

A
  • Continually assess renal function (urine output, lab values)
36
Q

Preventing AKI: Critically ill pts

A
  • monitor central venous and art pressures, hourly urine outputs to detect early onset of kidney disease
37
Q

Preventing AKI: Sepsis

A
  • Know S+S
  • Wounds , burns and treat infections promptly
  • Prevent and treat shock promptly, blood and fluid replacement

Goes for both septic and hypovolemic

38
Q

Preventing AKI: Hydration

A
  • Maintain hydration in pt at risk for dehydration, including before during and after surgery
39
Q

Preventing AKI: Meds/nephrotoxic agents

A

Identify nephrotixic agents/ enviromental toxins
* Radiocontrast dye
* Can use N-acetylcystine and bi carb to help mgmt
* Pre hydration with saline
* NSAIDS are number one cause
* Monitor kidney function before and after initiating med therapy with nephrotoxic meds

40
Q

Preventing AKI: Neoplastic disorders

A
  • Neoplastic disorders or disorders of the metabolism
  • Gout
  • Chemo
41
Q

Preventing AKI: Skeletal muscle injuries

A
  • Crash injuries
  • Compartment syndrome

Increased risk of renal injury

42
Q

Preventing AKI: Heat

A
  • Pt with heat induced illness
  • Heat stroke, heat exhaustion
43
Q

Radiocontrast dye

A
  • Major cause of hospital aquired AKI
  • Diagnostic studies that require fluid restriction and contrast agents
  • Older pts are more suceptible

Not an absolute contraindication in those with renal impairment, can premedicate and alot of caution

44
Q

Preventing AKI: Cath

A

Meticulous cath care, preventing ascending infections and discontinue cath asap

45
Q

Preventing AKI: BP

A

Treat hypotension promptly

46
Q

Nephrotoxic meds

A
  • NSAIDS
  • Mycin/ micin
  • Aminoglycosides
  • gentamicin
  • Tobramycin
  • Colistimethate
  • Polymyxin
  • Amphotericin
  • Vancomycin
  • amikacin
  • cyclosporin

Mycins are huge

47
Q

Medical mgmt of AKI: Goals and guidelines

A
  • Objective is to restore normal chem balance and prevent complications until repair of tissue and restoration of renal function occur
  • Eliminate underlying cause
  • Maintain fluid balance
  • Avoid fluid excesses
  • RRT as indicated (dialysis)
48
Q

Med mgmt of AKI: Prerenal:

A

OPtimizing renal perfusion
* IV Fluids or blood products
* Don’t wanna cause fluid excess tho

49
Q

Medical mgmt of AKI: Prerenal:

A

OPtimizing renal perfusion
* IV Fluids or blood products
* Don’t wanna cause fluid excess tho
* Fluid challenge, diuretics dopamine, calcium channel blockers

50
Q

Medical mgmt of AKI: Post renal

A

Relieving the obstruction (Kidney stone)

51
Q

Medical mgmt of AKI: Infrarenal

A
  • Removal of causative agents
  • Prompt treatment of shock and infection
  • Treat rhabdomyolysis in crush injury, compartment syndrome, heat induced illness
  • Myoglobin in the urine (Myoglobinuria)
52
Q

Medical mgmt of AKI: Fluid balance

A
  • Based on daily weight, CVP, Serum and urine concentrations, fluid losses, blood pressure
  • Parenteral and oral intake
  • Output (Urine, gastric drainage, stools, wound drainage, perspiration)
    • Calculated and used as the basis for fluid replacement (Output)
    • Consider insensible fluid loss through skin and lungs
  • Monitor for fluid excess, preventing fluid overload
  • Special care during blood transfusion as this can occur
53
Q

S+S Fluid excess

A
  • Dyspnea
  • Tachycardia
  • Distended neck veins
  • Lungs, moist crackles
  • Generalized edema
54
Q

