Beth - Week 12 - Exam 4 Flashcards
review: what does the kidney do?
◦ Excretion ◦ Filter ◦ Controls BP ◦ Regulate RBC production ◦ Metabolizes drugs and hormones ◦ Synthesizes Vit D ◦ Manages electrolytes - Ca++ balance ◦ Glucose homeostasis ◦ Balances pH
how is acute kidney injury defined?
- defined as a rapid loss of kidney function
- identified as increase in serum creatinine or ↓ urine output
what are the three characteristics of the pathophysiology of acute kidney injury?
- the degree of dysfunction depends on the early ID and interventions of the healthcare team
- AKI can be multifactorial
AKI is characterized as ____, ____, and ____
- prerenal
- intrarenal
- postrenal
what is the currrent data base of AKI defined?
- severity, duration, and outcome is complicated with both oliguria and relapses in AKI
- stage 3 AKI and AKI that has persisted over 7 days or more
what is the onset, cause, diagnostics, reversibility, and cause of death of AKI?
- sudden
- acute tubular necrosis
- acute drop in UO and ↑ creatinine
- potential reversibility
- infection and sepsis
what is the onset, cause, diagnostics, reversibility, and cause of death of CKD?
- gradual over years
- diabetic nephropathy
- GFR <60mL for 3 mo
- progressive, irreversible
- results in CV death
what is azotemia (early AKI)?
excessive nitrogenous waste in the blood - Urea - Creatinine ◦ 3 stages - Pre-renal - Intra-renal - Post-renal
what is oliguria?
Reduction of UO less than w400ml/day
what is uremia/uremic (late - CKD)?
◦ “urine in the blood” Raised level nitrogenous waste in
the blood
- Urea
- Creatinine
how does AKI start?
sudden episode
- can be hours to days
what are the risk factors of AKI?
decreased perfusion to the kidney
- hypotension
- hemorrhage
- dehydration
- acute MI
- liver failure
- burns (massive fluid loss)
- injury (trauma)
- major surgery
what are the direct causes of AKI?
- toxins (ATB)***test
- sepsis ***test
- multiple myeloma
- interstitial nephritis
- glomerulonephritis
- urinary obstruction (kidney stones, blood clots in urinary tract,
for direct causes of AKI, what are the specific toxins that can cause AKI?
- ANTIBIOTICS (vanco, aminoglycosides, amphotericin B, cephalosporins)
- OTHER DRUGS (diuretics, NSAIDs, contrast, chemo, illicit drugs)
- HEAVY METALS (lead, mercury, copper)
- ORGANIC SOLVENTS (glycol, gas, kerosene, turpentine)
- POISONS (mushrooms, insecticides
what are the three condition that predispose a person to AKI (can cause CKF)?
- prerenal
- intrarenal
- postrenal
TEST:how does prerenal conditions cause AKI?
- hypoperfusion
- low renal blood flow to the kidney, prevent BP going to kidneys
- outside the kidney*
TEST: what are the causes of prerenal condition?
hemorrhage, dehydration
• dehydration - burns, loss of large volumes via GI
• ↓ vascular filling - shock and sepsis
• HF - cardiogenic shock, low C.O. MI, CHF
• anaphylaxis
TEST: what are the findings for someone in a prerenal condition?
- oliguria
- labs: ↑ BUN, ↑ Cr
read pre-renal example.
David, 68, lives alone. 5 days ago, he developed
a fever & began vomiting. He took sips of
ginger ale to settle his stomach. Today, his
neighbor finds him weak and feverish, so she
brings him to the ER. Davids B/P is 78/60 &
his U/O is 15ml after straight cath. His BUN is
72mg/dl & Creat is 1.6mg/dl— ANSWER TO
FOLLOW
answer to prerenal example
- Dehydration resulting in sever hypotension
(low blood volume to the kidneys) as noted
by BUN, sl. Creat; ¯ U/O; temp, emesis X
5days - Kidneys aren’t removing urea however the
slight elevation of creat indicates that his
nephrons haven’t been damaged - PLAN: antiemetic PRN; fluid replacement to
volume to renal bld. flow and reverse the
pre-renal condition
is the prerenal condition reversible?
REVERSIBLE!
what is an intrarenal condition?
