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Complex Care > AKI > Flashcards

AKI Flashcards

1
Q

Acute kidney injury: rapid loss of kidney function

A
  1. rise in creatinine or reduction of urine output

2. can develop azotermia (increase in nitrogenous waste)

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2
Q

Acute kidney injury: can change in severity

A

develop over hours to days

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3
Q

Acute kidney injury: can range in how long it occurs and when it occurs

A

nephrotoxic takes longer to reach than oliguric phase

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4
Q

Acute kidney injury: most common causes

A

hypotension, hypovolemia, exposure to nephrotoxic agents

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5
Q

What is the most common cause of AKI in the hospital?

A

pre-renal and ATN (acute tubular necrosis)

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6
Q

What is AKI define by?

A

A rise in serum creatinine and/or reduction in urine output

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7
Q

What 3 causes is AKI classified into?

A
  1. prerenal
  2. intrarenal
  3. postrenal
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8
Q

Pre renal AKI is caused by..

A

External causes —> decreased perfusion of kidneys —> decreased function
Less blood going to kidneys to be filtered and decreased nutrient
Ex: cardiac issue, dehydration, bleeding and burns

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9
Q

How will the body compensate in prerenal AKI?

A

increase blood flow by increasing blood volume by:

  1. Angiotensin II
  2. Aldosterone
  3. Norepinephrine
  4. ADH
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10
Q

Prerenal can lead to..

A

intrarenal

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11
Q

Intrarenal AKI is caused by

A

direct damage to the kidney tissue –> impaired nephron functioning —> increased waste and H2O and decreased ability to maintain electrolytes

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12
Q

Direct damage can be caused by

A

prolonged ischemia, nephrotoxins, hemoglobin release from hemolyzed RBIs, myoglobin released from necrotic muscle cells or acute tubular necrosis
Infection, injury

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13
Q

Post renal AKI is caused by

A

mechanical obstruction of urinary flow and is below the kidneys —> prevention of draining system —> increase pressure and build up of waste —> decrease kidney function

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14
Q

What causes mechanical obstruction?

A

BPH, prostate cancer, calculi, trauma, external factors, neurological injury

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15
Q

Hydrpnephrosis

A

bilateral ureter obstruction

If blockage fixed within 48 hours, can usually make a complete recovery

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16
Q

Is post renal AKI common?

A

no, only about 10% of AKI

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17
Q

What is acute tubular necrosis caused by?

A

disruption in the basement membrane and patchy destruction of the tubular epithelium
Nephrotoxic agents blood up and plug tubules of kidneys –> tubular epithelial cells slough off and plug tubules –> alters kidney’s ability to filter appropriately

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18
Q

What happens if the basement membrane is not destroyed in ATN?

A

the epithelium can regenerate and the condition is more reversible

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19
Q

RIFLE

A 
Classificaiton of the stages of AKI. 
R- risk
I- injury 
F- failure
L- loss
E- end-stage kidney disease
Monitor I/Os closely, serum creatinine and GFR
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20
Q

AKI phases

A
  1. Oliguric
  2. Diuretic
  3. Recovery
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21
Q

Oliguria

A

decreased UO of less than 400ml/day

Can occur within 1-7 days of injury

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22
Q

What if the cause of oliguria is ischemia?

A

oliguria can happen in as fast as 24 hours

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23
Q

Can you determine the type of AKI by what urine is being produced?

A

Yes

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24
Q

Type of AKI if Anuria

A

less than 50ml/day

complete bilateral obstruction along urinary tract

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25
Q

Type of AKI if oliguria

A

prerenal

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26
Q

Type of AKI if nonoliguric

A

ATN or intrarenal ATN

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27
Q

Oliguric phase

A

Common symptom: oliguria: less than 400ml/day
50% won’t be oliguric
Longer in the oliguric phase –> poorer prognosis
Lasts 10-14 dyas

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28
Q

Oliguric vs. Nonoliguric

A

Nonoliguric patients have a higher GFR and/or they reabsorb less in the tubules
Less severe injury with nonoliguric

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29
Q

Diuretics and oliguria

A

can be used to increase UO but does not shorten the duration of renal failure, decrease retirement for dialysis or improve survival rate and may delay timely initiation of dialysis

30
Q

Diuretics with established ATN and oliguria

A

Should not be used as a therapy of ATN. Can be used for a short period of time for volume control but should not postpone dialysis starting
Can use crystalloid if hypovolemic

31
Q

Oliguric clinical manifestations: Fluid volume

A

Fluid retention often occurs d/t hypovolemia. Replacing fluids can resolve this
Fluid overload w/ some cases d/t anuria w/ distention of neck veins, pulmonary edema, HF

32
Q

Oliguric clinical manifestations: Metabolic acidosis

A

kidneys can’t excrete hydrogen –> acid builds up.

Bicarb is depleted and production is decreased

33
Q

Oliguric clinical manifestations: Sodium balance

A

Damaged tubules canot conserve sodium so urine has high sodium and normal to decreased serum sodium.
Be careful when replacing sodium b/c fluid volume expansion
Hyponatermia can cause cerebral edema

34
Q

Oliguric clinical manifestations: potassium excess

A

Kidneys can’t excrete potassium.
If AKI is also occurring with a massive trauma, even more potassium is released into extra cellar fluid
Monitor for hyperkalemia by peaked T waves, widening QRS, and ST segment depression

35
Q

Oliguric clinical manifestations: Hematologic disorder

A

leukocytosis

Most common cause of death in AKI is infection

36
Q

Oliguric clinical manifestations: waste product accumulation

A

Kidneys can’t excrete urea which is the end product of metabolism

37
Q

Oliguric clinical manifestations: neurologic disorders

A

nitrogenous waste builds up –> experience fatigue, difficulty concentrating, seizures, stupor, and/or coma

38
Q

Urine analysis for AKI in oliguric phase

A

RBC, casts, WBC, specific gravity: 1.010, proteinuria, electrolyte imbalances, osmolarity: 300 (similar to plasma)

39
Q

Why does it mean when the urine osmolarity looks similar to plasma osmolarity?

