Chapter 47: Acute and Chronic Kidney Flashcards
Risk
Serum creatinine increased × 1.5
OR
GFR decreased by 25%
Urine output
<0.5 mL/kg/hr
for 6 hr
Injury
Serum creatinine increased × 2
OR
GFR decreased by 50%
Urine output
<0.5 mL/kg/hr
for 12 hr
Failure
Serum creatinine increased × 3 OR GFR decreased by 75% OR Serum creatinine >4 mg/dL with acute rise ≥0.5 mg/dL
Urine output <0.3 mL/kg/hr for 24 hr (oliguria) OR Anuria for 12 hr
Loss
Persistent acute kidney failure;
complete loss of kidney
function >4 wk
End-stage
kidney
disease
Complete loss of kidney function
>3 mo
Nonoliguria AKI indicates a urine output
greater than
400 mL/day
a urinalysis may show
specific gravity fixed at around 1.010 and urine osmolality at
about 300 mOsm/kg (300 mmol/kg)
Fluid overload
can eventually lead to
HF, pulmonary edema, and pericardial
and pleural effusions.
Uncontrolled
hyponatremia or water excess
can lead to cerebral edema
The best serum indicator of AKI
creatinine
Asterixis
(flapping tremor when the wrist is extended)
is most common with liver failure, but has been known to occur
with advanced and severe kidney dysfunction.
During the diuretic phase of AKI, daily
urine output is usually around
1 to 3 L, but may reach 5 L or
more.
caused by osmotic diuresis
The recovery phase begins when the
GFR
increases, allowing the BUN and serum creatinine levels to
plateau and then decrease
Urine sediment
containing abundant cells, casts, or proteins suggests
intrarenal disorders
kidney ultrasound
first test done, since it provides
imaging without exposure to potentially nephrotoxic contrast
agents.
A primary nutritional goal in AKI
is to maintain adequate caloric intake
(providing 30 to 35 kcal/
kg and 0.8 to 1.0 g of protein per kilogram of desired body
weight) to prevent the further breakdown of body protein for
energy purposes. (diet consists of carbs and fat sources and supplements of essential amino acids.)
Nursing diagnoses and a potential complication for the patient with AKI (examples-NANDA) p1106
• Excess fluid volume related to kidney failure and fluid
retention
• Risk for infection related to invasive lines, uremic toxins,
and altered immune responses secondary to kidney failure
• Fatigue related to anemia, metabolic acidosis, and uremic
toxins
• Anxiety related to disease processes, therapeutic interventions,
and uncertainty of prognosis
• Potential complication: dysrhythmias related to electrolyte
imbalances
infection is the leading cause of death in AKI
meticulous
aseptic technique is critical
The Kidney Disease Outcomes Quality Initiative (KDOQI) of the National Kidney Foundation defines CKD as either the
presence of kidney damage or a
decreased GFR less than 60 mL/min/1.73 m2 for longer than 3
months.
end-stage kidney (renal)
disease (ESKD), occurs when
GFR is less than 15 mL/min.
At this point, RRT (dialysis or transplantation) is required to
maintain life
Stage 1
Kidney damage with normal or ↑ GFR ≥90 Diagnosis and treatment CVD risk reduction Slow progression
Stage 2
Kidney damage
with mild ↓ GFR
60-89
Estimation of progression
Stage 3
Moderate ↓ GFR
30-59
Evaluation and treatment of
complications
Stage 4
Severe ↓ GFR 15-29 Preparation for renal replacement therapy (dialysis, kidney transplant
Stage 5
Kidney failure <15 (or dialysis) Renal replacement therapy (if uremia present and patient desires treatment)
Uremia
is a syndrome in which kidney function declines to the point that symptoms may develop in multiple body systems occurs when GFR is 10 mL/min or less
ACI….. As the GFR decreases
the
BUN and serum creatinine levels increase
insulin depends on the kidneys for excretion
remains in circulation
longer.
Mild to moderate hyperglycemia and hyperinsulinemia may
occur.
The altered lipid
metabolism is related to
decreased levels of the enzyme lipoprotein
lipase, which is important in the breakdown of lipoproteins
hyperlipidemia
Sodium intake must be
individually determined but is generally
restricted to 2 g/day.
hormone produced by the kidney
erythropoietin
two
equations used most frequently to estimate GFR are the
Cockcroft-Gault formula and the Modification of Diet in Renal
Disease (MDRD)
Cockcroft-Gault GFR =
(140 − Age) × (Weight in kilograms) × (0.85 if female)/(72 × Cr).
A focus on stages 1 through 4 before the need for dialysis, stage 5
includes the control of hypertension,
hyperparathyroid disease, anemia, hyperglycemia, and dyslipidemia.