AKI - acute tubular necrosis
- direct damage to kidney
- *damage to the renal tissue**
what are the causes of intrarenal condition?
- prolonged kidney ischemia
- examples: trauma to kidney, Nephrotoxic agents, contrast, hemolytic transfusion reaction, chemicals, intratublar obstruction, acute renal disease (acute glomerulonephritis/pyelonephritis)
what are the findings in a intrarenal condition?
- oliguria
- labs: ↑ BUN, Cr
TEST: read the example for intrarenal
Gloria, 58, was in a MVA—In OR she was
hypotensive for 55 mins. Due to a open
fractured femur, she was also started on
Vancomycin to prevent osteomyelitis. Her
BUN and Creat are trending upward and today,
her BUN is 55 mg/dl & Creat is 5.2mg/dl with
no urine output—ANSWER TO FOLLOW
TEST: answer to the intrarenal example
- ARF due to a nephrotoxic drug— Vancomycin and massive myglobinuria
from tissue damage - Damage to the nephrons ( Creat)
- PLAN: Hydrate kidney, stop the drug and
do a trough—renal doses of meds;
probable dialysis if no response - GOAL: control primary disease, treating
the ARF, preventing further injury and
promoting renal healing
TEST: is intrarenal condition reversible?
REVERSIBLE if we catch
what is a postrenal condition?
acute bilateral ureteral and bladder outlet obstruction
obstruction
what are the causes of a postrenal condition?
calculi, BPH, neoplasm, urethral obstruction, crystals,
neurogenic bladder
◦ Leads to-Hydronephrosis
◦ If corrected within 48hrs-recovery
◦ If not correct after 12 wks.-no recovery
what the findings in a postrenal condition?
- U/O may be normal or ↓
- labs: ↑ BUN and Cr variable
read the postrenal examples
Joe, 76, has frequent urination & a weak stream
for years, but he never told his physician.
When he suddenly becomes confused, his
family brings him to the ER. His BUN is
50mg/dl and Creat is 2.0mg/dl. His bladder is
distended. —ANSWER TO FOLLOW
read the postrenal answer
- Cathed for 2000ml of urine (watch B/P)
- typical of an enlarged prostate preventing
urine to flow from the bladder - BUN and Creat climbing
- PLAN: TURP and meds to decrease size of
prostate and reverse post-renal condition - If blockage persists, hydronephrosis and
kidney damage will occur
is post renal condition reversible?
REVERSIBLE if we have intervention
what are the 3 highest reasons for increased mortality rate in AKI?
- hypotension
- hypovolemia
- nephrotoxic agents
what are the 4 phases of acute kidney injury?
- onset phase
- oliguric-anuric phase
- diuretic phase
- recovery phase
what is the characteristics of onset?
what are the precipitation events?
what is the characteristic of oliguric-anuric phase?
minimal to no urine
what are the sxs of the oliguric-anuric phase?
✸ Edema ✸ HTN ✸ wt. gain,fluid excess ✸ metabolic acidosis ✸ kussmaul respirations ✸ JVD ✸ bounding pulse ✸ elevated BUN, creat, K+ PO4- Mg and low Ca
what are the nursing diagnoses for the oliguric-anuric phase?
Fluid Volume Excess
At Risk for Injury due to hyperkalemia
Metabolic acidosis
what are the characteristics of the diuretic phase?
Quantity of urine ↑ BUT the quality of urine is
no better
Nephrons are not fully recovered
what sxs of the diuretic phase?
↑ U/O; hypovolemia Dehydration Hypokalemia Hyponatremia hypomagnesemia
what are the nursing diagnoses for diuretic phase?
Fluid Volume Deficit
High Risk for Injury R/T Fluid &Electrolyte imbalance
what are the characteristics of the recovery phase?
✸Improvement of renal function
✸better quantity and quality of urine (lower
BUN/Creat/K+)
✸Watch for infection—(cause of death!)
✸Vulnerable to additional renal injury during
this time
✸Permanent partial reduction of GFR
what are the nursing priority assessment for AKI?
◦ Heart (Tele) ◦ Lungs (Rate/rhythm) ◦ Neuro-cognitive- (seizures) ◦ Skin ◦ I&O ◦ Vital Signs (trends) ◦ IV Access ◦ Dialysis Access
what are the nursing lab results needed for AKI?