Mgmt of fluid excess: diuresis

A
  • Mannitol
  • Furosemide
55
Q

Where to assess for generalized edema

A
  • Pre tibial
  • Pre sacral
56
Q

Fluid challenge

A
  • Giving a bolus of fluids and seeing the person’s response, increased CVP means fluid challenge is effective
57
Q

Treatments for AKI: Albumin

A
  • Plasma expander, given if AKI is caused by hypovolemia
  • Helps fluid stay in the blood
58
Q

Treatments for AKI: Dialysis

A
  • Prevents complications of AKI
    • Hyperkalemia
    • Metabolic acidosis
    • Pericarditis
    • Pulmonary edema
  • Peritoneal dialysis
  • Continuous renal replacement therapies (CRRT) , Used in more unstable pts
  • Renal dosing of meds (ATB, ACE-I, Dig, Phenytoin)
59
Q

Mgmt of AKI: Hyperkalemia

A
  • K is greater than 5
  • Cation exchange resins, (sodium polystyrene sulfonate (Kayexalate)), orally or retention enema
  • Sorbitol + Kayexalate, K is removed through the bowel
  • Retention enema, need to retain for 30 min for best results
  • If EKG changes, IV dextrose and insulin, with calcium gluconate helps move it back into the cells
  • Sodium bi carb, moves K back into cell by correcting acidosis
60
Q

Mgmt of AKI: Severe acidosis

A
  • Monitor ABG and bicarb levels
  • Bicarb therapy or dialysis to mgmt
61
Q

Mgmt of AKI: Elevated serum phosphate level

A
  • Phosphate binding agents
  • Calcium or lanthanum carbonate, Aka phosLo, Phos renal
  • Binds to P while eating and poops it out
  • Don’t administer these meds while NPO because it works on the food being eaten
62
Q

Mgmt of AKI: Nutritional

A
  • N+V makes it hard to have adequate dietary
  • Need to weigh pts daily, 0.2-0.5 kg per day
  • Weight gains with hypertension= fluid retention (Crackles in lung)
  • Cannot eat a lot of protein due to creatine, mainly given to maximize benefit and prevent muscle waste
  • High carb meals
  • Nutritional support depends on cause of AKI, catabolic response, dialysis ,and co morbidities
  • Restrict foods high in potassium, or phosphorus
63
Q

Foods high in potassium

A
  • Banana
  • Citrus
  • Juices
  • Coffee
64
Q

Foods high in Phosphorus

A
  • Whole grain bread
  • Bran cereals
  • Oatmeal
  • Nuts
  • Sunflower seeds
  • Dark cola
65
Q

Nursing problems AKI

A
  • Excess fluid volume (Decreased urine output, dietary excess, retention of sodium and water)
  • Imbalanced nutrition (Anorexia, N+V, dietary restrictions, altered oral mucous membranes)
  • Deficient knowledge regarding condition and treatment
  • Activity intolerance (Fatigue, anemia, retention of waste, dialysis procedure)
  • Risk for situational low self esteem (Dependency, role changes, body image, change in sexual function )
66
Q

Nursing mgmt of AKI: Monitoring fluid and electrolyte balance

A
  • IV solutions based on fluid status
  • Monitor Cardiac function and musculoskeletal status for hyperkalemia
  • Urine output, edema, JVD, altered heart sounds/ breath increase difficulty in breathing
  • Accurate daily weights and I+O records
  • Disturbances may be treated with dialysis, PD, or CRRT
67
Q

Nursing mgmt of AKI: Reducing metabolic rate

A
  • Bed rest
  • Treat fever and infection
68
Q

Nursing mgmt of AKI: Promoting pulmonary function

A
  • T+P
  • Cough and deep breathing
  • Prevent atelectasis and respiratory tract infection
69
Q

Nursing mgmt of AKI: Preventing infection

A
  • Asepsis with invasive lines and cath
  • Avoid indwelling urinary cath but may be required for accurate I+O
70
Q