Never give sodium polystyrene sulfonate to a patient
with a hypoactive bowel (paralytic ileus) because fluid shifts
could lead to bowel necrosis.
recommended
that the target BP be
less than 130/80 mm Hg for patients with
CKD and 125/75 mm Hg for patients with significant proteinuria
a total parathyroidectomy
some parathyroid
tissue is transplanted into the forearm. The transplanted
cells produce PTH as needed.
Nursing diagnoses for CKD may include, but are not limited to,
the following:
• Risk for electrolyte imbalance related to impaired kidney
function resulting in hyperkalemia, hypocalcemia, hyperphosphatemia,
and altered vitamin D metabolism
• Imbalanced nutrition: less than body requirements related
to restricted intake of nutrients (especially protein),
nausea, vomiting, anorexia, and stomatitis
Instruct the patient to avoid certain over-the-counter
drugs such as
NSAIDs and aluminum- and magnesium-based
laxatives and antacids.
advantages of PD peritoneal dialysis
• Immediate initiation in almost any hospital • Less complicated than hemodialysis • Portable system with CAPD • Fewer dietary restrictions • Relatively short training time • Usable in patient with vascular access problems • Less cardiovascular stress • Home dialysis possible • Preferable for diabetic patient
disadvantages of PD
• Bacterial or chemical peritonitis • Protein loss into dialysate • Exit site and tunnel infections • Self-image problems with catheter placement • Hyperglycemia • Surgery for catheter placement • Contraindicated in patient with multiple abdominal surgeries, trauma, unrepaired hernia • Requires completion of education program • Catheter can migrate • Best instituted with willing partner
advantages of HD hemodialysis
• Rapid fluid removal • Rapid removal of urea and creatinine • Effective potassium removal • Less protein loss • Lowering of serum triglycerides • Home dialysis possible • Temporary access can be placed at bedside
disadvantages of HD
• Vascular access problems • Dietary and fluid restrictions • Heparinization may be necessary • Extensive equipment necessary • Hypotension during dialysis • Added blood loss that contributes to anemia • Specially trained personnel necessary • Surgery for permanent access placement • Self-image problems with permanent access
To perform HD,
a very rapid blood flow is
required, and access to a large blood vessel is essential
HD high risk for
air ebolus
PD more easier done at
home than HD
PD takes a
loner time than HD
HD has an increased risk for
hep B & C
AV GRAFT… description
synthetic tubing tunneled beneath the skin connecting an artery and vein
AV shunt
external loop of synthetic tubing connecting an artery and vein
AV fistula
internal surgical anastomsis between an artery and a vein
thrill
buzzing sensation indicates graft is patent
When caring for a patient during the oliguric phase of acute kidney injury (AKI), what is an appropriate nursing intervention?
Patients in the oliguric phase of acute kidney injury will have fluid volume excess with potassium and sodium retention. Therefore they will need to have dietary sodium, potassium, and fluids restricted. Daily fluid intake is based on the previous 24-hour fluid loss (measured output plus 600 ml for insensible loss). The diet also needs to provide adequate, not low, protein intake to prevent catabolism. The patient should also be weighed daily, not just three times each week.
The patient was diagnosed with prerenal AKI. The nurse should know that what is most likely the cause of the patient's diagnosis? IV tobramycin (Nebcin) Incompatible blood transfusion Poststreptococcal glomerulonephritis Dissecting abdominal aortic aneurysm
A dissecting abdominal aortic aneurysm is a prerenal cause of AKI because it can decrease renal artery perfusion and therefore the glomerular filtrate rate. Aminoglycoside antibiotic administration, a hemolytic blood transfusion reaction, and poststretpcoccal glomerulonephritis are intrarenal causes of AKI.
The nurse knows the patient with AKI has entered the diuretic phase when what assessments occur
Dehydration, hypokalemia, and hyponatremia occur in the diuretic phase of AKI because the nephrons can excrete wastes but not concentrate urine. Therefore the serum BUN and serum creatinine levels also begin to decrease.
Diffusion, osmosis, and ultrafiltration occur in both hemodialysis and peritoneal dialysis. The nurse should know that ultrafiltration in peritoneal dialysis is achieved by which method?
Ultrafiltration in peritoneal dialysis is achieved by increasing the osmolality of the dialysate with additional glucose. In hemodialysis the increased pressure gradient from increased pressure in the blood compartment or decreased pressure in the dialysate compartment causes ultrafiltration. Decreasing the concentration of the dialysate in either peritoneal or hemodialysis will decrease the amount of fluid removed from the blood stream.
Continuous venovenous hemofiltration (CVVH)
CVVH removes large volumes of water and solutes from the patient over a longer period of time by using ultrafiltration and convection