A

there is tubular damage and kidneys are no longer able to concentrate urine

40
Q

What are casts made of?

A

mucoproteins of the necrotic renal tubular epithelial cells which slough into tubules

41
Q

Diuretic phase

A
  1. Begins with gradual increase in UO (lasts 1-3 weeks, normalizing of acid-base and electrolyte and waste parameters indicate improvement of renal failure)
  2. Nephrons still can’t concentrate urine, but kidneys can excrete waste now
42
Q

What to assess for in the diuretic phase

A

hypovolemia and hypotension from fluid loss so replace fluids
hyponatremia, hypokalemia and dehydration

43
Q

Why do you see hyponatremia hypokalemia in the diuretic phase?

A

because thew nephrons can excrete waste but can’t concentrate it

44
Q

Recovery phase

A

begins when GFR increase which allows BUN and creatinine levels to plate/decrease

45
Q

How long can improve of AKI take?

A

up to 12 months

46
Q

What is the recovery phase dictated by?

A

overall health, severity of AKI, and complications

47
Q

AKI diagnostics

A
  1. History and physical
  2. UA
  3. Labs
  4. Ultrasound
  5. Renal scan
  6. CT
  7. Renal biopsy
48
Q

History and physical for AKI

A

Helps to determine the cause of AKI (pre, intra, or post renal) and is the most important
Assess recent s/s, drug treatment

49
Q

H&P pre renal

A

history of cardiac disease, dehydration, blood loss

50
Q

H&P intra renal

A

nephrotoxic medication, blood transfusion, exposure to contrast media

51
Q

H&P post renal

A

history of changes in urinary stream, hematuria, stones, cancer of bladder or prostate

52
Q

Urinary analysis for AKI

A

urine sediment containing abundant cells, casts or proteins suggests intrarenal disorders

53
Q

Labs for AKI

A

BUN/creatinine and urine sodium levels

54
Q

Ultrasound for AKI

A

no nephrotoxic agents needed, done first to rule out obstruction

55
Q

Renal scan for AKI

A

loss at renal blood flow and tubular function

56
Q

CT for AKI

A

identify lesions, masses, obstructions, vascular abnormalities

57
Q

Renal biopsy for AKI

A

best way to confirm an intrarenal cause of AKI

58
Q

Nurses role to prevent AKI

A

if patient if at risk for developing AKI like if the patient is dehydrated of receiving nephrotoxic drugs then looks for s/s of AKI
Change in UO or creatinine are late indications and at that point patient can already have a 50% reduction in kidney function

59
Q

Why are patent with AKI not given an MRI/MRA

A

because contrast should not be given when someone has an issue with their kidneys

60
Q

In general contrast dos and donts

A

No kidney disease
Not with metformin in past 48 hours d/t risk of lactic acidiosis
Give lots of hydration after scans

61
Q

Contrast induced nephropathy that causes AKI creatinine levels

A

creatine levels peak around day 4 and return to normal at day 10

62
Q

AKI professional care

A
  1. Prevention/eliminate cause, prevent complications
  2. Hydration: Maintain intravascular volume and CO
  3. Manage signs/symptoms while kidneys repair themselves
  4. Monitor exposure to nephrotoxins
  5. Diuretic therapy and volume expanders to prevent fluid overload
  6. Very close monitoring of I&Os
  7. Watch for hyperkalemia: ECG
63
Q

AKI nutrition

A

adequate calories, energy from carbs, increase fats, sodium restricted to prevent edema monitor labs

64
Q

Why would you start a patient with AKI on renal replacement therapy? (8)

A

Volume overload, increased potassium, metabolic acidosis, extremely increased BUN, significant change in LOC, cardiac tamponade, pericardia effusion, pericarditis

65
Q

What is renal replacement therapy (RRT)? Is age a barrier?

A

peritoneal dialysis, hemodialysis, or continuous renal replacement therapy
Age is not a barrier

66
Q

Care for hyperkalemia

A
  1. Insulin IV
  2. IV Ca Gluconate (Temporarily blocks K effect on the heart; stabilizes cardiac cells)
  3. Kayexalate (PO/NG or retention enema)
  4. IV Sodium Bicarbonate
    (Increases pH of the serum and moves K into the cells, lasts about 2 hours)
  5. Dialysis
  6. Dietary Restriction of Potassium
67
Q

ACE inhibitors and AKI

A
  1. ACE inhibitors can decrease perfusion and cause hyperkalemia so they may need to be reduced or stopped
  2. ACE inhibitors prevent proteinuria and progression of kidney disease
    OVERALL: dosage decrease during and during acute episode put on hold
68
Q

Infection with AKI

A

infection is the leading cause of death with AKI

  1. Monitor for s/s of local and systemic infections
  2. patients may not have a fever with AKI
69
Q

Local signs of infection

A

redness, swelling, pain

70
Q

systemic sign of infection

A

fever, leukocytosis

Complex Care (22 decks)

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