◦ K+ ◦ Na++ ◦ H/H ◦ phosphate - ABG’s ◦ pH ◦ Bicarb
what are the nursing priority assessments in regards to electrolytes - hyperkalemia?
hyperkalemia
- muscle cramps
- twitching
- arrhythmias
- peaked t waves test
what is the nursing plan for a AKI pt with hyperkalemia?
- I and O and lytes
- maintain fluids K+, protein restriction
- insulin IV, Dextrose
◦ (pulling the K+) - kayexalate
- dialysis
what are the nursing priority assessment in regards to electrolytes low calcium and rising phos?
- paresthesia
- tetany
- Chvostek sign
- calcification
- seizures
what are the nursing plans for low calcium and rising phos?
- monitor lytes
- institute seizure precautions
- give phos binders with food
- give vit. D supplement
- dialysis
what are the nursing priority assessment for acid base balance? (metabolic acidosis)
- kussmaul resp
- altered mental status
- hyperkalemia
- pH < 7.35 and HCO3 < 23
what are the nursing plans for acid base balance? (metabolic acidosis)
- tx catabolism with nutritional support
- oral and IV bicarb
- dialysis
what are the nursing priority assessment for fluid volume deficit non oliguric?
- poor skin turgor
- output > intake
- orthostatic hypotension
- dry mucous membrane
what are the nursing plants for fluid volume deficit non oliguric?
- monitor I & O–trends } daily wt
- monitor for postural B/P changes
- monitor lytes,
- BUN, creatinine imbalance
- fluid replacement
- monitor for overload
- dialysis less likely
what are the nursing priority assessments for fluid volume excess for oliguric AKI?
- rales
- peripheral edema
- intake > output
- HTN and tachycardia
- increase resp rate
what are the plans for fluid volume excess for oliguric AKI?
- Diuretics ◦ Lasix drip - daily wt - monitor for JVD (CVP) - monitor I/O-if any urine-- trends - restrict fluids ◦ meds w/ fluids at meal if poss. and oral hygiene - regulate lytes, BUN, creat - dialysis-
what is orthostatic hypotension?
an excessive fall in BP on standing
- > 20mmHg SBP >10 mmHg DBP or both
- sxs occur within seconds to a few minutes of standing and resolve rapidly on lying down
what are the sxs of orthostatic hypotension?
faintness, lightheadedness, dizziness, confusion, and blurred vision
what are the nursing priority assessment of neurological function (uremic toxicity)?
- lethargic
- confusion
- forgetful
- seizures
- stupor
- coma
what is the nursing plan for neurological function (uremic toxicity)?
- dialysis (keep BUN < 100)
- monitor for changes in LOC
- Frequent neuro exams
- explain to family that this will get better w/ recovery
- Reorient Frequently
- Reassure
- Explain procedures
what are the nursing priority assessment for infection lowered resistance?
- elevated WBC
- Fever
- Temperature alterations
- UTI
- Skin
- IV site
- Dialysis site
- Lung sounds
- Oral lesions
- Abdominal assessment
- *Sepsis????
what is the nursing plan for infection lowered resistance?
- Pan C&S
- Begin antibiotics (renal dose) after spec. obtained
- Minimize use of invasive lines/tubes
- Adequate nutrition
- Effective airway clearance
- IS
- Dietary consult
what is the nursing priority assessment for skin integrity? (poor nutrition/edema)
- oral (stomatitis)
- skin (edematous)
- poor nutritional status if not eating
what is the nursing plan for for skin integrity? (poor nutrition/edema)
- oral care q2hr
- skin assessment q8hr and when turning
- lubricating lotions
- meticulous skin care
- turn q2hr, ambulate, chair
- hold pressure to injection sites or venipuncture’s
longer - dietary consult
what is the nursing priority assessment for hematologic (anemia) erythropoietin production?
- low H+H
what is the nursing plan for hematologic (anemia) erythropoietin production?
- PRBC to tx symptomatic anemia
- epogen
- minimize the amt of blood sent to labs (use peds tubes)
what is the nursing priority assessment for nutrition less appetite?
- calorie intake
- wt loss (difficult)
- poor appetite (not palatable)
- start TF if not able to take oral (intubate)
what is the nursing plan for nutrition less appetite?
- monitor dietary intake
- goal: prevent protein catabolism
- dietary consult