Nursing mgmt of AKI: Skin care

A
  • Dry or susceptible to breakdown due to edema
  • Meticulous skin care
  • excoriation and itching from deposit of irritating toxins in patients tissues
  • Bath with cool water, T/P keep skin clean and well moisturized, fingernails trimmed (Especially with excoriation)
71
Q

Nursing mgmt of AKI: Psychosocial support

A
  • For pt and families needing Hemodialysis (HD), peritoneal dialysis (PD) or Continuous renal replacement therapy (CRRT)
  • Need to offer assistance, explanation and support
  • Purpose of treatment and explained to patient and family
  • High levels of anxiety and fear may necessitate repeated explanation and clarification
72
Q

Chronic kidney disease (CKD)

A
  • Kidney disease greater or a decreased GFR >3mo
  • Untreated CKD leads to End stage kidney disease, retention of uremic wase
    • Need for renal replacement therapies (RRT), dialysis or kidney transplantation
73
Q

Risk factors for CKD

A
  • Cardiovascular disease, diabetes, hypertension
  • Lesser: Glomerulonephritis and pyelonephritis, polycystic KD, Hereditary or congenital disorders, Renal cancers

HTN and Diabetes are the number one

74
Q

Normal GFR

A

125 ml/min/ 1.73

75
Q

Stage 1 CKD

A

GFR >90ml/min

76
Q

Stage 2 CKD

A

GFR is 60-89ml/min
Mild decrease in GFR

77
Q

Stage 3 CKD

A

GFR is 30-59 ml/min
Moderate decrease in GFR

78
Q

Stage 4 CKD

A

GFR is 15-29 ml/min
Severe decrease in GFR

79
Q

Stage 5 CKD

A

GFR is <15ml/min
ESRD or CKD

80
Q

Clinical manifestations of CKD

A
  • Elevated serum creatinine levels
  • Anemia
  • Metabolic acidosis
  • Abnormalities in calcium and Phosphorus
  • Fluid retention, Edema, CHF
  • Electrolyte imbalance
  • uncontrolled HTN
81
Q

Assessment and diagnostic findings CKD

A
  • S+S (HTN, Diabetes)
  • PHM
  • GFR
  • Creatinine clearance
  • Labs (CBC, CMP)
  • ABG
82
Q

Med mgmt of CKD

A
  • Treat the underlying cause
  • Keep BP < 130/80
  • Early referral to dialysis if they will need later
  • Prevention of complications (Control of cardio risk, treating hyperglycemia, anemia, smoking cessation, weight loss, exercise programs, reduce salt and alc)
  • Identify factors that contribute to ESKD
    • meds
    • Diet therapy
    • Dialysis
    • Renal transplant

Goal is to maintain kidney function and homeostasis for long as poss

83
Q

Medical mgmt of CKD: Pharm

A
  • Prevent or delay complications
    • Phosphate binders (Phoslo, renagel, phosrenol)
    • Ca with vit D support
    • Antihypertensive and cardiac meds (Hyperkalemia)
    • Anticonvulsant meds (Due to fluid shift, can cause hyponatremia, leading to seizures)
    • Recombinant human erythropoietin (For anemia)
84
Q

Medical mgmt of CKD: Dietary

A
  • Carbs and fat to prevent wasting
  • Vitamin supplements
  • 1.2-1.3 g/kg of protein per day, preferably of biological protein (Eggs, milk, meat)
  • Sodium (2-3g per day)
  • Fluid allowance (500-600 ml more than daily urine output)
  • Monitor diet, meds and fluids for K content
85
Q

AKI: IODR, Oliguric phase

A
  • Increase in serum concentration of substances that would be excreted by kidneys
  • Potassium is a huge concern here as it is retained and can lead to hyperkalemia
  • This phase last 10-14 days followed by diuresis phase

NSG 478 (23 decks)

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